游离股前外侧皮瓣和游离空肠重建下咽颈段食管的疗效

Efficacy of free anterolateral thigh flap and free jejunum in reconstruction for hypopharyngeal and cervical esophagus

目的:下咽颈段食管癌因其解剖位置较为隐秘,大多数患者就诊时即为晚期。目前,治疗该疾病多采用外科手术切除加放射治疗(以下简称放疗)为主的综合治疗方案,但由于手术切除范围较为广泛,常会导致患者下咽及颈段食管切除后大范围的环形缺损,因此肿瘤切除后的上消化道重建至关重要。本研究分别采用游离股前外侧皮瓣(free anterolateral thigh flap,ALT)和游离空肠(free jejunum,FJ)重建下咽颈段食管,探讨2种方法重建下咽颈段食管癌术后上消化道缺损的疗效及优缺点。方法:回顾性分析2004年1月至2016年1月中南大学湘雅二医院耳鼻咽喉头颈外科42例临床IV期下咽颈段食管癌患者的临床资料。所有患者行全喉全下咽及颈段食管的切除,肿瘤切除术后所致的环周缺损分别以ALT(22例)及FJ(20例)进行一期修复。4例术前已接受放疗和化学药物治疗(以下简称化疗)的ALT组患者术后未再行放疗和化疗,其余38例患者均在术后4~8周开始行辅助放、化疗。对所有患者采取电话或门诊复查的方式进行随访,随访截止时间为2021年1月。比较2组患者术后及放疗后并发症的发生率与术后的生存率之间的差异。采用Fisher检验分析组间个体特征的差异,采用χ检验分析组间各种并发症发生的差异,采用KaplanMeier生存曲线方法计算3年及5年总生存率。结果:ALT组术后的并发症主要为吻合口瘘、乳糜漏及供区皮下血肿,放疗后的并发症主要是吻合口狭窄;而FJ组术后的并发症主要为乳糜漏、肠梗阻及肠瘘,放疗后的并发症主要为吻合口瘘及组织瓣坏死。ALT组和FJ组术后分别发生7例和5例并发症(P=0.625);放疗后分别有3例和4例发生并发症(P=0.563)。ALT组和FJ组的3年总生存率分别为52.9%和46.7%,5年总生存率分别为35.1%和31.9%,2组生存率之间的差异无统计学意义(P=0.53)。ALT组放疗后发生吻合口狭窄的病例稍多于FJ组(P=0.097);FJ组放疗后发生空肠坏死及吻合口瘘的例数稍多于ALT组(P=0.066)。结论:采用ALT和FJ重建下咽颈段食道在术后及放疗后并发症发生情况、3年及5年生存率方面无明显差别。但ALT重建可能更易发生吻合口狭窄,而FJ重建可能不能耐受较大剂量的放疗。ALT和FJ均为下咽颈段食管重建的有效方法,临床上应根据其相应的优缺点慎重选择重建方式。

Objective:Because of its peculiar anatomical location,most patients with hypopharyngeal and cervical esophageal cancer are at advanced stage when they visit the hospital.At present,the treatment for hypopharyngeal and cervical esophageal cancer is primarily surgical resection and radiotherapy.However,due to the wide range of surgical resection,it can often lead to a large range of annular defects.Therefore,the upper digestive tract reconstruction after tumor resection is very important.We use the free anterolateral thigh flap(ALT)and free jejunum(FJ)transfer to reconstruct the hypopharyngeal and cervical esophagus,and to investigate the effect of both reconstruction methods on upper gastrointestinal tract defects.Methods:A retrospective analysis was conducted to investigate the clinical data of 42patients with hypopharyngeal and cervical esophageal cancer(Clinical Stage IV)from Jan.2004 to Jan.2016 in the Second Xiangya Hospital of Central South University.All patients underwent total laryngopharyngectomy and cervical esophageal resection.The hypopharyngeal circumferential and cervical esophageal defects were reconstructed with free ALT(n=22)or FJ(n=20).Four patients who underwent radiotherapy and chemotherapy before surgery did not receive radiotherapy or chemotherapy after surgery.The remaining 38 patients underwent postoperative radiotherapy and chemotherapy.All patients were followed up by telephone or outpatient review,with a follow-up deadline in Jan.2021.We compared the differences between the 2 groups in postoperative complications,radiotherapy complications,and survival rate.The differences in individual characteristics between 2 groups were analyzed using Fisher test.The differences in postoperative and radiotherapy complications between two groups were analyzed usingχ~2 test.The 3-and 5-year overall survival rates were calculated using Kaplan-Meier survival curve method.Results:In the ALT group,the postoperative complications mainly included anastomotic fistula,chylous fistula and subcutaneous hematoma of the donor site.The radiotherapy complication was anastomotic stenosis.However,in the FJ group,the postoperative complications mainly included chylous fistula,intestinal obstruction,and intestinal fistula.The radiotherapy complications mainly contained anastomotic fistula and tissue flap necrosis.The cases of postoperative complications in the ALT group and the FJ group were7 and 5,respectively(P=0.625),and the cases of radiotherapy complications were 3 and 4,respectively(P=0.563).The 3-year overall survival rates in the ALT group and the FJ group were 52.9%and 46.7%,respectively,and the 5-year total survival rates were 35.1%and31.9%,respectively(P=0.53).The cases of anastomotic stenosis after radiotherapy in the ALT group were more than those in the FJ group(P=0.097).However,the cases of jejunal necrosis and anastomotic fistula after radiotherapy in the FJ group were more than those in the ALT group(P=0.066).Conclusion:There are no significant differences in postoperative and radiotherapy complications and 3-and 5-year survival rates between the ALT group and the FJ group.The reconstruction with ALT is prone to develop anastomotic stricture.The reconstruction with FJ cannot withstand high-dose radiotherapy.The ALT and FJ are effective methods in the reconstruction of hypopharynx and cervical esophagus.The treatment protocol should be carefully chosen based on its advantages and disadvantages of these 2 methods.