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.     

The pectoralis myocutaneous flap for salvage of necrotic wounds

The authors have utilized six pectoralis major myocutaneous flaps in attempts to salvage extensive necrotic wounds of the pharynx and neck. The flap was employed in the following situations: massive necrosis of the entire neck skin with both carotid artery systems exposed, radiation necrosis of the neck skin with exposure of carotid artery, dehiscence of gastric pull-up from pharynx with resultant carotid exposure, failed trapezius flap in a radionecrotic oral cavity, and two cases of pharyngocutaneous fistula with extensive soft tissue necrosis. These flaps achieved healing in all cases. One death occurred 3 weeks following complete cutaneous healing secondary to a ruptured carotid pseudoaneurysm. One flap underwent total skin loss but the entirety of the muscle survived and the fistula was successfully closed with the back of the muscle being subsequently skin grafted. One case of dehiscence of the flap from oral mucosa resulted in a minor exposure of mandible with limited osteoradionecrosis controlled by topical means. This flap has performed extremely well in these precarious and difficult situations that previously may not have been salvageable. It has also been effective in abbreviating the required hospitalization and wound care. We conclude that the pectoralis myocutaneous flap should be the primary choice for the management of extensive postsurgical wound necrosis.     

喉全切除后气管造瘘口复发癌缺损外科修复比较

目的探索喉全切除后气管造瘘口复发癌缺损外科修复的治疗效果。方法对18例喉全切除后气管造瘘口复发癌实施外科治疗。其中Ⅰ型7例,颈部单纯切口,胸大肌肌皮瓣修复颈部皮肤气管造瘘口缺损;Ⅱ型6例,颈肢或胸联合切口,前臂皮瓣或胸大肌肌皮瓣(游离前臂皮瓣5例,胸大肌肌皮瓣1例)修复部分喉咽切除;Ⅲ型3例,颈腹联合切口,游离空肠修复全喉咽、颈段食管;Ⅳ型2例,颈胸腹联合切口,胃上拉修复全喉咽、全食管。Ⅱ、Ⅲ、Ⅳ型的颈部皮肤气管造瘘口缺损均用胸大肌肌皮瓣修复。结果颈部缺损胸大肌肌皮瓣均成活;咽瘘4例(其中游离空肠1例,前臂皮瓣2例,胃上拉咽瘘出血1例);全部病例术后均能进食;随访6～74个月,3例出现不同程度吞咽梗阻。结论喉全切除后气管造瘘口复发癌外科治疗缺损,修复选择应根据原发肿瘤治疗的经过及气管造瘘口复发癌侵及范围来确定修复方法。     

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。     

The musculocutaneous infrahyoid flap: surgical key points

For the first time in 1979, it was described by Wang that the infrahyoid musculocutaneous flap (IHMC flap) appears to be extremely suitable for medium-sized head and neck defect. Nevertheless, this flap remains unpopular because of its pretended lack of reliability. The aim of this study is to describe the surgical key points and to expose its main advantages. An IHMC flap was achieved on 32 patients to repair tissue loss due to surgical resection of a squamous cell carcinoma of the upper aero-digestive tract, from March 2006 to January 2010. Medical records of each of these patients were retrospectively analysed by the investigators including the detailed clinical, pathological and operative reports. No patient presented with total flap necrosis. However, we experienced four skin paddles necrosis. In two cases, the necrosis was total and in two cases partial. All donor sites were closed primarily without any tension. One patient showed a major dehiscence of the neck skin incision that required a pectoralis major flap. The IHMC flap is reliable and the harvesting technique is simple when the surgical key points are respected. Its advantages make it a convenient flap for medium-sized head and neck defect.     

