303例下咽癌的外科治疗及组织移植修复重建术的临床分析

目的探讨下咽癌的外科治疗及术后下咽食管缺损不同组织移植Ⅰ期重建方法在下咽癌治疗中的远期疗效。方法回顾性分析1965～1998年外科治疗下咽癌患者303例，其中130例经不同组织移植重建下咽食管手术治疗(1997年UICC分期：Ⅱ期5例；Ⅲ期16例；Ⅳ期109例)，其中梨状窝区94例，咽后壁区18例，环后区18例。游离空肠15例，胃代下咽食管81例，结肠代下咽食管10例，胸大肌肌皮瓣修复20例，其他方法4例。173例下咽癌患者不需要重建(Ⅰ期7例，Ⅱ期12例，Ⅲ期51例，Ⅳ期103例)，其中梨状窝160例，咽后壁8例，环后5例。结果Kaplan-Meire法统计生存率，130例组织移植重建患者3年生存率为43．2％，5年生存率为36．4％；173例不需要组织重建患者3年生存率为59．2％，5年生存率为47．7％。各组吞咽功能良好率均在80％，以上。胃代下咽食管手术死亡率为8．6％(7／81例)；胸大肌肌皮瓣修复手术死亡率15．0％，(3／209例)；游离空肠及结肠代食管下咽无手术死亡。总手术并发症20世纪90年代之前为44．3％(35／79例)，90年代手术并发症为13．7％(7／51例)，x^2=13．457，P=0．004，差异有显著性；其中90年代胸大肌肌皮瓣修复并发症最高为18．2％(2／11例)。结论游离空肠、胃代下咽食管、胸大肌肌皮瓣修复在下咽癌的生存率、吞咽功能的恢复及手术并发症等方面均取得较好的治疗效果，是值得提倡的重建方法。     

下咽颈食段食管环周缺损修复方法的探讨

目的探讨不同手术方法修复重建下咽颈食管环周缺损的适应证，对不同方法的优缺点进行比较。方法对1993年6月至2006年6月期间收治的72例下咽颈食管区肿瘤进行手术切除，并根据肿瘤切除术后缺损的范围，采用胸大肌肌皮瓣、喉管、游离空肠、游离前臂皮瓣和胃上提咽胃吻合5种方法对肿瘤切除术后所致的下咽颈食管环周缺损进行一期修复重建，并重点对所有患者术后的吞咽功能恢复情况进行观察和客观评估。结果胸大肌肌皮瓣修复重建31例，喉管代下咽颈食管8例，游离空肠移植12例，游离前臂皮瓣移植4例，胃上提咽胃吻合术17例。其中15例患者出现了不同程度的并发症，包括创口感染、咽漏、皮瓣部分坏死、胃壁部分坏死和食管吻合口狭窄等，除1例死亡外，其他患者经处理全部治愈。本组患者术后吞咽功能恢复满意，除2例食管吻合口狭窄患者可以进半流食外，其余患者均恢复了正常的进食功能。平均随访时间为1．6年，术后2年生存率为45．3％。结论下咽颈段食管癌切除术后所致的环周缺损可依据缺损的范围和患者的情况选择不同的修复方法，只要适应证掌握得当均可获得满意的修复重建效果。     

晚期下咽癌、喉复发癌术后颈部缺损整复组织的选择

目的:探讨以不同组织移植物Ⅰ期重建晚期下咽癌、喉复发癌术后颈部、下咽食管缺损的适应证及治疗效果。方法:喉复发癌36例, 肿瘤切除后采用胸大肌肌皮 瓣修补组织缺损18例,肩胸皮瓣修补4例,胃代食管修补2例,胸部推移皮瓣重建下颈部与上纵隔组织缺损,并消灭手术死腔12例。晚期下咽癌16例,颈段食管癌8例,以游离空肠整复1例, 健侧喉黏膜瓣修复咽部缺损8例,喉气管代食道8例,胸大肌皮瓣修复咽部缺损2例,胃代食管2例,游离前臂皮瓣修复下咽1例。 结果:术中无一例死亡,术后无修复组织坏死 ,全部组织瓣存活。采用健侧喉黏膜瓣修复者,仅 1例有术前放疗史的患者发生术后咽漏,胸大肌皮瓣 修复者发生咽漏1例,胃代食道术后发生咽漏1例。全部病例愈合后均恢复正常饮食。随访 9～84个月,14例出现吞咽梗阻,可进流质饮食。结论:下咽癌患者术后组织缺损的修复方法各有侧重。肿瘤的部位和手术后组织缺损的大小是选择修复方法的首要因素;其次,应结合患者的年龄和全身状况,考虑减少并发症。     

