喉切除术后咽瘘的预防和治疗

目的 本文讨论了减少喉切除术后咽瘘发生的外科技巧和围手术期处理。方法 共对365例经由喉全切除术和喉大部分切除术治疗的喉恶性肿瘤病例的临床资料进行分析,其中喉全切除术333例,喉大部分切除术32例。结果 365例喉切除术后28例发生咽瘘,发生率为7.7％;其中喉全切除术后27例发生咽瘘,发生率8.1%;喉大部分切除发音管重建术后1例发生咽瘘,发生率3.1％。结论 采用喉咽食管黏膜分层缝合方式,以及术后颈部持续负压引流对于降低咽瘘发生率关系密切。喉大部分切除发音管重建术的咽瘘发生率低于喉全切除术,可能与喉大部分切除保留一侧梨状窝黏膜,喉咽黏膜缺损较小有关。     

晚期喉咽癌和喉癌全喉切除术后咽皮肤瘘

目的:探讨晚期喉咽癌和喉癌患者施行全喉切除术后咽皮肤瘘的位置、易患因素、处置及其结果.方法:回顾性分析因喉咽癌或喉癌施行全喉切除术的198例患者的资料,分析多因素对咽皮肤瘘形成的影响.结果:发生咽皮肤瘘患者33例(16.7%),内瘘口位于黏膜吻合口上段23例(69.7%),下段7例(21.2%),中段3例(9.1%);喉咽癌与喉癌的咽皮肤瘘发生率分别为24.7%和11.6%,其差异具有统计学意义(P<0.05);术后持续发热>5 d与≤5 d者咽皮肤瘘的发生率差异具有统计学意义(P<0.01);28例通过保守治疗痊愈,5例手术修复.结论:全喉切除术后咽皮肤瘘内瘘口多发生于舌根处和气管造瘘后上方,肿瘤部位和术后发热是咽皮肤瘘形成的重要易患因素.     

全喉切除术后咽瘘的原因分析与防治措施

目的探讨全喉切除术后咽瘘发生的易感因素、治疗方法及预防措施。方法收集2000年1月～2011年12月行全喉切除术患者114例。对可能影响咽瘘发生的一系列因素包括年龄、术前放疗、颈廓清术范围、肿瘤位置和肿瘤临床分期等进行了回顾性研究。结果术后12例患者发生咽瘘(10.5%),7例咽瘘患者的愈合需要外科治疗干预,其中6例通过咽部黏膜组织的直接缝合而达到治愈,1例行胸大肌皮瓣移植术;另5例通过局部换药、加压包扎等保守方法,瘘口治愈闭合。所有患者均随访2个月以上。结论文献中关于咽瘘发生的相关因素虽存有很多的争议,但研究表明血红蛋白水平,是否有糖尿病,肿瘤位置,肿瘤TNM分级及临床分期与咽瘘发生密切相关。大部分患者的咽瘘通过保守换药治疗,必要时局部直接清创缝合的方法可以达到治愈的效果。     

湿性愈合理论应用于咽瘘患者伤口的护理体会

目的 探讨并总结湿性愈合理论应用于全喉切除术后并发咽瘘患者的伤口的护理方法.方法 对7例全喉切除术后并发咽瘘患者的伤口情况及全身情况进行全面评估,由国际造口治疗师按照湿性愈合理论,根据伤口不同阶段的特点选择合适的湿性愈合敷料,首先清洗伤口,并在炎症期、增生期及组织修复期针对伤口特点进行相应的处置,再结合全身治疗对患者实...     

喉癌全喉切除术后咽瘘的原因分析

目的探讨喉癌患者行全喉切除术后发生咽瘘的原因,以预防或降低咽瘘的发生率,提高喉癌术后切口的愈合率.方法回顾分析141例喉癌患者行全喉切除术后发生咽瘘的原因.结果141例患者咽瘘发生率为27.66%,与手术时间,拔除胃管时间,术前有无合并感染,以及抗生素的应用有关.结论喉癌术后发生咽瘘的原因有多重性,避免相关因素,能有效降低咽瘘的发生率,提高患者术后生存质量.     

