闭合器和手工缝合在喉癌切除术后喉咽关闭中的比较

目的　比较闭合器和手工缝合关闭喉全切除术后喉咽黏膜的疗效,探索喉全切除术后喉咽关闭的优化技术。方法　2012年6月～2014年6月共采用闭合器关闭因喉癌（T3~T4未累及舌骨上会厌及喉咽黏膜）行喉全切除术后喉咽黏膜患者16例,以同一术者及T3~T4喉癌为条件非随机配对选取2010年6月～2012年5月手工缝合法闭合喉咽的喉全切除术16例对照组患者。对比临床参数,分析闭合器法的安全性、优缺点。结果　研究组缩短手术时间30 min,术后发生咽瘘1例,对照组4例。研究组术后平均住院天数10 d,对照组12 d。结论　对未累及舌骨上会厌及喉咽的喉癌行喉全切除术后采用闭合器关闭喉咽黏膜是安全的,可缩短手术时间,可能降低咽瘘发生率。     

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.     

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.     

直线吻合器在全喉切除术中的应用

目的探讨一次性直线型吻合器在喉癌手术中的应用效果。方法选取我科2019年10例全喉切除手术患者,采用随机分组方法,分为封闭法和半封闭法两组。总结比较所用手术时间、术中出血量、术后咽瘘感染的发生率。结果所有手术都顺利完成,会厌软骨残留1例,咽瘘1例。结论直线吻合器在全喉切除术中具有较好的临床应用价值。     

全喉切除术后并发咽瘘的相关因素分析与防治

对78例全喉切除术病例临床资料进行回顾性分析,其中并发咽瘘29例,发生率37.2％;同时提示,手术技巧是咽瘘发生的关键因素,其次丝线间断缝合、血浆(半)管引流、缩短手术时间等有助于减少咽瘘的形成,而病变范围、术前放疗和术前气管切开等则可能促进咽瘘的发生,术前、术后Hb、切口类型对咽瘘形成影响不大。故应针对上述相关因素做好咽瘘的防治工作,减少咽瘘的发生。     

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。     

胸大肌肌皮瓣在放疗后喉癌及喉咽癌术后咽瘘中的应用

目的　探讨胸大肌肌皮瓣在放疗后喉癌及喉咽癌术后咽瘘修复中的重要作用及临床应用价值。方法 通过对8例放疗后喉癌及喉咽癌术后并发巨大咽瘘患者的治疗,并结合文献进行回顾性分析。结果　8例患者均先行局部换药、抗感染及营养支持等保守治疗,瘘口未能彻底愈合,再行带蒂胸大肌肌皮瓣修复咽瘘,7例手术均取得成功,术后经口进食,并行碘油造影证实喉咽及食管无造影剂外渗及梗阻情况,1例患者因胸肩峰动脉变异导致皮瓣坏死手术失败。结论　喉癌、喉咽癌行喉全切除术后并发咽瘘是该手术最常见的严重并发症之一,多数经换药等保守治疗方法可治愈,但对于放疗后喉癌及喉咽癌术后并发咽瘘的患者,因其颈部血供差,组织活性低,保守治疗很难使其痊愈,胸大肌肌皮瓣供血可靠,成活率高,抗感染能力强,对术前曾放疗的咽瘘患者可起到很好的修复作用。     

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.     

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。     

营养支持疗法对喉癌、下咽癌术后康复的影响

目的探讨营养支持疗法对喉癌及喉咽癌患者术后康复的影响.方法将55例喉癌及喉咽癌患者随机分为观察组和对照组.观察组34例给予围手术期全胃肠外营养配合混合奶,对照组21例给予混合奶,每日鼻饲5～6次.检测术前、术后7天、14天各项营养指标,比较咽瘘发生的情况和平均住院日.结果观察组体重迅速回升,免疫功能明显改善,保持正氮平衡,血红蛋白、血清白蛋白维持在正常水平,观察组平均住院日比对照组缩短16天左右.两组咽瘘发生率差异有显著性意义(P＜0.01).结论喉癌及喉咽癌术后患者围手术期全胃肠外营养配合混合奶可降低咽瘘的发生率,缩短平均住院日,提高患者生存质量.     

Pharyngocutaneous fistulae following total laryngectomy comparison between manual and mechanical sutures

The extension of the surgery and closure type of the pharynx can be the determinants in the pharyngocutaneous fistula development. The objective of the study is to evaluate the incidence of pharingocutaneous salivary fistulae after total laryngectomies comparing manual and mechanical sutures. The study is designed as non-randomized, prospective clinical study. Sixty patients with squamous cell carcinoma were submitted to total laryngectomies. In 30 cases, the linear stapler (75 mm) closure (surgical technique described in details) and in other 30 cases manual suture was used. The cases of mechanical suture were prospective and consecutive and the cases of manual suture were a review series of patients who underwent a manual suture of pharynx, in the same period of time. The statistical analysis between the two groups concluded that both were comparable. Fistulae incidence was 6.7% (2/30) in the group with the mechanical suture and 36.7% (11/30) in the group with manual suture closure, presenting a significant difference (p = 0.0047). The total laryngectomy with mechanical closure is an easy and fast learning technique, allowing watertight closure of the pharynx with a low risk of contamination of the surgical field. It is an assured method, even in previously irradiated patients, since we respect the limits of its indication regarding the extension of primary tumor that must be confirmed by previous suspension laryngectomy performed in the operating room.     

