喉全切除术后气管造瘘口狭窄的预防及处理

喉全切除术是治疗晚期喉癌、喉咽癌的常规手术,术后出现气管造瘘口狭窄是其严重并发症,狭窄的气管瘘口阻碍分泌物的排除,气管内痂皮堵塞可引起窒息。我科于2007-02-2009-06对12例喉全切除术患者采取保留最上一环气管软骨环完整     

喉全切除术后气管造瘘口狭窄

喉癌是耳鼻咽喉头颈外科常见的恶性肿瘤，喉全切除是治疗中晚期喉癌的最有效办法。喉全切除后要在颈部进行气管造瘘，气管造瘘口狭窄是术后常见的并发症之一，本文就喉全切除术后气管造瘘口狭窄的诊断、病因学及治疗学研究进展作一综述。     

喉环状软骨上部分切除术的临床应用

目的探讨喉环状软骨上部分切除术治疗喉癌的喉功能保留和治疗效果。方法对2003.6～2009.3行喉环状软骨上部分切除22例中晚期喉癌的临床资料进行详细分析,其中行环-舌骨-会厌固定术15例,环-舌骨固定术5例,气管-环-舌骨固定术2例。结果所有患者均在术后第10～21天(平均15天)拔除鼻饲管,恢复吞咽功能。术后的发音情况令人满意。术后20例患者拔除气管套管,拔管率90.9%;生存时间为3～72个月,中位数23个月,平均28.8个月;3年无瘤生存率94.74%,5年无瘤生存率81.20%。结论喉环状软骨上部分切除术是一种适合中晚期喉癌的手术方式,保留喉功能肯定。     

喉切除后气管造瘘口复发癌

喉切除术后气管造瘘口复发癌的发生是影响喉癌、下咽癌及颈段食管癌患自下而上的重要因素。为提高临床医师对该病的认识和正确合理地制定喉癌、下咽癌及颈段食管癌的治疗方案，本综述喉切除后气管造瘘口复发的病因、发病机理、间隔时间、治疗、预后及预防。     

全喉切除术后气管造口复发癌

目的 探讨喉癌、下咽癌全喉切除术后气管造口复发癌病因、诊断及治疗，提出气管造口复发癌预防措施。方法 回顾性分析16例喉癌、下咽癌全喉切除术后气管造口复发癌临床资料，对比手术和非手术治疗的效果。结果 16例气管造口复发癌全喉切除术前均有肿瘤声门下侵犯，5例术后绝缘阳性；手术治疗11例，5例术后病理证实为淋巴结转移；术后生存5－68个月，4例（4／9）存活3年以上；放射治疗或未治疗5例，生存3－7个月；手术明显延长生命（P＜0．01）。结论 气管造口复发癌病因可能与肿瘤残存、种植、淋巴结转移、肿瘤分化有关；预后差，应重在预防。全喉手术肿瘤的彻底切除，标本切缘的显微监控，精细的颈淋巴清扫手术是降低本病发生率的重要保证。     

全喉切除术后气管造口复发癌

目的探讨喉癌、下咽癌全喉切除术后气管造口复发癌病因、诊断及治疗,提出气管造口复发癌预防措施。方法回顾性分析16例喉癌、下咽癌全喉切除术后气管造口复发癌临床资料,对比手术和非手术治疗的效果。结果16例气管造口复发癌全喉切除术前均有肿瘤声门下侵犯,5例术后切缘阳性;手术治疗11例,5例术后病理证实为淋巴结转移;术后生存5～68个月,4例（4/9）存活3年以上;放射治疗或未治疗5例,生存3～7个月;手术明显延长生命（P<0.01）。结论气管造口复发癌病因可能与肿瘤残存、种植、淋巴结转移、肿瘤分化有关;预后差,应重在预防。全喉手术肿瘤的彻底切除,标本切缘的显微监控,精细的颈淋巴清扫手术是降低本病发生率的重要保证。     

喉环状软骨上部分切除术的应用进展

近年来喉癌的发病率呈上升趋势。手术治疗仍然是喉癌的主要治疗手段，手术方式从最初确保肿瘤完全切除的喉全切除术转变为在确保肿瘤完全切除的基础上最大程度的保留喉的功能，提高患者的生存质量。而喉环状软骨上部分切除术以保留环杓单元为特点，既能完整切除肿瘤，又可保留喉的生理功能，且不需要永久性气管造瘘，在不影响生存率和局部控制率的前提下，有效改善患者的生活质量，从而得到广泛应用。本文首先概述喉癌的发病与治疗情况，其次描述喉环状软骨上部分切除术的原理与特点，最后讨论喉环状软骨上部分切除术的最新应用进展。     

