应用喉气管重建喉咽与颈段食管1例

修复喉咽及颈段食管闭锁是一个复杂的问题,本例采用改良的BillrothⅡ氏胃大部切除术吻合原理,利用喉气管瓣重建下咽及上端食管,避免了传统方法常见的并发症,现报道如下。1临床资料患者,男,52岁,因喉咽癌术后3年,空肠造瘘术后7个月,吞咽困难4个月入院。患者3年前因喉咽后壁鳞状细胞癌在外院行"喉咽癌切除+双颈淋巴结清扫+气管切开术",术后不能大口进食,其后吞咽困难逐渐加重,遂行"空肠造瘘术",并予放化疗。入院查体:体重41.6 kg,     

气管开窗术1例报告

对需要做气管切开但不愿带气管套管的病人，可行永久性气管切开术。受Fee和Ward氏气管开窗术(permanent tracheal fenestration)的启发，用该术式治疗双侧喉返神经麻痹者，既解除病人长期带气管套管的麻烦，又保留其发音功能，手术简便，随访1年多，无造瘘口狭窄，现报道如下。     

应用会厌部分下移和颈前带状肌行喉重建术

目的 探讨喉扩大切除术后喉功能重建的方法。方法 1998年9月～1999年10月22例经过选择的T2、T3期声门型喉癌，行喉扩大切除术后将会厌部分下移和颈前带状肌修复喉腔和喉支架，重建喉功能。根据病情分别行同期同侧或双侧分区性颈清扫术，术后行放射治疗。结果 20例术后20d内恢复正常饮食；拔除气管套管，恢复了喉的全部功能，拔管率90．9％(20／22)。1例咽瘘，1个月后恢复经口进食；1例再次手术后恢复正常饮食。全部患者发音清晰，术后1～6个月纤维喉镜检查，20例喉入口形成括约瓣。Ⅱ期和Ⅲ期的3年生存率分别为9／9和92．3％(12／13)。1例3年后对侧声带肿瘤复发，行喉全切除术。结论 应用会厌部分下移修复支架，可扩大喉腔和重建喉入口，减轻会厌下拉时的张力，避免损伤黏膜。颈前带状肌修复喉腔，弥补只用会厌整复喉腔和支架材料不足的缺点，而且取材方便，组织丰富。二者联合应用，对恢复喉功能和提高喉癌患者的生活质量有一定的作用。     

下咽癌术后下咽缺损修复方法的选择

目的 :探讨下咽癌术后下咽缺损Ⅰ期修复的方法。方法与结果 :对 31例下咽癌术后下咽缺损患者行Ⅰ期修复 ,其中下咽、喉和食管颈段切除加胃造瘘术 1例 ,无咽瘘发生 ;直接缝合修复 17例 ,吞咽功能良好 15例 (88.2 % ) ;组织移植修复 13例 ,吞咽功能良好 6例 (46 .2 % )。同时行喉功能保存性手术 14例 ,吞咽功能良好9例 ,均为直接缝合修复病例 ;吞咽功能差 5例 ,2例为直接缝合修复病例 ,3例为组织移植修复病例 ,均发生误吸。结论 :直接缝合大多数吞咽功能良好。对下咽全缺损的修复 ,胃肠上徙比肌皮瓣优越。同时行喉功能保存性手术 ,必须严格选择病例 ,并把误吸的预防放在首位。下咽、喉和食管颈段切除加胃造瘘术有助于扩大下咽癌的手术适应证。     

喉体上前徙术治疗外伤性会厌功能障碍

目的 :探讨外伤性会厌功能障碍引起的吞咽呛咳的外科治疗途径。方法 :对 3例外伤性会厌部分缺失或完全缺失的患者 ,用喉上前徙术 ,即在清创缝合的同时将其喉体上抬 0 .5～ 0 .8cm、前倾 0 .6～ 0 .8cm ,以改变食管入口与声门的相应空间位置。结果 :术后随访 0 .5～ 2年 ,3例进食、饮水均未出现吞咽呛咳及误吸情况。结论 :该术式用于治疗会厌部分或全部缺失或会厌功能障碍较之传统的清创缝合术有着更好的应用价值     