咽食管括约肌切开术在喉全切除术后发音重建中的作用

目的：探讨咽食管括约肌切开术对减少咽食管括约肌失弛缓对喉全切除术后安装Blom-Singer发音管发音重建的影响。方法：喉全切除术后，咽食管括约肌收缩或是痉挛都会不同程度地影响食管的气流并阻碍发音。咽食管括约肌的解剖位置是环咽肌以及其上的下咽缩肌的一部分和颈段食管上段的一部分。手术操作是在喉全切除术中、术后于气管造瘘口外上方切除长5cm，宽1cm的咽食管括约肌。结果：33例喉全切除术的患者进行咽食管括约肌切开术后有32例发音成功，发音重建的成功率是97％。其中包括12例喉全切除术中I期进行环咽肌切开术，21例是Ⅱ期进行咽食管括约肌切开术的，后者又有9例是安装Blom-Singer发音管后发音不能再行咽食管括约肌切开术的。患者3年存活25例，5年存活18例。同期行喉全切除术和咽食管括约肌切开术的12例患者，Kaplan-Meier法统计3年生存率81．82％，5年生存率42．86％。结论：咽食管括约肌切开术能提高Blom-Singer发音管发音重建的成功率。     

线型闭合器在喉全切除术中的应用

目的 评价线型闭合器在喉全切除术中关闭喉咽腔黏膜的临床应用价值.方法 2010年8月至2011年12月16例喉癌患者行喉全切除术中应用线型闭合器关闭喉咽腔黏膜,其中放疗后未控2例,放疗后复发4例,初治10例.当线型闭合器关闭喉咽腔黏膜后,将亚甲蓝液体从鼻咽通气管注入喉咽腔,检查吻合口有无渗漏.结果 16例患者术中喉咽腔注入亚甲蓝检查吻合口,15例无渗漏;1例有轻微渗漏,缝合后愈合良好,术后未发生咽痿.无患者中转开放手术.所有患者外科切缘均为阴性.1例放疗70 Gy后失败的患者出现轻微咽瘘,保守治疗后痊愈.应用线型闭合器关闭喉咽腔黏膜与传统手工缝合相比,可以节省手工缝合喉咽腔的手术时间大约45 min,咽瘘发生率为6.25％ (1/16).结论 用线型闭合器关闭喉咽腔黏膜操作简单、可靠、实用,避免手术野的污染,节省手术时间,降低咽瘘发生率,值得临床推广应用.     

皮瓣打钉术在喉全切除术中的应用

目的探讨皮瓣打钉术预防咽瘘的价值。方法为喉全切除术8例应用皮瓣打钉术缝合切口,并 与同期未行此术的喉全切除术11例对照。结果前者术后48h术野平均引流量及术后咽瘘发生率均显著低 于后者(P<0.05)。结论皮瓣打钉术是预防咽瘘的有效办法。     

喉全切除术在治疗中晚期喉癌中的应用

目的:探讨喉全切除术治疗中、晚期喉癌的疗效。方法:对573例喉癌患者行喉全切除术,声门上型370例,声门型90例,跨声门型75例,声门下型21例,放疗后复发17例。其中143例行单纯喉全切除术,430例同期行颈廓清术(单侧239例,双侧191例)。在喉全切除术中行气管外口造大孔术,共308例。结果:3、5及10年生存率分别为69.5%(398/573),61.1%(350/573),46.3%(149/322);220例死亡病例中,45.0%(99/220)死于局部复发;22.3%(49/220)死于颈部转移。术腔感染和咽瘘的发生率分别为12.2%,5.2%。16.6%气管外口造大孔术患者气管外口再度狭窄需行Ⅱ期气管外口扩大术或戴套管维持呼吸。13.6%的患者可以行喉部分切除术,由于不同的原因行喉全切除术。结论:喉全切除术作为治疗中、晚期喉癌的主要手段,其适应证随喉癌外科技术的发展而逐渐缩小。在采取积极的颈廓清术情况下,局部复发是主要的死亡原因。     

全喉切除术后咽瘘病因探讨

目的 :探讨全喉切除手术后咽瘘发生的原因。方法 :对 1983～ 1998年间行全喉切除手术的 12 5例患者的临床资料进行回顾性分析 ,并应用 SAS软件进行单因素和多因素统计处理。结果 :12 5例患者中有 2 0例(16 % )发生术后咽瘘 ,单因素分析表明 ,临床 T分期、肿瘤类型、放疗剂量、手术中输血及手术时间等 5个因素与咽瘘发生有关 ;L ogistic模型全因素分析显示 ,临床 T分期和放疗剂量与咽瘘发生有关 ,但术前放疗也可能是一个导致咽瘘的因素 (P =0 .0 5 6 6 ) ;L ogistic模型逐步回归分析显示 ,临床 T分期和手术时间是导致咽瘘的相关因素。结论 :临床 T分期、手术时间这两个因素与咽瘘的发生密切相关 ,术前放疗剂量和是否术前放疗也是影响咽瘘发生的相关因素。对于晚期肿瘤 ,术前经过放疗且放疗剂量较大的患者 ,术前应估计到发生咽瘘的可能 ;术中仔细缝合 ,提高手术的熟练程度 ,缩短手术时间 ,可减少咽瘘的发生。     