喉癌下咽癌患者下咽及颈段食管术后缺损的修复方法

目的 :探讨喉癌下咽癌患者下咽或下咽及颈段食管术后缺损的修复方法。方法 :对保留喉功能的下咽术后缺损 9例 (伴颈段食管部分切除 3例 ,颈段食管癌行食管全切除 1例 ) ,用胸大肌肌皮瓣修复 4例 ,直接修复 4例 ,胃咽吻合术 1例。不保留喉功能 2 0例 (伴颈段食管部分切除 2例 ) ,舌瓣修复 16例 ,喉组织瓣 2例 ,胸大肌肌皮瓣与胸骨舌骨肌筋膜瓣联合重建下咽 2例。结果 :术后 8例Ⅰ期恢复吞咽及喉功能 ,1例下咽狭窄 ,Ⅱ期行残喉切除。余 2 0例中 16例Ⅰ期恢复吞咽功能 ,1例下咽狭窄经扩张进食 ,3例咽瘘 ,其中 1例咽瘘行Ⅱ期胃咽吻合术。 1、3及 5年的生存率分别为 92 %、6 4 .7%和 4 6 .2 %。结论 :保留喉功能的下咽或下咽及颈段食管缺损可直接修复或采用胸大肌皮瓣修复 ,不保留喉功能者 ,可采用舌瓣、胸大肌皮瓣修复或咽胃吻合术。肌皮瓣和肌筋膜瓣联合重建全下咽易引起下咽狭窄或咽瘘     

晚期喉癌下咽癌术后缺损的修复

目的总结分析晚期喉癌下咽癌术后的舌部、咽喉部、颈段食管及颈部皮肤等组织缺损的修复经验。方法2005年1月~2012年12月共手术治疗喉癌、下咽癌患者177例,男147例,女30例。年龄42~75岁,中位年龄51岁。其中首次治疗的IV期喉癌49例、IV期下咽癌44例、复发喉癌55例和复发下咽癌29例。原发灶切除：全喉+全下咽切除88例,全喉+全下咽+舌根切除29例,全喉+全下咽+颈段食管切除33例,全喉+全下咽+颈段食管切除+颈部皮肤切除26例,全舌+全下咽+全喉+颈段食管切除+颈部皮肤切除1例。缺损类型及修复材料：下咽近环周缺损120例患者行单一皮瓣修复,其中颏下皮瓣25例、胸大肌肌皮瓣53例、股前外侧皮瓣42例。下咽环周缺损57例患者行单一皮瓣修复下咽环周缺损15例,包括股前外侧皮瓣9例和胸大肌肌皮瓣6例;行游离空肠瓣修复下咽环周缺损合并口咽、颈段食道缺损者21例;联合应用游离空肠瓣、胸大肌肌皮瓣或（和）股前外侧皮瓣修复下咽环周缺损合并舌、口咽、颈段食道缺损或（和）颈部皮肤组织缺损者10例;采用胃上徙管胃成形修复下咽合并全食道缺损11例。术后放疗95例,组织瓣无放射性坏死。结果一次手术成功率92.1%（163/177）;修复瓣坏死14例患者行再次修复手术成功,包括空肠4例,另一侧胸大肌皮瓣6例,另一侧游离股前外侧皮瓣4例。咽瘘经换药后愈合6例。无手术死亡病例。咽部及造瘘口复发13例（再手术7例,放化疗6例）,食管二重癌5例予以放化疗,颈部淋巴结复发17例（再手术9例,放化疗8例）。肺转移6例,肝转移2例,多个远处转移4例,局部复发并远处转移7例。局部复发死亡23例,远处转移死亡12例。全组3年生存率50.4%;5年生存率39.4%。结论①晚期和复发的喉癌及下咽癌术后软组织缺损,需根据患者的缺损范围和身体状况选择自体修复材料;②复杂的多重组织和器官的缺损需要用多种自身材料叠加修复以重建上消化道;③密切观察游离组织瓣的血运状况,及早处理坏死的组织瓣并重新修复,以确保伤口尽快愈合。     