胸大肌肌皮瓣修复晚期口咽侧壁肿瘤手术缺损

对18例晚期口咽侧壁肿瘤患者的术后缺损，用胸大肌肌皮瓣修复。取瓣面积为15cm×10cm～3cm×3cm；3例发生部分坏死，4例行预防性气管切开；术后外形及口咽功能恢复均满意。术后3年和5年生存率分别为61．5％和40．0％。皮瓣的愈合与本前放疗及术中操作等因素有关。认为晚期口咽侧壁肿瘤术后缺损应首选胸大肌肌皮瓣作一期修复，以提高患者生存质量，延长其生命。     

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。     

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     

Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyperbaric oxygen therapy

CONCLUSION: Our experience confirms that pectoralis major flap is the first-choice technique for repairing recurrent hypopharyngeal fistulae in previously irradiated patients in whom microsurgical techniques are not indicated, and that hyperbaric oxygen therapy helps to solve this complex pathology. OBJECTIVES: A pharyngostome is a complication encountered when performing surgical operations on pharyngolaryngeal structures. The authors present their experience of treating recurrent complex pharyngostomes in previously irradiated patients in poor physical health. These patients need a simple, safe reconstruction with a low incidence of postoperative complications. MATERIAL AND METHODS: A pedicled pectoralis major flap was used for reconstruction: the skin side of the flap was used to restore the continuity of the pharyngeal mucosa, while the muscle was used to reconstruct the intermediate layer. The skin layer was completed by means of a free skin graft. In all cases, surgical treatment was combined with hyperbaric oxygen therapy before and after the operation. RESULTS: A total of 10 patients, all of whom had previously undergone surgery and radiotherapy, had recurring or pluri-recurring pharyngostomes. All patients (8 males, 2 females; age range 52-80 years) had previously been affected by carcinoma of the pharyngolaryngeal region. All underwent major local Ablation together with radical neck dissection and radiotherapy. In all cases there was mucosa on the posterior wall; a musculocutaneous pectoralis major flap was used in all cases for reconstruction.     

下颌外旋切除咽及颅底肿瘤

目的 探讨咽及颅底肿瘤切除的最佳手术入路。方法 １３例咽及颅底肿瘤中，鼻咽部２例，口咽部４例，咽旁间隙５例，咽旁颞下区２例。均采用下颌骨切开外旋入路进行了根治性切除。同期行咽后淋巴结清扫术５例，改良根治性颈清扫术２例，咽部缺损以胸大肌皮瓣整复５例。恶性肿瘤术后均接受了辅助性放射治疗。结果 １３例患者中恶性肿瘤１０例，良性肿瘤３例。１２例切口愈合良好，１例术后胸大肌皮瓣感染坏死，延缓愈合。１例吞咽困     

Oral cavity reconstruction using pectoralis major muscle and amnion

The pectoralis major myocutaneous flap has become the mainstay of major oral cavity reconstruction. The flap provides excellent soft-tissue bulk and cavity or surface lining for major defects. There is a high rate of primary take. However, the flap has some deficiencies. A group of patients were identified that are likely to have less than ideal results with the pectoralis major myocutaneous flap technique. In these cases, the flap has been modified and amnion has been added. Initial results indicate enhancement of reconstruction with the modified technique.     

双岛胸大肌皮瓣在头颈肿瘤切除、重建术中的应用

目的 探讨双岛胸大肌皮瓣在头颈肿瘤术后组织缺损修复重建应用的效果及优点。方法 应用双岛胸大肌皮瓣,对头颈肿瘤术后组织缺损的8例患者进行修复重建。结果 重建后的咽腔无狭窄,颈部皮肤均成活。皮瓣I期愈合7例;皮瓣重建颈部皮肤面边缘轻度坏死1例,经处理后愈合。患者于术后8～12d(平均10d)开始进食;术后14～20d(平均16d)出院。结论 双岛胸大肌皮瓣血供丰富,组织量多,是同时修复头颈肿瘤术后皮肤、黏膜双重缺损的优选方法。     

扁桃体癌手术及修复方法的选择

目的 探讨扁桃体癌手术切除入路与组织缺损的几种修复方法及疗效.方法 采用颈前舌骨入路及下颔骨正中裂开外旋入路切除19例扁桃体癌,分别应用舌瓣、颞肌筋膜瓣及胸大肌肌皮瓣修复缺损.结果 1例胸大肌肌皮瓣术后出现皮肤部分坏死,3例颞肌筋膜瓣修复者术后张口轻度受限,其余患者术后呼吸、吞咽、咀嚼和语音功能恢复良好.结论 在选择合适的手术入路彻底切除肿瘤的前题下,熟练地掌握多种修复方法,择优采用,是恢复良好口咽功能,提高患者术后生活质量的重要保证.     

