Clayman G L, DeMonte F, Jaffe D M, Schusterman M A, Weber R S, Miller M J, Goepfert H
Department of Head and Neck Surgery, University of Texas M. D. Anderson Cancer Center, Houston, USA.
Arch Otolaryngol Head Neck Surg. 1995 Nov;121(11):1253-7. doi: 10.1001/archotol.1995.01890110031006.
To determine the complications of extensive cranial-base resection requiring free-tissue transfer (FTT) and the effect of these resections on local control and survival among patients with malignant neoplasms of the skull base.
Before the advent of FTT, cranial-base surgery was often limited by our inability to adequately repair defects comprising communication between the central nervous system and upper aerodigestive tract. The use of FTT in cranial-base resections was therefore assessed to determine whether the improved procedure (ie, extensive resections) would improve local control and prolong survival.
A retrospective review of 39 consecutive craniofacial resections with FTT reconstruction in patients with malignant neoplasms involving the cranial base.
All 39 patients had malignant neoplasms, including 20 squamous cell carcinomas, eight basal cell carcinomas, two melanomas, two neuroendocrine carcinomas, two adenoid cystic carcinomas, and various other malignant neoplasms. Resections involved the anterior, middle, or posterior cranial fossa in 19 patients (49%), 10 patients (26%), and three patients (8%) of cases, respectively. The remaining seven surgeries (18%) involved resection of more than one of these cranial base sites.
Early (< 14 days after surgery) complications occurred in 14 (36%) of 39 patients. Major complications included failure of microvascular anastomosis (n = 1), pneumonitis (n = 3), perioperative myocardial infarction (n = 1), and cerebrovascular accident (n = 1). The microvascular anastomosis failure was promptly treated with surgical intervention. Two patients (5%) experienced late postoperative complications; one had cellulitis at the donor site, and the other had pneumonitis. No perioperative deaths or complications such as meningitis, epidural abscess, or tension pneumocephalus occurred. The 2-year disease-specific survival rate was 55%, and the 2-year local control rate, 49%; both were determined by the Kaplan-Meier method. The nine patients who died of their disease had a median survival of 9 months. Log-rank testing showed that pathologically positive margins and transdural pathology were the most significant predictors of local recurrence and death of disease.
Contemporary surgical approaches provide an opportunity for wide surgical excision of dura and skull-base structures that normally separate the intracranial and extracranial cavities. These major skull-base resections can be reconstructed safely and effectively with FTT. Patients with malignant neoplasms of the dura and skull base should be approached with the understanding that transdural disease portends an increased risk of local recurrence and death of disease.
确定需要游离组织移植（FTT）的广泛颅底切除术的并发症，以及这些切除术对颅底恶性肿瘤患者局部控制和生存的影响。
在游离组织移植出现之前，颅底手术常常受到限制，因为我们无法充分修复包括中枢神经系统与上呼吸道消化道之间连通的缺损。因此，对游离组织移植在颅底切除术中的应用进行评估，以确定这种改进的手术方法（即广泛切除术）是否能改善局部控制并延长生存期。
对39例连续接受颅面切除术并采用游离组织移植重建的颅底恶性肿瘤患者进行回顾性研究。
39例患者均患有恶性肿瘤，包括20例鳞状细胞癌、8例基底细胞癌、2例黑色素瘤、2例神经内分泌癌、2例腺样囊性癌以及其他各种恶性肿瘤。手术切除分别涉及前颅窝、中颅窝或后颅窝的患者有19例（49%）、10例（26%）和3例（8%）。其余7例手术（18%）涉及切除不止一个上述颅底部位。
39例患者中有14例（36%）发生早期（术后<14天）并发症。主要并发症包括微血管吻合失败（n = 1）、肺炎（n = 3）、围手术期心肌梗死（n = 1）和脑血管意外（n = 1）。微血管吻合失败通过手术干预得到及时治疗。2例患者（5%）出现晚期术后并发症；1例供区蜂窝织炎，另1例肺炎。未发生围手术期死亡或诸如脑膜炎、硬膜外脓肿或张力性气颅等并发症。采用Kaplan-Meier法确定的2年疾病特异性生存率为55%，2年局部控制率为49%。9例死于疾病的患者中位生存期为9个月。对数秩检验显示，病理切缘阳性和经硬膜病理是局部复发和疾病死亡的最显著预测因素。
当代手术方法为广泛切除通常分隔颅内和颅外腔隙的硬脑膜和颅底结构提供了机会。这些大型颅底切除术可以通过游离组织移植安全有效地重建。对于患有硬脑膜和颅底恶性肿瘤的患者，应认识到经硬膜疾病预示着局部复发和疾病死亡风险增加。
