Mebeed Ali H, Hussein Hesham A, Saber Tarek Kh, Zohairy Mohamed A, Lotayef Mohamed
The Departments of Surgical Oncology , National Cancer Institute, Cairo University.
J Egypt Natl Canc Inst. 2009 Mar;21(1):23-32.
This study was carried out to minimize the incidence of pharyngocutaneous fistula (PCF) following salvage laryngeal surgery using vascularized pedicle pectoralis major myocutaneous flap (PMMC) for enhancing wound healing, rapid intake of oral feeding, reconstruction of desqauamated irradiated skin, achieving short hospital stay and protection against catastrophic blow out mortality.
This case series study of sixteen patients carried out from May 2005 to July 2009, at the National Cancer Institute, Cairo University where we applied PMMC flap in salvage laryngeal surgery for those with high risk to develop complications: Patients of poor general conditions (anemia, hypoproteinemia, diabetics) and/or poor local conditions for healing (irradiated neck, extensive local or nodal recurrence with skin desquamation, infiltration or tumor fungation which need extensive resection). Five cases had been treated with primary cobalt radiotherapy laryngeal field only and 4 cases laryngeal field with draining neck nodes, while photon therapy was given in 4 cases as laryngeal field only and 3 cases laryngeal field with draining neck nodes. All cases were squamous cell carcinoma (13 cases grade 2, 2 cases grade 3 and one case grade 1) proved before radiotherapy. Supraglottic recurrence was detected in 7 cases (43.75%) and glottis in 9 cases (56.25%). Following salvage surgery, 11 cases were staged T3 N0, N1 and N2, 3 cases were T2 N0 or N1 and 2 cases were T4 N2 with skin infiltration. Tracheostomy was there in 4 cases.
The study included fifteen males (93.75%) and one female (6.25%), age was between 38-73 years (mean=55.5 years). Five cases were operated on as total laryngectomy with excision of skin flaps + PMMC flap, 4 cases as total laryngectomy with skin flap excision + functional block neck dissection + PMMC flap and 7 cases as total laryngectomy + block neck dissection with skin excision (modified radical in 4 cases &radical in 3 cases) + PMMC flap reconstruction. Flaps survived in all cases, PCF developed in 2 cases (12.5%) with wound infection but healed conservatively within 2 weeks. Dropped shoulder occurred in 3 cases (18.75%) treated by physiotherapy. Mild postoperative chest infection developed in 7 cases (36.84%) improved by broad spectrum antibiotics and chest physiotherapy.
Routine use of pectoralis major myocutaneous flap in salvage laryngeal surgery is of great help in such high risk patients to minimize incidence of pharyngocutaneous fistula and to allow primary skin wound healing. This flap will give the patient the advantage of early oral feeding, good tracheostomy care, short hospital stay and protection against catastrophic vascular blow out mortality.
Pectoralis major myocutaneous flap - Prevention of pharyngocutaneous fistula - Salvage laryngectomy.
本研究旨在通过使用带血管蒂的胸大肌肌皮瓣（PMMC）进行挽救性喉手术，以降低咽皮肤瘘（PCF）的发生率，促进伤口愈合，使患者能够快速经口进食，修复脱屑的放疗后皮肤，缩短住院时间，并预防灾难性的血管破裂死亡。
本病例系列研究于2005年5月至2009年7月在开罗大学国家癌症研究所对16例患者进行，我们在挽救性喉手术中对有发生并发症高风险的患者应用PMMC瓣：全身状况差（贫血、低蛋白血症、糖尿病）和/或局部愈合条件差（放疗后的颈部、广泛的局部或淋巴结复发伴皮肤脱屑、浸润或肿瘤呈蕈状生长，需要广泛切除）的患者。5例仅接受了原发性钴喉野放疗，4例接受了喉野加颈部引流淋巴结放疗，4例仅接受光子喉野治疗，3例接受光子喉野加颈部引流淋巴结治疗。所有病例在放疗前均确诊为鳞状细胞癌（13例为2级，2例为3级，1例为1级）。声门上复发7例（43.75%），声门复发9例（56.25%）。挽救性手术后，11例分期为T3 N0、N1和N2，3例为T2 N0或N1，2例为T4 N2伴皮肤浸润。4例患者进行了气管切开术。
该研究包括15名男性（93.75%）和1名女性（6.25%），年龄在38 - 73岁之间（平均 = 55.5岁）。5例行全喉切除术，切除皮瓣 + PMMC瓣；4例行全喉切除术，切除皮瓣 + 功能性颈部淋巴结清扫 + PMMC瓣；7例行全喉切除术 + 颈部淋巴结清扫并切除皮肤（4例改良根治性，3例根治性） + PMMC瓣重建。所有病例皮瓣均存活，2例（12.5%）发生PCF伴伤口感染，但经保守治疗在2周内愈合。3例（18.75%）出现肩部下垂，经物理治疗后好转。7例（36.84%）发生轻度术后肺部感染，经广谱抗生素和胸部物理治疗后改善。
在挽救性喉手术中常规使用胸大肌肌皮瓣对这类高风险患者非常有帮助，可降低咽皮肤瘘的发生率并促进皮肤伤口一期愈合。该皮瓣能使患者受益于早期经口进食、良好的气管切开护理、缩短住院时间以及预防灾难性的血管破裂死亡。
胸大肌肌皮瓣 - 预防咽皮肤瘘 - 挽救性喉切除术