五黄油治疗咽瘘的临床观察

咽瘘是指唾液和食物经下咽、食管腔与皮肤相通形成的窦道向皮肤外溢出,是喉癌、下咽癌术后的常见并发症,它不仅增加了患者术后痛苦,也妨碍了患者术后的后续治疗。1998~2006年我们对19例咽瘘患者应用五黄油纱条进行瘘口换药,取得了很好的效果。1资料与方法1.1资料本组19例患者,均为男性;年龄41~82岁,平均63.7岁。喉癌术后12例(垂直侧前喉部分切除1例、环状软骨上喉次全切除4例、全喉切除术7例),下咽癌术后7例(其中3例术中行胸大肌修补);除1例垂直侧前喉部分切除患者外,其余均于癌肿切除的同时行单侧或双侧颈廓清术,术前均未行放射治疗,1例并…     

喉癌、下咽癌复发的临床分析和治疗转归

目的探讨喉癌、下咽癌术后复发的原因及挽救性手术的可行性.方法回顾分析98例复发性喉癌、下咽癌的临床资料.68例行癌复发手术切除及术后常规放疗,其中喉部分切除术后局部复发21例,颈淋巴结转移7例,局部复发并颈淋巴结转移5例;全喉切除术后气管造瘘口复发癌8例;下咽癌切除术后局部复发2例,颈淋巴结转移15例;30例行单纯放疗或姑息性治疗.68例行癌切除术和(或)改良根治性颈清扫术,其中胸大肌皮瓣修补术29例,胃上提代食管下咽15例,游离结肠上徙代下咽食管2例.结果喉癌手术后1年、3年生存率分别为96.10%和33.33%,下咽癌手术后1年、3年生存率分别为64.71%和5.88%,而单纯放疗或姑息治疗1年及3年的生存率仅为10%和0%.结论复发性喉癌、下咽癌的预后较差,适当的手术治疗可延长患者生命,提高生存质量.     

喉全切除术在治疗中晚期喉癌中的应用

目的:探讨喉全切除术治疗中、晚期喉癌的疗效。方法:对573例喉癌患者行喉全切除术,声门上型370例,声门型90例,跨声门型75例,声门下型21例,放疗后复发17例。其中143例行单纯喉全切除术,430例同期行颈廓清术(单侧239例,双侧191例)。在喉全切除术中行气管外口造大孔术,共308例。结果:3、5及10年生存率分别为69.5%(398/573),61.1%(350/573),46.3%(149/322);220例死亡病例中,45.0%(99/220)死于局部复发;22.3%(49/220)死于颈部转移。术腔感染和咽瘘的发生率分别为12.2%,5.2%。16.6%气管外口造大孔术患者气管外口再度狭窄需行Ⅱ期气管外口扩大术或戴套管维持呼吸。13.6%的患者可以行喉部分切除术,由于不同的原因行喉全切除术。结论:喉全切除术作为治疗中、晚期喉癌的主要手段,其适应证随喉癌外科技术的发展而逐渐缩小。在采取积极的颈廓清术情况下,局部复发是主要的死亡原因。     

改良环状软骨上喉次全切除术疗效分析

目的探讨改良环状软骨上喉次全切除术的可行性及优越性。方法随机选取25例早中期喉癌患者,行改良环状软骨上喉次全切除术,并以残存的披裂黏膜翻转进行发音重建,同时将环状软骨或环甲膜直接与下拉的会厌缝合,完成环会厌吻合,重建喉功能,术后随访,并3年估疗效。结果术后随访1~3年,25例患者无一例死亡,拔管率为100%,平均拔管时间为45 d;误吸发生率为52%,所有患者发音较清晰,均能进行正常的言语交流;1例患者出现术后颈部淋巴结转移,再次行功能性颈淋巴结清扫;1例患者喉癌局部复发,再次行全喉切除。结论改良环状软骨上喉次全切除术,该术式操作简单,易掌握,可有效提高术后拔管率,降低喉狭窄发生率,提高发音质量,改善患者术后的生存质量。     

Chondrosarcoma of larynx: a case successfully reconstructed after total cricoidectomy

A case of a 64-year-old male with low-grade chondrosarcoma of the left posterolateral lamina of the cricoid cartilage is reported, in which a total cricoidectomy and partial resection of the left thyroid cartilage were performed. The rest of the thyroid cartilage and the arytenoid mucosa were approximated with sutures to the first tracheal ring, and a silastic T-tube was placed through the tracheostoma as a stent. The postoperative course has been successful except for the existence of a tracheal stoma and slight hoarseness. There has been no evidence of laryngeal stenosis nor recurrence at about 9 years postoperatively.     