Experience with the modified pectoralis major myocutaneous flap.

Results of 75 reconstructions with a modified pectoralis major myocutaneous flap are described in patients with advanced (stages III and IV) head and neck tumors between 1982 and 1986. The course of the supplying thoracoacromial artery was determined with angiographic studies and was found to follow the middle clavicular line in most cases. The pectoralis major muscle was mobilized up to its acromial attachment, which made the bridging of considerable distances possible between the site of the removed tumor and the donor site. The bulk of the pedicle was reduced at the same time without endangering the safety of the blood supply of the pectoralis major myocutaneous flap. The flaps were viable in the 70 evaluable patients. Partial necroses were observed in three cases. Postoperative fistulas were encountered in 13 patients (surgical closure was necessary in three). Reconstruction with the pectoralis major myocutaneous flap is a safe and versatile procedure, yielding good clinical and functional results in patients with advanced head and neck tumors.     

Pharyngoesophageal reconstruction. Is a skin-lined pharynx necessary?

Current methods of pharyngoesophageal reconstruction have in common the creation of an epithelial lined pharynx. We performed eight cases of pharyngoesophageal reconstruction with a pectoralis major muscle flap. In the first six cases, split-thickness skin was quilted onto the muscle. In the last two cases, pectoralis major muscle alone was used, allowing epithelialization to occur from adjacent mucosa. The results with this simplified technique have been as good as when a skin-grafted muscle flap was used. We prefer a pectoralis major muscle flap, with or without split-thickness skin, to a pectoralis myocutaneous flap. There is no hair growth, it is easy to tube, and a thin-walled pharynx is produced. This is an advantage for the development of an esophageal voice, and tracheoesophageal puncture can be easily performed if no voice is achieved. All of our patients received full-dose, preoperative radiotherapy. One patient developed a fistula that closed spontaneously. There have been no strictures at the pharyngoesophageal junction. All patients quickly established a good oral intake.     

头颈部岛状肌皮瓣和皮瓣的改良设计及临床应用

目的　探讨制作单一血管为蒂的头颈部局部带蒂肌皮瓣或皮瓣的安全性。方法　解剖学观察20例胸肩峰动脉分支,观察最远入肌点走行特征。通过术前超声观察和术中透视法观察定位最远入肌点,在最远入肌点上方1～2 cm断离肌肉,形成单纯动静脉血管为蒂的胸大肌岛状肌肌皮瓣。利用同样的技术方法,设计岛状的胸锁乳突肌、下位斜方肌的岛状肌皮瓣。结果　解剖学观察胸肩峰动脉分支分为单支型12.5%（5/40）,双支型67.5%（27/40）,多支型20%（8/40）。术前超声定位胸大肌皮瓣的最远入肌点成功率为29.1%（14/48）,DSA成功显影乳内动脉穿支66.7%（12/18）,共完成胸大肌岛状肌皮瓣48例,乳内动脉岛状皮瓣12例,颏瓣18例,下位斜方肌岛状肌皮瓣4例,胸锁乳突肌岛状肌皮瓣4例,颈横血管岛状皮瓣3例,胸肩峰动脉穿支的岛状皮瓣3例。失败2例,1例为胸大肌肌皮瓣的岛状设计中电刀误伤胸肩峰动脉胸肌支;1例为颈横血管浅支,术中修复扁桃体癌咽侧壁缺损。3例胸大肌部分坏死,清理完坏死组织,换药后痊愈。结论　在头颈部设计单一血管为蒂的岛状肌皮瓣（皮瓣）的改良设计安全可行,在受区皮瓣容易塑形固定,供区不仅外形美观且功能保全。     

Complications of pectoralis myocutaneous flaps.

