下咽癌累及颈段食管的处理  

Surgical treatment of hypopharyngeal cancer with cervical esophageal invasion

作　　者：雷大鹏[1] 潘新良[1] 许风雷[1] 刘大昱[1] 张立强[1] 李学忠[1] 解光[1] 栾信庸[1] 

机构地区：[1]山东大学齐鲁医院耳鼻咽喉科,济南250012

出　　处：《中华耳鼻咽喉头颈外科杂志》2005年第9期691-695,共5页Chinese Journal of Otorhinolaryngology Head and Neck Surgery

摘　　要：目的总结下咽癌累及颈段食管的处理经验。方法回顾性分析1989年—2000年48例累及颈段食管的下咽癌患者的手术治疗情况,其中男38例,女10例;年龄26～71岁,平均54.3岁。梨状窝癌33例,下咽后壁区癌14例,环后癌1例,均无远处转移。根据UICC1997年TNM分期标准均为T4M0期,其中cN028例,cN115例,cN25例。喉全切除术8例,喉部分切除残喉气管瓣修复下咽17例,23例保留了喉功能。所有病例均行改良性颈清扫术,其中单侧清扫38例,双侧清扫10例。患侧甲状腺叶切除42例。下咽食管缺损的修复方法分别为:喉气管瓣修复11例,胸大肌肌皮瓣13例,喉气管瓣+胸大肌肌皮瓣6例,裂层皮片+胸大肌肌皮瓣10例,胃上提咽胃吻合3例,结肠上徙5例。术后均接受放射治疗,剂量为55～75Gy。结果手术证实颈部淋巴结转移20例病理诊断;高分化鳞状细胞癌18例,中分化鳞状细胞癌24例,低分化鳞状细胞癌6例。术后并发症包括胸部刀口裂开1例,咽瘘10例。直接法计算生存率,失访2例以死亡计。全组患者3、5年生存率分别为52.1%(25/48)和27.3%(12/44)。保留喉功能组3、5年生存率分别为65.2%(15/23)和33.3%(7/21),不保留喉功能组3、5年生存率分别为40.0%(10/25)和21.7%(5/23)。23例保留了喉功能,15例患者拔除了气管套管,恢复了全部喉功能(发音、呼吸、吞咽保护),8例患者恢复了部分喉功能(发音、吞咽保护),拔管率为65.2%(15/23)。结论下咽癌累及颈段食管的处理以手术+放疗的综合治疗为主,需行患侧颈清扫术,应尽量保留喉功能,无法保留喉功能时可以采用喉气管瓣或联合裂层皮片、胸大肌肌皮瓣修复下咽颈段食管缺损,颈段食管缺损较大时则采用胃或结肠代替。Objective To review the experience of different surgical construction methods for hypopharyngeal cancer with cervical esophageal invasion. Methods From 1989 to 2000 ,forty-eight patients with advanced hypopharyngeal cancer and cervical esophageal invasion were retrospectively reviewed, including 38 males and 10 females. The median age was 54. 3 years old, ranged from 26 to 71 years old. According to UICC 1997 criteria, all the tumors were T4 stage and originated from the pyriform sinus（33）, posterior pharyngeal wall（14） ,postcricoid area（1） ,there were 28 patients in cN0, 15 in cN1,5 in cN2 and no distant metastasis. Precise preoperative evaluation was performed with computed tomography scan, barium swallow perspective and biopsy. All the patients received modified neck dissection, including both unilateral （38 patients ） and bilateral （10 patients ）. Pharyngoesophageal defect reconstruction methods were： laryngotracheal flap in 11 patients, pectoralis major musculocutaneous flap in 13, laryngotracheal flap combined with pectoralis major musculocutaneous flap in 6, pectoralis major musculocutaneous flap combined with the split graft in 10, stomach pulling-up in 3, colon interposition in 5 patients. Total laryngectomy was carried out in 8 patients. All patients received radiotherapy postoperatively （ dose 55 N 75 Gy）. Results The cervical lymph node metastasis was found in 20 patients. Pathologic findings showed that well,moderately and lower differentiated squamous cell carcinomas were 18,24,6 cases, respectively. The overall 3 and 5 year survival rates were 52. 1% （25/48） and 27.3% （12/44） , respectively. The 3 and 5 year survival rates in functionally preserved group were 65.2% （ 15/23 ） and 33. 3% （7/21）, while in non- functionally preserved group were 40.0% （10/25） and 21.7% （5/23）, respectively. Fifteen patients laryngeal functions （voice, respiration and deglutition） were completely restored and 8 patients partially restored （voice and deglutition）.

关 键 词：下咽肿瘤 食管 修复外科手术 存活率 颈段食管缺损 下咽癌 高分化鳞状细胞癌 胸大肌肌皮瓣 保留喉功能 5年生存率 

分 类 号：R739.63[医药卫生—肿瘤] R735.1[医药卫生—临床医学]