头颈部缺损重建术后持续性口底瘘或口咽瘘的救治性治疗

Re-reconstructions for cases with persistent post-reconstructive orocutaneous or oropharyngocutaneous fistulas after extensive reconstructive operations in head and neck region

目的 :探讨对持续性难治性口底瘘或口咽瘘的患者,运用清创+皮瓣修复的方法进行治疗的效果及预后影响因素。方法:回顾性分析上海交通大学医学院附属第九人民医院2009年1月—2018年12月因持续性口咽瘘和口底瘘,而进行二期或三期清创及皮瓣修复重建的患者。总结瘘管发生的可能原因,修复重建的方法,相关并发症及随访结果,并对预后影响因素进行Cox多因素分析。结果:共纳入31例患者,19例(61.3%)为口底瘘,12例(38.7%)为口咽瘘,修复重建手术中,股前外侧皮瓣占15例(48.4%)是最常用的皮瓣。19例患者(61.3%)有既往头颈部放疗史。在持续性难治性口咽瘘和口底瘘的皮瓣修复方法上,股前外侧皮瓣占8例(25.8%),胸大肌皮瓣占18例(58.1%),腓骨皮瓣占3例(9.7%),所有皮瓣术后均成活。并发症发生率为38.7%(12/31),以肺部感染和轻微术区伤口裂开最为常见,随访期间患者总生存率为58.1%(18/31)。经Cox多因素分析,与总生存率相关的预后因素包括并发症(P=0.043)、瘘管形成至修补修复的时间间隔(P=0.025)。结论:对于难治性持续性口底瘘或口咽瘘的病例,清创及皮瓣修复手术具有挑战性,需要详细周密的手术计划和熟练的修复重建技术方能完成。

PURPOSE: Orocutaneous or oropharyngeal fistulas may develop after extensive surgery in the head and neck region. This paper described our experiences in applying salvage secondary or tertiary reconstructions in these situations.METHODS: A retrospective study was performed based on the 10-year experiences of secondary or tertiary reconstruc-tions for correction of persistent post-reconstructive orocutaneous or oropharyngocutaneous fistulas in our institution. Thir-ty-one cases were considered as eligible. The possible causes for these fistulas were recorded. The salvage reconstructive approaches were summarized, while related complications and follow-up outcomes were reported as well. Multivariate sta-tistical analyses for the survival-related factors were performed using SPSS 25 software package. RESULTS: Among all these cases, 19 cases(61.3%) were with post-reconstructive orocutanenous fistulas, while 12(38.7%) were with oropharyn-gocutaneous fistulas. Anterolateral thigh flaps(n=15, 48.4%) were the most used flaps in the failed prior operations. Most of the cases(n=19, 61.3%) were with histories of prior irradiation. As for the specific salvage reconstructive approaches, 8 cases(25.8%) were re-reconstructed with anterolateral thigh free flaps, while 18(58.1%) were with pectoralis major myocuta-neous flaps and 3(9.7%) with fibular flaps, respectively. All re-reconstructive flaps survived postoperatively. Complication rate reached 38.7%(12/31),with pulmonary infections and minor wound dehiscence representing the most likely ones. The overall survival rate reached 58.1%(18/31) calculated at recent follow-ups. CONCLUSIONS: Secondary or tertiary reconstructions for these cases are challenging. Careful planning and considerable expertise in re-reconstructive surgery are both required for successful management of these serious complications.