喉癌术后咽瘘发生的相关因素分析

目的探讨喉癌切除术后咽瘘发生的相关因素。方法回顾性总结2012年1月-2012年12月首次住院的124例喉癌手术患者的临床资料,应用SASS 9.2软件对影响咽瘘的因素进行统计学分析。结果 124例喉癌患者中12例（9.7%）发生术后咽瘘,所有咽瘘患者均经保守治疗后瘘口愈合。结论单因素分析表明慢性病、术前营养状况、术前气管切开、术前放疗、肿瘤分型、临床分期、手术时间、手术方式、同期颈廓清术及术后感染等因素与咽瘘发生有关;多因素分析表明同期颈廓清术、肿瘤分型及慢性病与咽瘘发生有关。     

改良负压封闭引流装置在难治性咽瘘治疗中的应用

目的 探讨改良负压封闭引流(VSD)装置在难治性咽瘘治疗中的应用。 方法 两例患者诊断分别为下咽癌(环后区, T2N2M0)和喉癌(声门区, T1N0M0),年龄为48岁和62岁,行下咽肿瘤切除术和支撑喉镜下二氧化碳激光声带部分切除术,术后下咽癌患者行放化疗,喉癌患者行放疗,分别于同步放化疗后5 d、放疗后146 d出现难治性咽瘘,应用自制改良VSD装置治疗,对两例患者咽瘘愈合过程进行观察。 结果 2例患者使用改良VSD装置治疗后分别于第6天、第3天瘘口红肿消退,第58天、第38天创面明显缩小,后行咽瘘修补术,第74天、第63天咽瘘愈合。 结论 经过改良的VSD装置可以根据创面情况灵活应用,有助于头颈部肿瘤治疗后并发的难治性咽瘘的治疗。     

Repair of post-laryngectomy pharyngocutaneous fistulas using a pectoralis major flap

IntroductionThe pectoralis major flap is a reconstructive option to consider in the treatment of pharyngocutaneous fistula after a total laryngectomy. There are not large studies assessing variables related to pharyngocutaneous fistula recurrence after removal of the larynx. Our objectives were to review the results obtained with this type of treatment when pharyngocutaneous fistula appears in laryngectomized patients, and to evaluate variables related to the results.MethodsWe retrospectively reviewed our results using either a myocutaneous or fasciomuscular pectoralis major flap to repair pharyngocutaneous fistula in 50 patients.ResultsThere were no cases of flap necrosis. Oral intake after fistula repair with a pectoralis major flap was restored in 94% of cases. Fistula recurrence occurred in 22 cases (44%), and it was associated with a lengthening of the hospital stay. Performing the flap as an emergency procedure was associated with a significantly higher risk of fistula recurrence. Hospital stay was significantly shorter when a salivary tube was placed.ConclusionsThe pectoralis major flap is a useful approach to repair pharyngocutaneous fistula. Placing salivary tubes during fistula repair significantly reduces hospital stay and complication severity in case of pharyngocutaneous fistula recurrence.     

喉全切除术后咽瘘影响因素的Meta分析

目的 系统评价喉恶性肿瘤喉全切除术后咽瘘发生的危险因素.方法 检索MEDLINE、EMBASE数据库和中国生物医学文献数据库、中国学术期刊全文数据库和重庆维普数据库,手工检索所有纳入试验的参考文献,采用RevMan4.2软件对纳入文献的数据进行汇总分析(meta-analysis,Meta分析).结果 共纳入44个临床病例研究,病例总数6917,咽瘘发生例数1004.Meta分析结果显示感染、拔胃管时间、病变部位、术中输血、术前放疗、手术时间、术前气管切开、手术切缘、合并慢性全身性疾病以及T分级与喉全切除术后咽瘘发生有关.结论 感染、拔胃管时间过早或过晚、原发肿瘤部位位于声门上和跨声门区、术中输血、术前放疗、手术时间超过4小时、术前气管切开、手术切缘瘤细胞阳性、合并慢性全身性疾病以及局部晚期肿瘤(T3、T4级)是喉全切除术后咽瘘发生的危险因素.     

