原发灶不明侵及皮肤的巨大颈部转移癌的手术及修复

Repair surgery for giant neck metastatic carcinoma of unknown primary focal neck skin invasion

目的探讨原发灶不明的侵及皮肤的巨大颈部转移癌的手术方法、手术技巧及修复方法。方法：原发灶不明的侵及皮肤的巨大颈部转移癌患者16例，行根治性颈淋巴结清扫术，术中切除足够的受侵皮肤，妥善解决暴露、止血、颈内静脉上下极的处理、颈动脉、迷走神经、颈交感神经干、膈神经及臂丛神经的保护等问题，应用肌皮瓣修复颈部巨大皮肤缺损，术后给予同期放化疗。结果：16例患者术中无颈动脉破裂大出血，2例因与颈总动脉粘连紧密分离时颈总动脉外膜破裂给予直接缝合修复血管；1例颈总动脉切除约1．5 cm，游离动脉后无张力给予端端吻合；1例术中证实颈内动脉已闭塞给予切除；2例切除部分迷走神经，1例行迷走神经端端吻合，1例胸长神经移植吻合；2例切除膈神经；16例均保留颈交感神经干及臂丛神经；16例颈部皮肤缺损均用胸大肌皮瓣修复。手术时间200～300min，术中失血量190～350ml。胸大肌皮瓣全部存活，无1例坏死。手术放化疗后随访3～50个月，死亡8例，死亡时间距离发病时间最长48个月。死于肺转移4例，骨转移2例，颈部复发1例，鼻咽大出血1例；其中3例发现原发灶，分别为鼻咽癌、扁桃体癌及食管癌。结论：原发灶不明的侵及皮肤的巨大颈部转移癌的手术是安全的，胸大肌皮瓣修复皮肤缺损疗效满意，不影响术后放化疗，可以提高局部控制率和患者的生存质量。

Objective:To explore the repair surgical methods,surgical skills and repair methods of the giant neck metastatic carcinoma of unknown primary focal neck skin invasion.Method:Radical lymphadenectomy were performed on 16 patients suffered from giant neck metastatic carcinoma of unknown primary focal neck skin invasion.The invasion skin was removed enough,the exposure,hemostatic,internal jugular vein of the upper and lower pole processing,carotid artery,vagus nerve,cervical sympathetic nerve,the phrenic nerve and brachial plexus nerve protection and other issues were all properly resolved.Neck skin giant defect was repaired with myocutaneous flap and concurrent chemoradiotherapy was carried out after surgery.Result:In 16 patients without carotid artery rupture,2cases due to adhesion and carotid artery closely separated carotid artery rupture with direct suture repair vessel;1cases of carotid resection of about 1.5cm,with anastomosis without tension;internal carotid artery occlusion confirmed was given resection in 1cases;2cases of partial vagus nerve resection;1cases of vagus nerve anastomosis,1cases of long thoracic nerve anastomosis;2cases of resection of phrenic nerve;16cases cervical sympathetic trunk and brachial plexus were preserved;16cases of neck skin defect were repaired with pectoralis major myocutaneous flap.The operative time 200-300 min,intraoperative blood loss 190-350 ml.Pectoralis major muscle flaps were all survival.All the patients were followed up for 3-50 months,8cases of death,the longest death time was 48 months from the disease,4cases died of lung metastasis,bone metastasis in2 cases,1cases of cervical recurrence,nasopharyngeal bleeding in 1cases;primary tonsil carcinoma,esophageal carcinoma and nasopharyngeal carcinoma were found in 3cases respectively.Conclusion:Repair surgery is safe for giant neck metastatic carcinoma of unknown primary focal neck skin invasion.Skin defect repair curative effect is satisfied repaired with pectoralis major myocutaneous flap which not only does not affect postoperative chemotherapy but also can improve the local control rate and life quality of patients.