CHEP with the total removal of the arytenoid on the tumor-bearing side

A supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP) consists of the resection of the whole thyroid cartilage and paraglottic space, while preserving the cricoid cartilage, the hyoid bone, most of the epiglottis and the arytenoids. Laryngeal reconstruction is achieved be suturing the cricoid cartilage and the hyoid bone. This procedure is mainly indicated for large T2 glottic carcinomas and provides a complete resection and laryngeal preservation without requiring a permanent tracheostomy. Although bilateral arytenoids are usually preserved to ensure better laryngeal function after CHEP, we unavoidably had to remove the arytenoid on the tumor-bearing side during a complete resection performed in a 56-year-old male with a rT2 tumor who had undergone radiation and demonstrated impaired vocal fold motion. Despite the resection of one arytenoid, the final laryngeal function proved to be satisfactory. CHEP should be utilized as an alternative surgical modality for conventional vertical partial laryngectomies or total laryngectomies. CHEP with the total removal of the arytenoid on the tumor-bearing side may be a useful laryngeal preservation procedure for the treatment of patients with glottic carcinoma associated with an impaired vocal fold motion or a fixed vocal fold.     

喉癌垂直部分喉切除术疗效分析

目的 :评价垂直部分喉切除术治疗喉癌的效果。方法 :1979～ 1990年行手术加放疗 2 4例 ,单纯手术 1例 ;1991～ 1997年行单纯手术治疗 2 2例 ,术后放疗 3例。新声门重建采用甲状软骨外软骨膜修复 2 2例 ,单蒂胸骨舌骨肌修复 14例 ,创面直接对合重建声带 10例 ,游离皮片移植 2例 ,颈前皮瓣修复 1例 ,舌骨肌瓣修复 1例。结果 :拔管率为 98.0 % (47/ 4 8) ,有良好的发声和吞咽功能 ;3、5、10年生存率分别为 89.6 %、82 .9%、6 6 .7% ;局部复发死亡 4例 ,死于远处转移 1例 ,死于食管癌 1例 ,非肿瘤死亡 5例。结论 :垂直部分喉切除术是治疗喉癌的有效术式 ,麻醉方式、手术切除范围和修复方法的合理选择可进一步提高疗效     

Central-part laryngectomy is a useful and less invasive surgical procedure for resolution of intractable aspiration

A novel narrow-field laryngectomy procedure known as central-part laryngectomy (CPL) for less invasive laryngeal diversion in patients with intractable aspiration is introduced. We conducted retrospective case reviews of 15 patients who underwent CPL. In this procedure, an area of the glottis including the mid-part of the thyroid cartilage and cricoid cartilage is removed to separate the digestive tract from the air way. The lateral part of the thyroid cartilage, the entire hypopharyngeal mucosa and epiglottis are preserved. The superior laryngeal vessels and nerve are not invaded. All fifteen patients were relieved of aspiration without major complications. In good accordance with cutting of the cricopharyngeal muscles and removal of the cricoid cartilage, postoperative videofluoroscopy demonstrated smooth passages of barium. Ten of 12 patients who had hoped to resume oral food intake became able to do so after CPL and two others also achieved partial oral deglutition. CPL is a useful procedure for treatment of intractable aspiration and offers considerable advantages over other laryngotracheal diversion procedures from the view point of oral food intake.     

保留杓状软骨喉次全切除喉功能重建的体会

目的　探讨应用保留杓状软骨的喉次全切除喉功能重建术治疗T3 喉癌 (声门及声门上型 )的拔管率和 3、5年生存率。方法　对 2 0例T3 级喉癌 ,其中声门型 3例 (T3 N0 M0 )、声门上型 17例(T3 N1 M0 5例 ,T3 N0 M0 12例 ) ,根据病变范围行保留单侧或双侧杓状软骨喉次全切除及功能重建术 ,并设计环咽吻合术式。结果　 3、5年生存率分别为 16/ 17(94 1% )和 11/ 12 (91 8% )。全部患者均恢复了吞咽和发音功能 ,拔管率为 95 0 %。结论　保留杓状软骨喉次全切除及功能重建术是治疗T3 喉癌的一种很好术式。手术的关键是不能损伤杓状软骨及喉返神经 ,设计好环咽吻合方案。     

伴有声带运动障碍的下咽癌手术

目的 探讨手术治疗伴有声带运动障碍下咽癌患者喉功能保留的可能性.方法 回顾性分析手术治疗伴有声带运动障碍的下咽癌26例患者的临床资料,其中梨状窝内侧壁癌23例,前壁癌2例,环后癌1例;T220例,T3 4例,T42例.全部患者均行梨状窝切除+喉部分切除术,切缘术中冰冻病理检查.残留下咽黏膜缝合修复5例,会厌复合组织瓣转移修复21例,术后均给予放射治疗.结果 全部患者3、5年生存率分别为61.4%、50.8%,喉功能全部恢复者(发音、呼吸及存咽保护功能)20例(76.9%),喉功能部分恢复者(发音及吞咽保护功能)6例(23.1%).结论 对伴有声带运动障碍的下咽癌患者,经过选择可行保留喉功能手术,以提高患者的生活质量.