喉切除重建"会厌"防止发声口的误咽

目的 :探讨全喉切除防止气管 食管通路发声口误咽的方法。方法 :对 2 6例喉鳞癌患者行全喉切除 ,保留带蒂环状软骨瓣并修成会厌形薄片 ;改良气管 食管通路发声口 ;将会厌形骨片固定在发声口上方形成“檐状会厌” ;缝合气管断端并向后挤压“檐状会厌”凸入食管腔中。结果 :2 6例在术后 3、7或 12d拔除鼻饲管 ,经6～ 11d常规进食适应后均无误咽。随访 2～ 5年 ,2 1例无误咽 ,3例失访 ,2例癌复发。结论 :环状软骨瓣重建“檐状会厌”能有效防止全喉切除术后气管 食管通路发声口的误咽。     

用肉毒杆菌毒素A治疗慢性误吸使喉关闭术成功

由于神经功能紊乱可使喉括约肌机能失调，产生持续性误吸，甚至危及生命。治疗误吸有各种手术方法和保守疗法。手术治疗目的是将气道与消化道隔离，有采用全喉切除永久性气管造瘘术，但更好的是既达到气管支气管与食管隔离的目的又保留喉的手术疗法，就是喉关闭术，对于治...     

气管切开术倒“U”形气管粘膜软骨瓣的应用

1970年Dukes首先报道在气管切开术中应用倒“U”形气管粘膜软骨瓣取代传统的垂直切口，此种造口法可减少造口处狭窄和明显减少术后脱管。我们在15年间（1980年5月～1995年4月）应用本术式气管切开术，现将有记录可查的82例小结如下。一、临床资料82例中男59例，女23例，年龄1～83岁，平均年龄42岁。其中喉癌、喉部肿瘤切除术20例；鼻咽血管纤维瘤、鼻窦癌、咽旁间隙巨大肿瘤切除术15例；各种原因昏迷、呼吸肌麻痹14例；喉炎、喉水肿急性喉梗阻8例；颈椎骨折3例；喉外伤行探查术5例；头、面部烧伤4例；喉狭窄手术3例；破伤风喉痉挛2例；气管…     

喉次全切除会厌及胸舌骨肌筋膜瓣喉发声及呼吸功能重建

目的 探讨会厌及胸舌骨肌筋膜瓣在喉次全切除喉发声及呼吸功能重建术中的应用价值。方法 对7例T3N0M0声门型喉癌患者进行喉次全切除术，以会厌及胸舌骨肌筋膜瓣重建喉功能。结果 患者均于术后10-12天拔除气管套管及鼻饲管恢复正常饮食，无明显进食呛咳；均恢复正常语言交流，未出现喉腔狭窄和发声失败者。结论 喉次全切除后会厌及胸舌骨肌筋膜瓣是重建喉发声及呼吸功能较为理想的方法。     

喉全切除术后喉咽闭锁

1 临床资料 患者,男,60岁,因喉癌喉全切除术后1年,喉咽闭锁不能进食6个月为主诉入院。患者1年前因喉癌于外院行喉全切除术及颈淋巴结清扫术,术后出现感染咽瘘并行局部清创、换药及颈部局部皮瓣转移喉咽修复、颏下皮瓣转移颈部缺损修复术治疗,咽瘘愈合后行根治性放疗,8个月前放疗结束,出现喉咽狭窄,仅能进水,于外院行胃造瘘术进行营养,逐渐加重,6个月前喉咽完全闭锁不能进食,于我院就诊,以喉癌术后喉咽闭锁收入院。患者一般状态良好,     

Airway interruption in encephalopathic children: a clinical and histological analysis

Severe, incessant aspiration can be a most troublesome sequel to the already tragic problem of a vegetative mental state in a previously normal child. Three patients, aged 2 to 4 years, underwent surgery to treat their aspiration. A different type of procedure was used for each patient: cord closure combined with an epiglottic flap, cord closure alone, and a laryngeal stent. Laryngeal histopathology of a case is presented for the first time; findings suggest that the theoretical reversibility of that particular type of procedure could prove formidable. Clinically, the immediate cessation of aspiration has provided all parents and health care personnel with a surprising sense of gratification and has enabled each child to be transferred to a less-costly care facility or to home.     

