梨状窝内侧壁癌切除与喉功能保留

目的 探讨梨状窝内侧壁癌切除喉功能保留犬的技术方法和临床疗效。方法 回顾分析手术治疗的梨状窝内侧壁癌71例。其中49例行喉功能保留术；22例未保存喉功能。喉功能保留手术方法：①切除范围：声带活动正常者行患侧水平上半喉＋梨状窝内侧壁切除；声带活动受限者行同侧水平半喉＋声门旁间隙＋梨状窝内侧壁切除；声带固定者行患侧垂直半喉＋梨状窝内侧壁和部分梨状窝外侧壁切除，梨状窝尖受累者切除范围扩大到环状软骨环和颈段食管；②修复:喉修复对利用会厌、甲状软骨膜、带状肌肌筋膜、颈前皮瓣修复喉缺损；梨状窝修复对缺损范围小者用下咽粘膜瓣或残缘粘膜后直接讨合，对缺损范围大者用胸大肌肌皮瓣转移及胸三角皮瓣修复；③颈淋巴结处理：71例中65例（91．5％）行颈清扫术，其中同侧颈清扫术39例，双侧颈清扫术26例；④术后全部病例予以辅助放射性治疗，剂量60－75Gy。结果 寿命表法统计3年、5年生存率：喉功能保留组分别为63．4％和49．6％；喉功能不保留组分别为52．4％和42．4％。喉功能保留组喉功能全部恢复者占71．4％（35／49），部分恢复者占28．6％（14／49）。结论 梨状窝内侧壁癌易侵入喉部，但多数病例在彻底切除肿瘤病灶的前提下保留喉功能是可行的。

Preservative surgery of medial wall pyriform sinus cancer]

OBJECTIVE: To study the surgical methods and functional outcome of preservative surgery for medial wall pyriform sinus cancer. METHODS: Seventy-one patients with medial wall pyriform sinus cancer, who were treated surgically between 1985 and 1997, were reviewed. Of the 71 cases, 49 underwent preservative surgery, and 22 total laryngectomy. Preservative surgical procedure was defined as follows: 1. Extent of resection: Supraglottic horizontal partial laryngectomy and resection of medial wall of pyriform sinus were performed in patients without fixation of the true vocal cord, and the section extended to paraglottic space, partial lateral wall of pyriform sinus, preepigottic space, superior-posterior of thyroid cartilage in those with restrained vocal cord motility. Supracricoid hemilaryngopharyngectomy and resection of medical wall and partial lateral wall of pyriform sinus were practiced in those with fixed hemilarynx. Cricoid ring and cervical esophagus were removed partially if the pyriform sinus apex was involved. 2. Reconstruction: Larynx: the remains of epiglottis, perichondrium of thyroid cartilage, the infrahyoid muscular fascia, and the platysmal flap were utilized to restore the defects of larynx. Pyriform sinus: Suturing the remaining pharyngeal mucosa directly to cover the wound if the defect was relatively small. For the large defect produced by extended resections, the pectoralis major myocutaneous flap and deltopectoral flap were used. 3. Surgical treatment of cervical lymphaden: Sixty five out of the 71 cases (91.5%) underwent neck dissection. Of which ipsilateral neck dissection were done in 39 cases, and bilateral neck dissection in 26 cases. 4. All patients received postoperative radiotherapy with doses of 60-75 Gy. RESULTS: In the group of preservative surgery the 3- and 5-year survival rates were 63.4% and 49.6% respectively, whereas those in the total laryngectomy group were 52.4% and 42.4% respectively. Of the 49 cases with preservative surgery, 71.4% (35/49) had all laryngeal functions restored and 28.6% (14/49) partially restored. CONCLUSION: Despite the fact that the medial wall pyriform sinus cancer tends to have laryngeal invasion, preservative surgery can be practiced for the majority of the cases with the lesions entirely removed.