Gößler U R
Universitäts-HNO-Klinik, Universitätsmedizin Mannheim, Mannheim.
Laryngorhinootologie. 2012 Mar;91 Suppl 1:S63-85. doi: 10.1055/s-0031-1297242. Epub 2012 Mar 28.
The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background. The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon's armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing. In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function. In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool. In conclusion, the choice of a surgical treatment modality is influenced by the patient's anatomy, tumor size and location as well as the surgeon's personal expertise.
对于头颈外科医生而言，喉和下咽恶性肿瘤的治疗仍然是一项具有挑战性的任务，因为所选择的治疗方式常常需要在肿瘤学上合理的根治性与功能保留之间找到平衡。由于早期肿瘤阶段经口激光手术的增加以及晚期阶段放化疗的应用，传统经皮入路的使用在最近有所减少。此外，保留功能的手术方法以及尽可能高的生活质量的需求已变得明显。鉴于这些事实，在当代背景下讨论传统经皮入路治疗喉和下咽恶性肿瘤的基本原理及重要性。经皮开放性部分喉切除术仍然是外科医生治疗早期和晚期喉癌的重要工具，特别是在使用硬质喉镜无法全面观察喉部的情况下。开放性部分喉切除术在前连合处能提供更好的视野和肿瘤学安全性，尤其是在复发病例中。在某些晚期病例和挽救性手术中，环状软骨上喉切除术是以术后高发病率和极具挑战性的吞咽功能康复为代价，提供一种保留功能但肿瘤学上安全的手术治疗的重要工具。在下咽恶性肿瘤中，早期肿瘤阶段经口激光手术的使用增加导致经皮切除（通过部分喉切除术联合部分咽切除术）减少。在梨状窝和环状软骨后区肿瘤累及喉部的晚期阶段，全喉切除术联合部分咽切除术是一种肿瘤学上安全的方法。使用环状喉咽切除术联合/不联合食管切除术的根治性手术方法适用于晚期复发的挽救性病例，或作为放化疗无法提供足够的肿瘤学控制或功能保留时患者的主要手术方法。在即将进行重建的病例中，在颈段食管未受累的情况下，游离筋膜皮瓣（股前外侧皮瓣、桡侧前臂皮瓣）似乎比肠瓣能提供更好的效果，从而实现更好的嗓音康复，并发症和术后发病率更少。在挽救性手术中，胃网膜游离皮瓣已被证明是一种有价值的工具。总之，手术治疗方式的选择受患者的解剖结构、肿瘤大小和位置以及外科医生的个人专业知识影响。