Separation of the larynx and trachea for intractable aspiration

Aspiration becomes an intractable problem for some patients who have lost normal neurological function of the glottis. Over the long term, a cuffed tracheotomy tube is inadequate. Several methods have been developed to relieve this problem surgically. These include the use of muscle flaps, tracheoesophageal anastomosis, and use of an epiglottic flap. In this paper, we discuss these previous surgical attempts to alleviate aspiration and present our own technique, which involves creation of a tracheostome and closure of the larynx at the level of the first tracheal ring. This has been used with success in three patients. We feel this technique is less complex and results in less surgical trauma to the larynx, important factors when dealing with critically ill patients. This_ technique is theoretically reversible by re-anastomosing the trachea to the cricoid cartilage after excising the first tracheal ring.     

Simple and new surgical procedure for laryngotracheal separation in pediatrics

Objectives: In children with severe physical and mental disabilities who repeatedly develop aspiration pneumonia due to intractable aspiration, laryngotracheal separation/tracheoesophageal anastomosis or laryngotracheal separation has been performed in many institutions for the prevention of aspiration, and good results have been reported. However, families sometimes show a marked reluctance to give consent to these surgical techniques because of tracheal transection. A purpose of this study is to evaluate a new surgical procedure for laryngotracheal separation without tracheal transection. Study Design: Case‐series study. Methods: As a new, simple, less invasive surgical technique for the prevention of aspiration without tracheal transection, we performed tracheal closure (tracheal flap method) in six children. A U‐shaped flap of the tracheal anterior wall from the 2nd to the 4th/5th tracheal ring was produced, bent toward the tracheal lumen, and sutured to the tracheal posterior/lateral walls by mattress stitches for tracheal closure. In addition, the closure was covered with a cutaneous U‐shaped flap for reinforcement and a permanent tracheal stoma was constructed. Results: In all six patients, aspiration pneumonia could be prevented without severe complications. Conclusions: Tracheal closure (tracheal flap method) has effects comparable to those of other surgical techniques for the prevention of aspiration, and may be useful for aspiration prevention in children with severe physical and mental disabilities.     

Madelung病的诊断及手术治疗

目的　探讨Madelung病的诊断、外科手术方法。方法　回顾性分析2011年1月～2015年11月之间我科收住并接受手术治疗的Madelung病患者的临床资料。6例患者均为男性,年龄35～65岁,均表现为颈部项增粗,CT或MRI检查表现为大量脂肪堆积,1例CT显示伴有喉累及。均有大量嗜酒史,其中2例合并心脏、肺部或脑部疾患,1例糖耐量异常。1例因呼吸困难急诊就诊,5例均有不同程度睡眠呼吸暂停低通气综合征临床表现,所有患者均无吞咽困难。结果　6例患者均接受手术治疗,其中4例行择期双颈部增生脂肪切除术及气管切开术,1例行择期双颈部增生脂肪组织切除术,1例因呼吸困难急诊行颈前增生脂肪切除+气管切开术,术中术后均无严重并发症出现。5例择期双侧颈部手术者术者及患者均对术后颈部外形满意,并均于术后10天内拔除气管套管,1例急诊手术患者因合并心脏、肺部及脑部疾病,再次手术风险大,未再行彻底颈部增生脂肪组织切除术,因肺部同期有感染,术后第3天转入呼吸科继续治疗,出院后长期带管。随访15 d～48个月,颈部外形均可,无明显复发。所有患者术后病理诊断均为颈部脂肪组织瘤样增生或脂肪瘤样改变。结论　Madelung病是一种脂肪代谢障碍引起的脂肪组织弥漫性、对称性沉积于颈肩部筋膜间隙的良性疾病,常发生于有嗜酒史的男性,发病部位有特征性,易合并其他内科疾病,手术治疗是以改善外形及功能为目的,手术切除效果良好,术中注意保护颈部重要神经血管,以免损伤。术中选取合适的解剖标志为参考有利于手术的顺利进行。     

Study on postoperative diastasis of epiglottic closure procedure (Biller method)

