Anthony J P, Singer M I, Deschler D G, Dougherty E T, Reed C G, Kaplan M J
Department of Surgery, University of California at San Francisco 94143-0932.
Am J Surg. 1994 Nov;168(5):441-5. doi: 10.1016/s0002-9610(05)80095-9.
For recovery to be deemed adequate, the laryngectomized patient requires restoration of both the ability to swallow and to speak. Immediate results and long-term functional recovery after pharyngoesophageal (PE) reconstruction with the radial forearm free flap were studied in 22 consecutive patients who had undergone primary (n = 3) or secondary (n = 19) reconstructions after total laryngectomy. Circumferential reconstructions were done in 13 patients (mean length 10 cm, range 6 to 16) and patch reconstructions in 9 patients (defect size range 4 x 4 cm to 8 x 7 cm). Flap leakage was evaluated for all patients, and postoperative diet and ability to swallow were evaluated for 16 patients with an intact tongue base. Voice was evaluated for 6 patients with circumferential reconstructions who had later undergone tracheoesophageal puncture with placement of a Blom-Singer voice prosthesis, and the results compared with those of a control group of 5 voice-restored patients who had undergone laryngectomy with primary closure of the pharyngoesophagus. All 22 flaps survived and none of the patients died. Although 7 (32%) reconstructions leaked, all but 1 closed spontaneously. Fourteen (88%) of the patients with an intact tongue base have no dysphagia and are on a regular diet, and 2 remain on an oral liquid diet. Compared with controls, patients with a radial free-flap reconstruction had similar loudness with soft speech (43 dB for controls versus 52 dB for radial patients) and loud speech (61 dB versus 63 dB), comparable fundamental frequencies (136 Hz versus 125 Hz), and increased jitter (2% versus 5%). Speech intelligibility was judged by untrained listeners as excellent for 4 of the patients with radial flaps and good for the other 2. The radial free flap offers the advantages of rapid harvest, high flap reliability, and minimal donor-site and patient morbidity. Leakage rate and deglutition restoration were similar to those of other reconstructions, including the free jejunal flap. Speech rehabilitation in patients secondarily reconstructed with the radial free flap was nearly equivalent to that of total laryngectomy patients who have primary closure of the pharynx and was superior to that reported with other popular PE reconstructions, including the gastric pull-up and the free jejunal flap.
为了使恢复被认为是充分的，喉切除患者需要恢复吞咽和说话的能力。对22例接受全喉切除术后一期（n = 3）或二期（n = 19）咽食管（PE）重建的连续患者，研究了采用桡侧前臂游离皮瓣进行PE重建后的即时结果和长期功能恢复情况。13例患者进行了环形重建（平均长度10 cm，范围6至16 cm），9例患者进行了补片重建（缺损大小范围为4×4 cm至8×7 cm）。对所有患者评估皮瓣渗漏情况，对16例舌根完整的患者评估术后饮食和吞咽能力。对6例进行环形重建且后来接受气管食管穿刺并植入Blom-Singer语音假体的患者评估语音情况，并将结果与5例接受喉切除并一期关闭咽食管的语音恢复患者的对照组进行比较。所有22个皮瓣均存活，无患者死亡。虽然7例（32%）重建出现渗漏，但除1例外在所有患者中均自行闭合。14例（88%）舌根完整的患者无吞咽困难且饮食正常，2例仍采用口服流食。与对照组相比，采用桡侧游离皮瓣重建的患者轻声说话时响度相似（对照组为43 dB，桡侧皮瓣患者为52 dB）、大声说话时响度相似（分别为61 dB和63 dB），基频相当（分别为136 Hz和125 Hz），但抖动增加（分别为2%和5%）。未经训练的听众判断，4例采用桡侧皮瓣的患者语音清晰度极佳，另外2例良好。桡侧游离皮瓣具有切取迅速、皮瓣可靠性高、供区和患者并发症最少等优点。渗漏率和吞咽恢复情况与其他重建方法相似，包括游离空肠皮瓣。采用桡侧游离皮瓣进行二期重建的患者的语音康复情况与一期关闭咽腔的全喉切除患者几乎相当，并优于其他常用的PE重建方法，包括胃上提术和游离空肠皮瓣。
