Koh Hui Kai, Tan Ngian Chye, Tan Bien Keem, Ooi Adrian S H
SingHealth Duke-NUS Head and Neck Disease Centre.
Department of Plastic, Reconstructive & Aesthetic Surgery, Singapore General Hospital, Singapore.
Ann Plast Surg. 2019 Jun;82(6):646-652. doi: 10.1097/SAP.0000000000001776.
The literature reports a wide variety of reconstructive methods for pharyngolaryngoesophageal (PLO) defects, the most widely used being anterolateral thigh (ALT), radial forearm (RFF), and jejunal free flaps (JFF). However, there is a lack of uniform agreement among head and neck surgeons as to which technique offers the best results. With an increasing number of salvage PLO extirpations, determining the role of radiotherapy in influencing postoperative complication rates is becoming ever more important. Hence, this study aims to provide an up-to-date comparison of surgical and functional outcomes of the fasciocutaneous ALT and RFF versus the intestinal JFF for circumferential and partial PLO defects and determine whether radiotherapy, both preoperative and postoperative, influences the postoperative fistula and stricture rates in circumferential defects.
A systematic review and meta-analysis were performed using PubMed for reports published in the most recent 10 years between 2007 and 2017.
A total of 33 articles comprising 1213 patients were reviewed. For circumferential defects, fistula and stricture rates were significantly lower in JFF than ALT and RFF. Of note, there was no statistical difference in tracheoesophageal speech and oral alimentation rates between JFF and the FC flaps. For near-circumferential and partial defects, ALT has a significantly lower fistula rate than RFF. There was no statistical difference in stricture and oral alimentation rates between ALT and RFF [corrected]. Fistula rates were significantly higher in patients who had preoperative radiotherapy than those without. However, there was no significant difference in fistula and stricture rates for postoperative radiotherapy.
Jejunal free flaps still remain an excellent first choice for PLO reconstruction of circumferential defects. For near-circumferential and partial defects, ALT seems to have a better performance than RFF. Preoperative radiotherapy was associated with an increased risk of fistula formation in circumferential PLO defects but not postoperative radiotherapy.
文献报道了多种用于咽喉食管（PLO）缺损的重建方法，其中应用最广泛的是股前外侧（ALT）皮瓣、桡侧前臂（RFF）皮瓣和游离空肠瓣（JFF）。然而，头颈外科医生对于哪种技术能带来最佳效果尚未达成统一共识。随着挽救性PLO切除手术数量的增加，确定放疗对术后并发症发生率的影响变得愈发重要。因此，本研究旨在对用于环形和部分PLO缺损的筋膜皮瓣ALT和RFF与肠管JFF的手术及功能结果进行最新比较，并确定术前和术后放疗是否会影响环形缺损的术后瘘管和狭窄发生率。
使用PubMed对2007年至2017年最近10年发表的报告进行系统评价和荟萃分析。
共纳入33篇文章，涉及1213例患者。对于环形缺损，JFF组的瘘管和狭窄发生率显著低于ALT组和RFF组。值得注意的是，JFF组与筋膜皮瓣组在食管气管发音和经口进食率方面无统计学差异。对于近环形和部分缺损，ALT组的瘘管发生率显著低于RFF组。ALT组和RFF组在狭窄和经口进食率方面无统计学差异[校正后]。接受术前放疗的患者瘘管发生率显著高于未接受术前放疗的患者。然而，术后放疗在瘘管和狭窄发生率方面无显著差异。
游离空肠瓣仍是环形缺损PLO重建的极佳首选。对于近环形和部分缺损，ALT似乎比RFF表现更佳。术前放疗与环形PLO缺损中瘘管形成风险增加相关，但术后放疗则不然。