下咽食管狭窄的治疗

目的:探讨下咽食管狭窄的重建术,以取得更好的治疗效果.方法: 总结35例下咽食管狭窄患者的治疗方法,包括类固醇激素和抗生素治疗、扩张治疗、下咽食管成形术(胸大肌肌皮瓣、胸三角肌皮瓣、胸锁乳突肌皮瓣、全厚皮片、结肠上徙、胃上提、游离空肠、瘢痕切除局部粘膜减张缝合或纵切横缝).结果:35例中,33 例治愈,恢复正常饮食.经1～19年的随访治愈病例未出现狭窄复发,疗效巩固.结论:早期轻度的下咽食管狭窄可采用类固醇激素加抗生素治疗和扩张治疗,严重的下咽食管狭窄需行下咽食管成形术,局限于下咽部的狭窄在瘢痕切除后以胸大肌肌皮瓣或局部粘膜的纵切横缝整复,合并有食管狭窄者可以结肠上徙代食管术.胸大肌肌皮瓣和结肠不易感染坏死,手术成功率高,功能恢复满意,是下咽食管狭窄较好的修复材料.     

下咽和颈段食管的重建

下咽及颈段食管切除后的重建,从最早采用的颈部皮瓣,到60年代的前胸皮瓣及70年代的胸大肌皮瓣,以及自60年代开始广泛采用的利用内脏(胃结肠与空肠)修复手术,均为目前的常用方法。迄今为止,根治性手术治疗晚期下咽和颈段食管癌的远期生存率还很低。从这个意义上说,手术本身在很大程度上是姑息性的,因此,理想的重建方式,应使手术死亡率及病发率最低,住院期最短,恢复吞咽的成功率最高及开始进食的时间最早。作者报告82例(共84次)下咽-食管的重建手术。其中颈部皮瓣法31例,胸部皮瓣法29例(前胸皮瓣12例,胸大肌皮瓣17例),胃代食管法12例(其中5例保留喉),结肠代食管法10例,     

前臂桡侧游离皮瓣咽食管重建

下咽部晚期肿瘤传统采用手术切除联合放疗 ,下咽部手术缺损早些时候多采用颈部临近组织进行修复 ,如胸大肌肌皮瓣、斜方肌肌皮瓣、背阔肌肌皮瓣等。195 9年 Seidenberg介绍了游离空肠移植咽食管重建 ,1985年 Harii介绍了一种游离管状皮瓣咽食管重建方法 ,此后 ,游离前臂桡侧皮筋膜瓣 (RFFF)逐渐被用于进行下咽和颈段食管缺损修复重建。RFFF供皮区定位在前臂桡侧非优势桡动脉和头静脉供血区 ,皮瓣连接食管端的宽度为 6～ 8cm,与口咽部连接的宽度为 12～ 14 cm,皮瓣末端呈 2 cm长的三角形突出和颈段食管纵切口嵌合。以从口咽部残端到食管…     

非开胸胃代食管术治疗同时性下咽并胸段食管重复癌5例

目的探讨非开胸胃代食管术治疗同时性下咽并胸段食管重复癌的方法和疗效。 方法对5例同时性下咽并胸段食管重复癌患者,均行非开胸食管内翻拔脱胃上徙术。喉功能保留3例,其中1例下咽后壁癌患者因胃上徙高度不够,采用前臂桡侧游离皮瓣修复下咽及颈段食管;全喉切除2例。结果5例吞咽功能全部恢复,无吞咽困难发生。1例发生咽瘘,经保守治疗痊愈。3例保留喉者均有不同程度呛咳症状。3例保留喉功能者术后全部拔管,发音质量良好。随访1～4年,1年生存率100%(5/5),3年生存率60%(3/5)。结论提高对同时性下咽并胸段食管重复癌的认识,采用非开胸胃代食管术治疗,优越性为成功率高、并发症较少,是一个较理想的手术方法。     

