游离组织瓣的缺血再灌注损伤、气道管理及与口腔癌患者的预后

Ischemiareperfusion injury of free tissue flaps,airway management,and prognosis in oral cancer patients

游离组织瓣移植是口腔颌面部恶性肿瘤术后缺损修复重建的首选方案,但对于口腔颌面⁃头颈肿瘤外科医生在多个方面仍面临挑战,如缺血再灌注(ischemia⁃reperfusion,I/R)损伤、气道管理、生存质量与预后等。I/R损伤是游离组织瓣移植手术中不可避免的并发症,除了手术过程中尽量缩短血管吻合时间,可尝试应用物理干预治疗、抗氧化和活性氧(reactive oxygen species,ROS)清除剂治疗、高压氧治疗等预防和治疗游离组织瓣I/R损伤,但缺乏大规模临床随机对照试验证据进一步的佐证。口腔颌面部游离组织瓣修复患者的术后气管管理至关重要,近年来,延迟拔除气管插管被提出作为传统气管切开术的替代方案,该方法可以方便患者伤口护理、减少感染、加快患者康复,并减少血管危象的发生率;未来有望通过制定更符合延迟拔管的患者适应证和重症监护方案,提高延迟拔管的实用性和安全性。术前根据缺损类型,选择合适的游离组织瓣进行修复重建,有利于更好提高患者的生存质量和生存率。同时,对于需要术后放疗的患者,可通过术中神经吻合、放疗前口腔卫生维护、早期语音训练等方法,减少术后放疗患者的并发症,提高患者的生存质量。

Free tissue flap transplantation is the preferred option for repairing and reconstructing postoperative defects in oral and maxillofacialhead malignant tumors.However,challenges remain for oral and maxillofacialhead and neck oncology surgeons in terms of ischemiareperfusion(I/R)injury,airway management,quality of life and prognosis.I/R injury is an inevitable complication of freeflap transplantation surgery.In addition to shortening the vascular anastomosis time as much as possible during the surgical process,many studies have attempted to further prevent and treat freeflap I/R injury using physical intervention therapy,antioxidant and reactive oxygen species(ROS)scavenger therapy,hyperbaric oxygen therapy,etc.However,there is a lack of largescale clinical randomized controlled trial evidence to further support these methods.Postoperative tracheal management of patients receiving free tissue flap transplantation is very important.In recent years,delayed extubation has been proposed as an alternative to traditional tracheostomy.This method can facilitate wound care for patients,reduce infections,speed up patient recovery,and reduce the incidence of vascular crises.In the future,such management is expected to improve the practicality and safety of delayed extubation by formulating more appropriate patient selection criteria and intensive care plans.Preoperative selection of suitable free tissue flaps according to the defect for repair and reconstruction is beneficial for improving the quality of life and survival rate of patients.At the same time,for patients who require postoperative radiotherapy,reducing the complications of postoperative radiotherapy and improving the quality of life of patients can be achieved through intraoperative nerve anastomosis,preradiation oral hygiene maintenance,early speech training,and other methods.