Murakami Y
Gan To Kagaku Ryoho. 1986 Apr;13(4 Pt 2):1766-76.
A combination of total laryngopharyngectomy and primary reconstruction of the cervical esophagus is the operation of choice in the treatment of advanced hypopharyngeal cancer. For the excision, the most important task for the surgeon is to estimate the adequate safety margins superiorly and inferiorly. In order to ensure safer margins, animal experiments on lymph-flow in the submucosal layer of the hypopharyngeal cavity that is considered to be responsible for invisible submucosal invasion of cancer, were undertaken. Based on the results of both these experiments and clinical observations of many cases, it appeared most likely that cancers in the pyriform sinus or in the posterior wall tend to spread upward to the oropharyngeal cavity, while those in the postcricoid region have a tendency to invade in every direction but mainly downward to the cervical esophagus. In many cases, therefore, the cavity should be excised at a level just inferior to the palatine tonsil with a safety margin of more than 2 cm. The inferior excision level, on the other hand, should be decided according to whether the invasion extends beyond the level of the 7th cervical vertebra. When the tumor invades down to the level of the thoracic vertebrae, total esophagectomy should be indicated because of the high incidence of skip lesions in the lower esophagus. For better prognosis, bilateral neck dissection is recommended, since hypopharyngeal cancer has high (more than 30%) incidence of contralateral neck metastasis except for well differentiated T2 lesions in the pyriform sinus. For reconstruction of the cervical esophagus, a one-stage technique using a pectoralis major myocutaneous flap has many advantages over other options, and technical details are reported here in this paper. In some patients, however, this technique is not advisable. In female patients with large breasts or thick subcutaneous fat, the flap cannot be utilized because of its bulkiness, and a newly developed technique that uses a skin-grafted pectoralis major muscle flap is indicated. For patients with a history of heavy radiotherapy, the use of the flap is also contra-indicated because of the risk of salivary fistula, and a staged operation using a deltopectoral skin flap is recommended.
全喉咽切除术联合颈段食管一期重建术是治疗晚期下咽癌的首选手术方式。对于切除手术，外科医生最重要的任务是评估上下方足够的安全切缘。为确保更安全的切缘，我们进行了动物实验，研究下咽腔黏膜下层的淋巴引流情况，该层被认为与癌症的隐匿性黏膜下侵犯有关。基于这些实验结果以及对众多病例的临床观察，梨状窝或后壁的癌症似乎最容易向上蔓延至口咽腔，而环状软骨后区的癌症则倾向于向各个方向侵犯，但主要是向下侵犯至颈段食管。因此，在许多情况下，应在腭扁桃体下方水平切除病变，安全切缘应超过2厘米。另一方面，下方的切除水平应根据侵犯是否超过第7颈椎水平来决定。当肿瘤侵犯至胸椎水平时，由于下食管跳跃性病变的发生率较高，应行全食管切除术。为了获得更好的预后，建议行双侧颈部清扫术，因为除了梨状窝高分化T2病变外，下咽癌对侧颈部转移的发生率较高（超过30%）。对于颈段食管重建，采用胸大肌肌皮瓣的一期技术比其他方法有许多优势，本文在此报告其技术细节。然而，在一些患者中，这种技术并不适用。对于乳房较大或皮下脂肪较厚的女性患者，由于皮瓣体积较大，无法使用，应采用新开发的带皮肤移植的胸大肌肌瓣技术。对于有重度放疗史的患者，由于存在唾液瘘的风险，也禁忌使用该皮瓣，建议采用胸三角皮瓣分期手术。