咽癌切除术后咽部的重建:两种方法的比较

1977～1987年,作者为117例下咽和口咽癌病人施行了喉咽切除术,咽重建方法分胸大肌肌皮瓣和游离空肠微血管吻合自体移植两种。为便于临床分析,将全部病人分为四组:应用胸大肌肌皮瓣一期重建者12例(第一组),5例成功(42％),7例瘘口形成(58％),其中6例(86％)经挽救手术修复成功;应用游离空肠一期重建者70例(第二组),44例成功(63％),9例失败(13％),其中5例经再次应用游离空肠、1例经胸大肌肌皮瓣挽救成功,17例瘘口形成(24％),其中9例(53     

经皮旋转扩张气管切开术

目的介绍在无气管镜辅助下应用经皮旋转扩张气管切开术的初步经验，评价该术对患者术中、术后的影响。方法对2005年1月至2005年8月于北京大学第一医院用pereutwist气切组套行经皮旋转扩张气管切开术的10例，对手术时间、患者术中情况、操作难易程度、出血情况、术后并发症等进行评估。手术在无气管镜辅助下进行。结果10例患者中1例在旋入扩张器时出现血氧饱和度一过性下降至0．88；其余患者在操作过程中血氧饱和度均在0．95—1．00。患者术中血压、心率均未出现大幅度变化。手术时间为3-10min，平均6．2min。8例操作没有任何困难，2例操作稍有困难。6例患者术后1周内行气管镜检查，均无气管后壁损伤。除1例术后出血、1例伤口感染外，无其他术中及术后并发症。结论经皮旋转扩张气管切开术与传统气管切开术相比，具有操作简单，手术时间短，出血少等优点。可以在无气管镜辅助下进行。只要谨慎操作，可以避免严重并发症的发生。     

Neck dissection complications

Because of the proximity of vital structures, certain complications are inherent to neck dissection (ND) for the treatment of patients with squamous cell carcinoma of the upper aerodigestive tract.Aim: To establish the incidence of complications of ND.Methods: A cross-sectional retrospective study of patient registries. ND with curative intention was evaluated in 480 patients with squamous cell carcinoma of the upper aerodigestive tract from January 1995 to December 2008 to identify perioperative complications.Results: Considering the total quantity of dissected neck sides, 413 radical ND and 295 selective ND were studied, of which 220 were supraomohyoid ND and 75 were jugular ND, totaling 708 sides. There were no deaths. The most frequent complication was marginal mandibular nerve injury (5.5%), followed by accessory nerve injury (5.1%). However, in 18 out of 21 cases this nerve was sacrificed for oncological completeness.Conclusions: There were no perioperative deaths. Nerves were the most commonly injured structures; the marginal mandibular branch is injured most (5.5%).     

Complications of sinusitis: An 80-case series from the ENT and neurosurgery departments of the Fann university hospital center of Dakar,Senegal

IntroductionLocoregional complications of sinusitis are dominated by oculo-orbital and/or cranioencephalic manifestations that may be life-threatening or jeopardize functional prognosis. The aim of this study was to report epidemiological, diagnostic and therapeutic aspects.Materials and methodsA retrospective study included inpatients managed for sinusitis complications in the ENT and neurosurgery departments of the Fann university hospital center in Dakar, Senegal between January 1, 2005 and December 31, 2016.ResultsIn all, 80 files were collected. Mean age was 18.5 years, with male predominance. Mean time to treatment was 18.2 days. Cranio-encephalic complications were the most frequent (54 cases; 67.5%): mainly subdural empyema (30 cases) and brain abscess (10 cases). Seventeen patients (21.25%) had oculo-orbital complications: mainly orbital cellulitis (52.9%) and preseptal cellulitis (29.4%). Nine patients (11.25%) had both cranioencephalic and oculo-orbital complications. Acute sinusitis (82.5%) was the main cause of complications. 52.5% of patients showed pansinus involvement. Medical treatment consisted in broad-spectrum antibiotic therapy combining third-generation cephalosporins, metronidazole and gentamycin in cranio-encephalic complications and clavulanic acid and metronidazole in oculo-orbital complications. Thirty-four patients (42.5%) underwent surgical sinus drainage. Neurosurgical drainage was performed in 35 cases (43.75%). Post-treatment course was marked by 6.25% mortality (5 cases) and 16.25% sequelae.ConclusionWith 6.25% mortality and a high rate of functional sequelae, complications of sinusitis are a serious concern in our region. Improving prognosis requires earlier management and better coordination between health professionals.     