Abstract：

Objective To explore the feasibility of laryngeal function preservation in surgical treatment of hypopharyngeal carcinoma with restrained vocal cord motility. Methods Twenty-six cases of hypopharyngeal carcinoma with restrained vocal cord motility treated with conservative hypopharyngectomy were retrospectively analyzed. Partial resection of pyriform sinus and partial laryngectomy were performed.The hypopharyngeal wounds were repaired by remaining hypopharyngeal mucosa in 5 cases and by epiglottis complex flaps in 21 cases. All patients received postoperative radiotherapies. Results The overall 3- and 5-year survival rates were 61.4% and 50. 8% respectively. Laryngeal functions ( voice, respiration and deglutition) were completely restored in 20 cases (76. 9% ) and partial laryngeal functions (voice and deglutition) were restored in 6 cases (23. 1% ). Conclusions To improve the postoperative life quality of the patients, the preservative surgery is feasible for some selected cases of hypopharyngeal carcinoma with restrained vocal cord motility.     

下咽、颈段食管癌手术切除后保留喉功能与发声重建

目的：探讨下咽、颈段食管癌根治术患者喉功能保留与发声重建的手术方法。方法：对16例下咽、颈段食管癌患者手术切除肿瘤后，实施保留全喉及部分喉切除喉功能重建；全喉切除后Blom-Singer 1期、2期发声重建术，同时下咽及颈段食管缺损分别采用胃－咽吻合、前臂游离皮瓣、胸大肌肌皮瓣、胸三角皮瓣、胸锁乳突肌肌皮瓣，颈前肌皮瓣、喉气管粘膜瓣等方法进行整复。保留全喉8例，保留部分喉喉重建3例，全喉切除后行Blom-Singer发声重建1期4例，2期1例。结果：16例中除1例术后14d心脏病变发死亡外，均恢复了吞咽功能，13例恢复发声功能，6例恢复了全喉功能，2例恢复了部分喉功能（不能拔管）。5例行Blom-Singer发声重建者，均发声成功。结论：依据患者病变部位、肿瘤分期、身体状况、年龄等因素，切除肿瘤后采用不同的手术方法行喉功能保留及发声重建，可提高患者术后生存质量。     

Supracricoid laryngectomy with cricohyoidopexy: a partial laryngeal procedure for selected supraglottic and transglottic carcinomas

The partial horizontal supracricoid laryngectomy with cricohyoidopexy consists of resection of the whole thyroid cartilage and paraglottic space, as well as the epiglottis and the whole pre-epiglottic space. The cricoid cartilage, the hyoid bone, and at least one arytenoid cartilage are spared. Sixty-eight patients with squamous cell carcinoma of the supraglottis who underwent this procedure during the period from 1974 through 1986 are presented. Conventional horizontal supraglottic laryngectomy was contraindicated in all cases. All but three patients (95.4%) recovered physiologic deglutition, and none required a permanent tracheostomy. The 3-year actuarial survival rate was 71.4%. No local recurrences were encountered. The indications for the procedure are carcinomas of the supraglottis that 1. involve the glottis and anterior commissure, 2. invade the ventricle, 3. present with a marked limitation of true vocal cord mobility (transglottic lesions), and 4. invade the thyroid cartilage. The procedure is presented as a useful alternative to radiation therapy, horizontal supraglottic laryngectomy, and total laryngectomy in select cases of supraglottic carcinoma.     

喉全切除后气管造口植入式镍钛合金支架的研制和临床应用

目的 :研制喉全切除后气管造口植入式镍钛合金支架并临床应用 ,以期替代金属全喉套管预防术后气管造口狭窄。材料与方法 :直径为 0 .8mm的镍钛形状记忆合金钢丝 ,镍 5 0 %、钛 5 0 % ,支架形状为半圆形 (2 / 3)结构 ,其表面光滑 ,支架直径 18mm、19.5 mm、2 1mm三种规格。全喉切除 2 2例 ,选择大小合适的气管造口植入式镍钛合金支架 ,缝合固定于气管残段的第一和第二气管软骨环之间筋膜后 ,常规气管造口。术后气管造口敞开 ,免用金属全喉套管。结果 :术后造口 期愈合 19例 ;术后感染 3例。术后气管造口皮缘疤痕环形增生所至狭窄 6例 ,后经局麻下疤痕环切扩大造口治愈。术后无呼吸道症状 ,放疗后造口局部无组织坏死或感染。结论 :气管造口植入式镍钛合金支架临床应用安全、预防气管造口狭窄 ,可望替代金属全喉套管并预防气管造口狭窄。