Free tissue reconstruction of the hypopharynx after organ preservation therapy: analysis of wound complications

PURPOSE: Previous series have demonstrated a 77% rate of major wound complications in salvage surgery of the larynx following organ preservation protocols. The purpose of this study is to determine the incidence of wound complications in these patients when microvascular free tissue transfers are used for reconstruction of the hypopharynx. DESIGN: Retrospective case series. SETTING: Academic tertiary care center. PATIENTS AND METHOD: We reviewed the medical records of 42 patients with stage III and IV laryngeal squamous cell carcinoma treated with an organ-sparing protocol consisting of induction chemotherapy followed by definitive radiation therapy. Ten of these patients who required surgical salvage were reconstructed using radial forearm free tissue or lateral arm transfer and constitute the study group. MAIN OUTCOME MEASURES: Wound complications. RESULTS: Wound complications occurred in 2 patients (20%) undergoing free flap reconstruction of the hypopharynx after organ preservation protocols, which was significantly lower (P =.003) than previous reports using other forms of closure and/or reconstruction. One patient in this study group had a small pharyngocutaneous fistula that resolved with conservative therapy after 1 week. The other patient had a larger pharyngocutaneous fistula that resolved over 3 weeks. The mean interval from completion of the chemoradiation regimen to surgery was 21.3 months (range, 2-60 mo). The average free tissue flap size was 94.3 cm(2) (range, 45-165 cm(2)). Average harvest and ischemia times were 59 minutes (range, 41-87 min) and 187.7 minutes (range, 120-240 min), respectively. All flaps survived, and one patient had a minor donor site wound dehiscence. The average hospital stay was 7.8 days. There were no mortalities in this series. CONCLUSIONS: Our results suggest that free tissue transfer reconstruction of the hypopharynx is the preferred method of reconstruction following combined chemotherapy and radiation therapy protocols. Surgical complications are significantly reduced and hospital stays are minimized.     

Negative-pressure wound therapy for the treatment of pharyngocutaneous fistula

IntroductionPharyngocutaneous fistula is a well-known complication of head and neck cancer surgery. The purpose of this study was to determine the value of negative-pressure wound therapy (NPWT) for the treatment of these fistulas. NPWT is used in many fields of medicine, but its use in otorhinolaryngology has been rarely reported. NPWT is a cost-effective means to accelerate wound healing.Patients and methodsA single-centre retrospective study was conducted on 7 patients with pharyngocutaneous fistula following surgery for squamous cell carcinoma between January 2011 and April 2013. These fistulas were treated by negative-pressure wound therapy (NPWT).ResultsThis series comprised seven male patients with a mean age of 65 years and 9 months. The mean duration of treatment was 23 days (range: 11 to 42 days). Two patients had a history of radiotherapy for pharyngolaryngeal cancer. Negative-pressure wound therapy achieved cure of the fistula in all patients with satisfactory acceptability. Mean follow-up was 10 months (range: 6 months to 2 years).ConclusionNegative-pressure wound therapy represents a valuable treatment option in certain settings for the management of pharyngocutaneous fistula following head and neck cancer surgery.     

Early oral feeding following total laryngectomy

OBJECTIVES: The time to begin oral feeding after total laryngectomy remains a subject of debate among head and neck surgeons. The prevailing assumption is that early initiation of oral feeding may cause pharyngocutaneous fistula; thus, the common practice of initiating oral feeding after a period of 7 to 10 days. The objective of the study was to demonstrate the feasibility and safety of oral feeding 48 hours after total laryngectomy. STUDY DESIGN: Two-part study includes, first, a sequential study and, second, a prospective analysis of our practice. METHODS: Patients undergoing total laryngectomy without partial pharyngectomy or radiation treatment (except irradiation through small ports for a T1 or T2 glottic carcinoma) were included. In the first, sequential part of the study (part I), a group of 18 patients who were fed 7 to 10 days after total laryngectomy (control group) was compared with a group of 20 patients who received oral feeding within 48 hours. To confirm the results of part I, a prospective analysis of this practice was conducted (part II) in which 35 additional patients who met the above criteria were fed within 48 hours after surgery. RESULTS: In part I, pharyngocutaneous fistula occurred in one patient (5%) in the early feeding group and in two patients (11%) in the control group. In part II, pharyngocutaneous fistula occurred in one patient (2.8%). Overall, fistula occurred in two patients in the combined early feeding group (3.6%). This rate of pharyngocutaneous fistula compares favorably with the fistula rate in the control group of 18 patients. Pharyngeal stricture that required dilation occurred in three of our patients in the study group and two in the control group (5.5% vs. 11%, respectively). The length of hospital stay was significantly shortened from 12 to 7 days. CONCLUSION: Our results indicate that in this patient population initiation of oral feeding 48 hours after total laryngectomy is a safe clinical practice.     