Surgical complications in 550 consecutive cochlear implantation

Cochlear implantation is a safe and reliable method for auditory restoration in patients with severe to profound hearing loss.ObjectiveTo describe the surgical complications of cochlear implantation.Materials and MethodsInformation from 591 consecutive multichannel cochlear implant surgeries were retrospectively analyzed. All patients were followed-up for at least one year. Forty-one patients were excluded because of missing data, follow-up loss or middle fossa approach.ResultsOf 550 cochlear implantation analyzed, 341 were performed in children or adolescents, and 209 in adults. The mean hearing loss time was 6.3 ± 6.7 years for prelingual loss and 12.1 ± 11.6 years for postlingual. Mean follow-up was 3.9 ± 2.8 years. Major complications occurred in 8.9% and minor in 7.8%. Problems during electrode insertion (3.8%) were the most frequent major complication followed by flap dehiscence (1.4%). Temporary facial palsy (2.2%), canal-wall lesion (2.2%) and tympanic membrane lesion (1.8%) were the more frequent minor complications. No death occurred.ConclusionThere was a low rate of surgical complications, most of them been successfully managed. These results confirm that cochlear implant is a safe surgery and most surgical complications can be managed with conservative measures or minimal intervention.     

Radiation dewlap*

A dewlap is a hanging fold of skin under the throat of oxen and dogs. A similar swelling sometimes occurs in man after radiation therapy. The incidence and natural history of this ‘radiation dewlap’ has been assessed in patients receiving radiotherapy to malignant growths in the head and neck region. The appearance of this complication has been correlated with the age of the patient, the site and stage of the tumour and the type of radiation employed. The aetiology and significance of the complication are discussed with reference to the anatomy and physiology of the affected tissues and the physical characteristics of the radiotherapy administered. Possible methods of prevention are suggested.     

几丁糖预防CO2激光声带切除术后声带粘连短期观察的实验研究

Objective To observe the effect of immediate topical application of chitosan on preventing anterior giottic stenosis (AGS) after microsurgical resection of both vocal fold with CO<,2> laser , including the anterior commissure, in a canine model. Methods Sixteen canine larynges were injured by microresecting procedure of both vocal folds with CO<,2> laser. The dogs were randomly divided into two groups, chitosan group and control group. The chitosan and isotonic sodium chloride solution(control) were used for 5 minutes immediately after surgery. One week after the initial surgery, three dogs in each group were randomly selected , ultrastructure of fibroblast were examined with transmission electronic microscope and expression of basic fibroblast growth factor(bFGF) and traansforming growth factor betal (TGF-β1) were evaluated by enzyme-linked immunosorbent assay(ELISA). Three weeks after surgery, the rest dogs' glottic web were lysed and repeatedly treated with chitosan and isotonic sodium chloride solution respectively. The glottic wound healing and AGS formation were examined every week, and all larynges were harvested and examined histologically six weeks after the initial surgery. Results Transmission electronic microscope examination of the ultrasmcture of fibroblast indicated that chitosan inhibited the proliferation of fibroblast. Chitosan increased the expression of bFGF and TGF-β1, and bFGF and TGF-β1 in chitosan group, which was significantly higher than that in control group (z = -2.887 and -2.005, P =0.002 and 0.041). Chitosan decreased the extent of AGS formation. Three weeks after the surgery, the AGS lesion in the control group affected mean 49% of the length of the vocal folds from the anterior commissure to the vocal process, while chitosan group affected mean 7%, which was significantly less than the extent of web formation in the control group, (z = - 2. 619, P = 0. 008). The grade of collagen content in chitosan group was significantly lower than that in control group (P = 0. 003). Conclusion Chitosan is effective in preventing AGS after CO<,2> laser cordectomy.