Using a linear stapler for pharyngeal closure in total laryngectomy

This study aimed to evaluate the value of using a linear stapler device in total laryngectomy using a prospective study. Twenty-one total laryngectomies were performed from August 2010 to April 2012, using TA-60 linear stapler for pharyngeal closure. Data collected included age, sex, staging, surgical margins and postoperative course (including complications and swallowing). Patients comprised twenty men and one woman. The mean age was 64 years. Two patients underwent preoperative radiotherapy. Four patients recurred after radiotherapy. Fifteen patients were untreated. Negative surgical margins were achieved in all patients. One patient developed slight pharyngocutaneous fistula. Patients resumed oral intake at 7 days. The mean hospital stay was 10 days. Using a linear stapler to close laryngopharyngeal cavity in total laryngectomy is simple, reliable and practical, avoids pollution of surgical area, saves operation time and decreases the incidence of pharyngocutaneous fistula. It is worthy of clinical application for selected cases. Level of Evidence Case-series     

下咽癌术中经口使用环形吻合器重建消化道的临床探讨

目的探讨下咽癌术中经口使用环形吻合器连接重建消化道上吻合口的方法及疗效。方法回顾性分析2016年3月~2018年12月因下咽癌就诊于北京协和医院耳鼻咽喉科行手术治疗并于术中经口应用环形吻合器修复口咽缺损的7例患者的临床资料。结果7例患者均未出现咽瘘和上吻合口狭窄。1例于术后19个月因肺部转移死亡,1例于术后9个月出现下吻合口狭窄。 结论下咽癌术中可以经口置入环形吻合器以重建消化道上端,效果较好,术后吻合口瘘、上吻合口狭窄的发生率低于手工缝合,同时更加省时,可靠。关于经口使用环形吻合器的适应证与禁忌证仍需更多的临床探索。     

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。     

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.     

Acellular dermal graft pharyngeal repair augmentation after laryngectomy

Purpose

Pharyngocutaneous fistula (PCF) after laryngectomy continues to be a serious complication, especially after radiation. Recruitment of non-radiated tissue into the surgical defect may decrease the risk of fistula. These techniques however have significant morbidity and increases operative time. We hypothesized that using acellular dermal graft to reinforce the pharyngeal closure could decrease the risk of fistula, without the added morbidity of a vascularized flap.

显微支撑喉镜下低温等离子微创治疗儿童先天性梨状窝瘘

目的探讨显微支撑喉镜下低温等离子微创治疗儿童急性感染期（AIS）与炎症静止期（IQS）先天性梨状窝瘘（CPSF）的临床疗效。方法回顾性分析2017年12月—2019年12月上海交通大学附属儿童医院收治并行低温等离子微创治疗的51例CPSF患者临床资料,其中AIS 22例,IQS 29例,2组患儿均在气管插管全麻支撑喉镜下行低温等离子射频消融封闭梨状窝内瘘口,而AIS的患儿同期行颈部脓肿切开引流术,留置纱条,术后每日颈部换药。全部患儿术后留置胃管２周,应用抗生素治疗7～10 d。观察其疗效、术后复发率及并发症。结果3例处于IQS的患儿分别于术后第5、6、7天因颈部脓肿形成行切开排脓手术,换药4 d后痊愈。2例AIS的患儿术后出现一过性声嘶,于术后1个月内恢复正常。术后随访2～26个月,1例IQS患儿术后半年复发,2次全麻内镜下低温等离子内瘘口烧灼术,其余50例CPSF内瘘口1次封闭,未发生咽瘘、喉返神经损伤、大出血等并发症,无复发,疗效显著。结论推荐显微支撑喉镜下低温等离子微创根治术作为CPSF的首选疗法,对于IQS的CPSF宜实施单纯内瘘口烧灼术,但术前充分告知家属,术后可能因颈部局部脓肿形成,需要切开引流、换药,对于AIS的CPSF,不必等待炎症控制以后,直接同期行颈部脓肿切开引流术。     

A randomized controlled trial of early oral feeding in laryngectomized patients

OBJECTIVE: To evaluate the safety and efficacy of early oral feeding by comparing it with feeding through primary tracheoesophageal puncture after total laryngectomy with primary pharyngeal closure. STUDY DESIGN: A prospective, randomized, controlled study. METHODS: Patients who underwent total laryngectomy with primary pharyngeal closure and who were candidates for primary voice restoration (an in whose cases primary tracheoesophageal puncture [TEP] was created) were included. After total laryngectomy, patients were randomly assigned to either the oral group (study group) or the TEP group (control group). Patients in the oral group were fed orally with a clear liquid diet on the first postoperative day, then advanced to a regular diet, whereas patients in the TEP group were fed through tracheoesophageal puncture and received nothing orally until the seventh postoperative day; then they were fed orally if fistula had not occurred. Standard criteria for discharge were used for all the patients. RESULTS: During a 3-year period, 67 patients were enrolled in the trial, and complete data were available for 65 patients (32 patients in the oral group, 33 patients in the TEP group). The two groups were similar for factors reported to influence the rate of pharyngocutaneous fistula. In three (9%) patients in the TEP group, fistula occurred on the 5th, 7th, and 14th postoperative days, respectively. Two (6.2%) fistulas occurred in the oral group on the sixth and eighth postoperative days, respectively. In patients without fistula, the mean length of hospital stay was 7.6 days (range, 4-19 d [SD = 3.1 d]) for the oral group and 8.2 days (range, 7-18 d [SD = 2.6 d) for the TEP group. There was no significant difference between two groups for either the incidence of fistula or the length of hospital stay. CONCLUSIONS: Initiation of oral feeding on the first postoperative day in patients undergoing total laryngectomy with primary pharyngeal closure is a safe clinical practice. However, it does not shorten the length of hospital stay for these patients.