Pharyngeal Reconstruction After Laryngectomy

A method of pharyngeal reconstruction following laryngectomy is described. In 44 successive laryngectomies using this technique, no postoperative pharyngocutaneous fistulas occurred. Ten of the patients had received full courses of radiation therapy prior to the surgical procedure and had recurrent carcinomas. Other reports have noted that laryngectomy following full courses of “unplanned preoperative” radiation therapy is usually associated with a high incidence of postoperative pharyngeal fistula. The pharyngeal fistula problem, and the pharyngeal repair that was used in our series, are discussed. The pharynx was closed carefully in three layers with fine, absorbable sutures, and a submucosal inverting technique was used for the important mucous membrane closure. Tube feedings were used for two weeks after surgery. A high incidence of pharyngocutaneous fistula after laryngectomy in the irradiated patient can be prevented.     

Modified Continuous Mucosal Connell Suture for the Pharyngeal Closure After Total Laryngectomy: Zipper Suture

Objectives

Pharyngocutaneous fistula is a serious complication after total laryngectomy, and there are some risk factors stated in the literature. The surgical suture techniques are not studied so much. The aim of this study is to evaluate the effectiveness of ''modified continuous mucosal Connell suture'' on the incidence of pharyngocutaneous fistula after total laryngectomy.

Methods

This is a retrospective case series study based at a tertiary center with 31 patients who underwent total laryngectomy between July 2011 and December 2013. Pharyngocutaneous fistula formation after total laryngectomy was evaluated with the patients who underwent modified continuous mucosal Connell suture for pharyngeal repair.

Results

Pharyngocutaneous fistula was observed in only one patient (3.2%) who had a history of previous radiotherapy, and it was spontaneously healed within 6 days by conservative treatment.

Conclusion

We defined a new suture technique for the pharyngeal repair after total laryngectomy. This technique is a simple modification of continuous mucosal Connell suture. We named it as zipper suture. It is effective in the prevention of pharyngocutaneous fistula for pharyngeal reconstruction after total laryngectomy.     

Early oral feeding following total laryngectomy

INTRODUCTION: Pharyngocutaneous fistula is one of the most common nonfatal laryngectomy complications (7.6% to 65% of all total patients). Preoperative radiotherapy, advanced tumor stage, poor preoperative medical status, and concomitant pharyngectomy are usually accepted causative factors in fistula formation. Delay of oral feeding is a common practice used by head and neck surgeons to prevent the development of pharyngocutaneous fistula. In this article we analyze our experience with special emphasis given to the early start of postoperative feeding. PATIENTS AND METHODS: The postoperative records of 48 patients who had undergone total laryngectomy or total laryngopharyngectomy were reviewed. All patients were orally fed with water and clear liquids on the first postoperative day. The patients were closely observed at every feeding attempt, and if any sign of fistula was noted, a nasogastric tube was inserted. Preoperative radiotherapy, stage of disease, tumor differentiation, and pharyngectomy with total laryngectomy were statistically analyzed as potential risk factors contributing to fistula formation. The Fisher exact test was used to analyze the data. RESULTS: The overall pharyngocutaneous fistula rate was 12.5% in our series. The only statistically significant factor that increased the rate of fistula formation was resection of pharyngeal mucosa as an extension of total laryngectomy. Other parameters failed to show any statistical significance in development of this complication. CONCLUSION: Evaluation of fistula incidence in our series indicates that initiating oral feeding on the first postoperative day does not contribute to fistula formation. Additionally, the relatively shortened hospital stay and elimination of the psychologic and traumatic side effects of tube feeding are benefits of this approach that should be studied in further prospective quality-of-life studies.