Among surgical treatment for severe aspiration pneumonia, the epiglottic closure procedure, which makes phonation possible, is very useful, but sewing the epiglottis has resulted in postoperative diastasis, and improvement of restitution by epiglottic cartilage elasticity is a problem, so we made reference of configuration and power of restitution of epiglottis clear. We classified epiglottis configurations into flat, intermediate, and omega types and studied epiglottis histology using pathological autopsy. We measured the power of restitution of epiglottis, by a type classification and by the site classification (upper, middle, and lower point) using the extracted larynx. We studied 349 cases: flat, 167 (48%), intermediate, 126 (36%), and omega, 56 (16%). In histological examination, we recognized ossification of the epiglottic cartilage with aging. For the power of restitution, we recognized a significant difference in all except intermediate and omega of upper point with reference by configuration to each point. We found that the epiglottis had different configuration. In addition, power of restitution of epiglottis was greatly involving the configuration classified in visual, and in particular, power of restitution was big in flat type. Accordingly we thought that indication of diastasis prevention procedure should have been selected by epiglottis configuration.     

改良会厌喉成形术

目的：探讨声门癌Ｔ３病变在喉大部切除后重建喉支架的手术方法。方法：３６例声门癌Ｔ３病变,在喉大部切除后施行改良会厌喉成形术;１一侧甲状软骨全乇除、会厌软骨侧向下移取代;２对侧甲状软骨部分保留,肌筋膜瓣或肌甲状软骨膜瓣修复声带;３会厌前侧缘与甲状软骨前缘对合成锐角前连合,后侧缘与对侧杓部形成后连合,会厌上缘与对侧声带形成新声门。结果：３３例拨管,３０例发声清晰、宏亮且易懂,３例发声低沉沙哑。３年和５     

会厌瓣和胸骨舌骨肌肌筋膜瓣在喉癌喉部分切除喉功能重建中的应用

目的:探讨和评价喉癌喉部分切除喉功能重建的手术方法。方法:265例喉癌患者喉部分切除术后同期采用会厌瓣、颈前胸骨舌骨肌肌筋膜瓣、会厌瓣加胸骨舌骨肌肌筋膜瓣联合修复喉缺损。其中79例同期行颈淋巴结清扫术。结果:265例患者鼻饲管于术后10~15d拔除。术后拔除气管套管218例,拔管率为82.26%。12例术后发生伤口感染,其中2例发生咽瘘。3、5年生存率分别是74.72%、70.88%。结论:喉部分切除术后应用胸骨舌骨肌肌筋膜瓣、会厌瓣Ⅰ期喉功能重建,手术操作简单,取材方便,创伤小,成活率高,手术效果好,是值得推广的手术方法。     

Intractable aspiration in a young child and its surgical management

Intractable aspiration is a life-threatening condition. The problems encountered in a young child with severe intractable aspiration due to bilateral bulbar palsy following the surgical removal of a cerebellar astrocytoma are described. The various options of surgical treatment are discussed and Sasaki's technique of triple layer closure of the larynx using a superiorly based sternohyoid muscle flap is outlined in detail.     

Surgical management of type III and IV laryngotracheoesophageal clefts: The three-layered approach

Objective

The objective of this paper is to present our surgical experience with a cohort of four infants with laryngotracheoesophageal cleft (LTEC) in order to highlight our early failures and complications and to propose a comprehensive, three-layered approach in treating stages III and IV LTEC.

Method

An IRB approved, retrospective chart review was carried out of a cohort of four cases occurring within a 2-year period of time.

Results

All patients had other significant anomalies, and the mortality rate was high: 75%. After our initial failures and difficulties with recurrent fistulas, tracheomalacia and tracheotomy dependence, we were able to achieve a successful outcome of a functional separation of the airway and the digestive tract without a tracheotomy in our last two patients. Unfortunately, both these patients died from factors not directly associated with the LTEC so long-term follow up was not possible. We now have one survivor, our second case, who is tracheotomy dependent.

Conclusion

Laryngotracheoesophageal clefts are rare congenital anomalies with high morbidity and mortality despite various forms of surgical repair. Fistulas, tracheostomy dependence, tracheomalacia, and chronic lung disease secondary to aspiration are frequent problems following LTEC repairs. We advocate an anterior approach to the cleft repair, a three-layered closure of the cleft to include an interpositional muscular flap, and a physiologic repair of the posterior larynx with a standard cartilage graft technique used in laryngotracheal reconstruction.