The myocutaneous pectoralis major flap has recently caught the attention of head and neck surgeons. Over the last 12 months, our service has used this flap in 14 patients. Reconstruction in the oral cavity and larynx as well as closure of large areas of skin necrosis of the neck have been the indications. Our complications occurred in 4 of the 14 patients and included neck abscess and fistula, flap necrosis, and chest wall hematoma or abscess. The flap is an eminently useful and successful flap when designed and performed as indicated in the body of the paper.     

胸大肌肌皮瓣在头颈肿瘤术后组织缺损修复中的应用

目的总结胸大肌肌皮瓣在头颈肿瘤术后组织缺损修复中的应用。方法回顾性总结2 0 0 7年1月～2 0 1 0年1 2月收治的3 6例患者因头颈部肿瘤手术后巨大组织缺损应用胸大肌肌皮瓣进行修复的临床资料。结果 32例(88.9%)胸大肌肌皮瓣完全存活,4例(11.1%)胸大肌肌皮瓣远端部分坏死。经换药、口腔护理等对症支持治疗后愈合。结论胸大肌肌皮瓣是一种临床应用广泛的修复材料。它具有丰富的组织量和确切的血液供应,修复操作简单,易存活,适用于头颈部肿瘤扩大切除术后组织缺损的即刻修复。     

Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyperbaric oxygen therapy

Conclusion. Our experience confirms that pectoralis major flap is the first-choice technique for repairing recurrent hypopharyngeal fistulae in previously irradiated patients in whom microsurgical techniques are not indicated, and that hyperbaric oxygen therapy helps to solve this complex pathology.Objectives. A pharyngostome is a complication encountered when performing surgical operations on pharyngolaryngeal structures. The authors present their experience of treating recurrent complex pharyngostomes in previously irradiated patients in poor physical health. These patients need a simple, safe reconstruction with a low incidence of postoperative complications.Material and methods. A pedicled pectoralis major flap was used for reconstruction: the skin side of the flap was used to restore the continuity of the pharyngeal mucosa, while the muscle was used to reconstruct the intermediate layer. The skin layer was completed by means of a free skin graft. In all cases, surgical treatment was combined with hyperbaric oxygen therapy before and after the operation.Results. A total of 10 patients, all of whom had previously undergone surgery and radiotherapy, had recurring or pluri-recurring pharyngostomes. All patients (8 males, 2 females; age range 52–80 years) had previously been affected by carcinoma of the pharyngolaryngeal region. All underwent major local Ablation together with radical neck dissection and radiotherapy. In all cases there was mucosa on the posterior wall; a musculocutaneous pectoralis major flap was used in all cases for reconstruction.     

Pulmonary atelectasis after reconstruction with pectoralis major flaps

Forty-four patients were reviewed to determine the incidence of atelectasis following pectoralis major myocutaneous flap reconstruction of head and neck defects. Patients underwent tumor resection with subsequent pectoralis major myocutaneous flap reconstruction (flap group, n = 24) or another major head and neck procedure (control group, n = 20). Chest roentgenograms taken on the first postoperative day were scored for atelectasis by preestablished criteria. Sixty-five percent of control and 70% of flap patients demonstrated postoperative atelectasis roentgenographically. The flap patients with skin paddles larger than 40 cm2 had a 60% incidence of major atelectasis compared with 5% in control patients. The skin island area was strongly correlated with the atelectasis score in the flap group. These results suggest that atelectasis is common following pectoralis major myocutaneous flap reconstruction of head and neck defects. As well, decreased chest wall compliance after primary closure of large donor defects may contribute to the atelectasis observed.