胸壁肿瘤术后胸壁复杂缺损修复重建策略  

A general algorithm for complex oncologic chest wall reconstruction based on a retrospective review

作　　者：宋达疆[1] 李赞[1] 周晓[1] 彭小伟[1] 周波[1] 肖高明[2] 吕春柳[1] 杨丽嫦[1] 彭文[1] 欧延[1] 

机构地区：[1]湖南省肿瘤医院肿瘤整形外科,长沙410078 [2]湖南省肿瘤医院胸外科,长沙410078

出　　处：《中华胸心血管外科杂志》2017年第3期164-167,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

摘　　要：目的 总结复杂胸壁缺损修复10年经验,探讨胸壁肿瘤术后胸壁复杂缺损修复的原则、方法.方法 2005年1月至2015年12月共收治胸壁肿瘤术后复杂缺损需修复重建的患者87例,其中男37例,女50例;年龄24～75岁,中位年龄52.3岁.病理类型包括皮肤鳞状细胞癌10例,软组织肉瘤22例,骨软骨肉瘤13例,乳腺癌复发42例.胸壁缺损类型包括单纯胸骨肋骨缺损19例,单纯软组织缺损33例（缺损无法直接缝合或邻近皮瓣转移修复）,胸壁全层缺损35例.26例小的、非重要部位的肋骨缺损采用单纯网片修复,28例胸骨、心前区、大范围的肋骨缺损采用“网片＋骨水泥＋网片”三明治的方法加强内固定.软组织修复采用带蒂胸廓内动脉穿支皮瓣3例,带蒂腹壁上动脉穿支皮瓣（4例）,带蒂胸大肌皮瓣8例,游离股前外侧穿支皮瓣9例,游离腹壁下动脉穿支皮瓣17例,带蒂胸外侧皮瓣5例,带蒂背阔肌皮瓣17例,带蒂腹直肌皮瓣15例,游离腹壁下动脉穿支皮瓣联合对侧腹直肌皮瓣移位4例,带蒂双叶背阔肌皮瓣5例.结果 1例带蒂腹直肌皮瓣修复胸壁患者术后部分皮瓣坏死,再采用游离股前外侧皮瓣修复;1例带蒂双叶背阔肌皮瓣修复患者一叶皮瓣远端坏死约1/4,经换药后伤口愈合;2例游离腹壁下动脉穿支皮瓣修复患者分别于术后第1、2天出现静脉危象,急诊手术探查,重新吻合血管后成功挽救皮瓣,伤口一期愈合.其余患者伤口均愈合良好,皮瓣成活良好.随访9～72个月,中位值31个月,均无复发,外观功能恢复满意.结论 根据胸部缺损区域的大小、位置和复杂程度选择相应、合适的组织瓣修复可获得满意效果.游离皮瓣是修复肿瘤切除术后巨大、复杂胸壁软组织缺损的有效方法.Objective To review our single institutional 10-year experience in complex chest wall reconstruction and identify a working algorithm based on our retrospective analysis.Methods A retrospective analysis of 87 patients who underwent chest wallreconstruction in our department from January 2005 to December 2015.Fifty female patients and 37 male patients who underwent the above procedure were reviewed retrospectively.The median age of the patients is 52.3 years （24-75years）.Histologic diagnosis including squamous-cell carcinoma （n =10）,soft tissue sarcoma（n =22）,chondrosarcomas（n =13） and metastasis from breast cancer（n =42）.Type of skeletal defect including partial ribs/sternum defects in 19 cases,soft tissue defects alone in 33 cases,complicated composite chest wall defects involving multiple layers（soft tissue,ribs/sternum,and intrathoracic organs） in 35 cases.Sole methylmethacrylate/polypropylene mesh was used for small sized rib defects in 26cases.Methylmethacrylate/polypropylene mesh sandwich prostheses was used in 28 cases with extensive skeletal reconstruction after partial sternectomy and rib resection.The chest wall defects were repaired with pedicled internal mammary artery perforator flap（3 cases）,pedicled deep superior epigastric artery perforator flap（4 cases）,pedicled pectoralis major flap（8 cases）,free anterolateral thigh perforator flap（9 cases）,free deep inferior epigastric artery perforator flap（17 cases）,pedicled lateral thoracic flap（5 cases）,pedicled latissimus dorsi flap（17 cases）,pedicled rectus abdominis flap（15 cases）,free deep inferior epigastric artery perforator flap combined with pedicled rectus abdominis flap （4 cases）,pedicled bipaddled latissimus dorsi flap（5 cases）.11 cases with extensive full-thickness defects of the chest wall,the skeletal reconstruction was achieved with prosthetic sandwich and then covered with the omental flap,further free flaps were harvested for skin and soft tissue repairing.Results 1 case with p

关 键 词：胸壁缺损 外科皮瓣 游离皮瓣移植 

分 类 号：R734.4[医药卫生—肿瘤]