帶有感覺神經(jīng)重建的股前外側(cè)皮瓣修復(fù)舌癌術(shù)后缺損的研究
發(fā)布時(shí)間：2019-05-24 02:13
【摘要】：目的觀察應(yīng)用股前外側(cè)皮瓣修復(fù)舌癌切除術(shù)后缺損的修復(fù)效果,探討帶有神經(jīng)重建的股前外側(cè)皮瓣與未行神經(jīng)吻合的股前外側(cè)皮瓣修復(fù)舌癌術(shù)后缺損,患者語音功能、吞咽功能及再造舌的感覺功能恢復(fù)的差異,應(yīng)用美國華盛頓大學(xué)生存質(zhì)量調(diào)查問卷(University of Washington head and neck quality-of-life questionnaire,UW-QOL)評價(jià)股前外側(cè)皮瓣修復(fù)舌癌術(shù)后缺損患者的術(shù)后生存質(zhì)量,比較帶有神經(jīng)重建患者與未行神經(jīng)吻合患者生存質(zhì)量的差異。方法共收集52例局部中晚期(T3-4N0-3M0)舌癌患者,將其分為試驗(yàn)組和對照組,于全身麻醉和經(jīng)鼻氣管插管下進(jìn)行手術(shù)。1、舌癌連續(xù)整塊切除:根據(jù)舌癌TNM分期選擇不同的頸清掃術(shù),清掃過程中需要保留面動(dòng)、靜脈,甲狀腺上動(dòng)、靜脈,對于頸內(nèi)靜脈切除患者則需要將頸外靜脈保留以供血管吻合。2、股前外側(cè)肌皮瓣的制備:沿髂前上棘外緣與髕骨外緣做一連線,從該連線中點(diǎn)向腹股溝韌帶中點(diǎn)作第二連線,該線相當(dāng)于旋股外側(cè)動(dòng)脈的體表投影。根據(jù)組織缺損情況及穿支血管情況對皮瓣的大小及厚度進(jìn)行設(shè)計(jì),試驗(yàn)組在皮瓣上保留股外側(cè)皮神經(jīng)的分支。3、舌與口底缺損重建:在顯微鏡下根據(jù)供區(qū)血管蒂與受區(qū)血管管徑變化,采用端端吻合或端側(cè)吻合將供區(qū)血管與受區(qū)血管吻合。試驗(yàn)組另行股外側(cè)皮神經(jīng)與舌神經(jīng)的吻合。將穿支皮瓣用于舌與口底粘膜及部分面部皮膚缺損的修復(fù),必要時(shí)需要折疊皮瓣修復(fù)。4、術(shù)后皮瓣監(jiān)測及患者功能檢測:術(shù)后觀察患者皮瓣顏色、是否腫脹、Doppler超聲血流探測評估皮瓣血管通暢性,同時(shí)觀察術(shù)后愈合情況。術(shù)后6個(gè)月檢測患者語音功能、吞咽功能,術(shù)后3、6個(gè)月檢測再造舌感覺功能。并采用華盛頓大學(xué)生存質(zhì)量調(diào)查問卷(UW-QOL)對兩組患者的生存質(zhì)量進(jìn)行評價(jià)。結(jié)果1、52例患者中,試驗(yàn)組25例,行軟組織修復(fù)及股外側(cè)皮神經(jīng)與舌神經(jīng)的吻合;對照組27例,僅行舌癌切除術(shù)后軟組織的修復(fù)。兩組患者中51例皮瓣全部成活,皮瓣成活率為98.1%。試驗(yàn)組1例患者皮瓣術(shù)后1天發(fā)生血管危象,手術(shù)探查后恢復(fù)血運(yùn)。術(shù)后9天部分皮瓣蒼白壞死,部分成活。2例患者術(shù)后發(fā)生淋巴管漏,經(jīng)清創(chuàng)縫合術(shù)后傷口愈合。其余患者傷口均愈合良好。2、52例患者中10例患者于術(shù)后約4個(gè)月行放療。2例患者術(shù)后失訪,3例患者因腫瘤復(fù)發(fā)死亡,1例患者原發(fā)腫瘤復(fù)發(fā)。其余46例患者于術(shù)后6個(gè)月行功能檢測,試驗(yàn)組24例,對照組22例。檢測結(jié)果顯示,兩組患者語音功能及吞咽功能均恢復(fù)較好。試驗(yàn)組患者語音功能評分為4.13±0.68,對照組患者語音功能評分為3.73±0.70,兩組患者術(shù)后語音功能沒有明顯差別;試驗(yàn)組患者吞咽功能為5.50±0.51,對照組患者吞咽功能評分為5.10±0.75,試驗(yàn)組患者吞咽功能優(yōu)于對照組(P=0.04)。對照組僅4例患者測得冷熱感覺,試驗(yàn)組21例患者有冷熱感知覺;對照組2例患者再造舌有痛覺,試驗(yàn)組20例患者檢測到痛覺。術(shù)后6個(gè)月,對照組患者皮瓣均無兩點(diǎn)辨別覺,而試驗(yàn)組患者20例可檢測到兩點(diǎn)辨別覺(5.15 mm±3.20);并且,隨著術(shù)后恢復(fù)時(shí)間的延長,兩點(diǎn)辨別能力增強(qiáng)。3、術(shù)后6個(gè)月對患者生存質(zhì)量進(jìn)行評價(jià),結(jié)果顯示股前外側(cè)皮瓣修復(fù)舌癌術(shù)后缺損,患者總體生存質(zhì)量得分為907.39分。其中,得分最高的3個(gè)分項(xiàng)目為肩功能、焦慮和疼痛,得分最低的3個(gè)分項(xiàng)目為咀嚼、味覺和語言。試驗(yàn)組患者在活力、吞咽、情緒項(xiàng)目得分高于對照組,且試驗(yàn)組患者的生存質(zhì)量總評分高于對照組患者(t=3.07,P=0.00)。結(jié)論股前外側(cè)皮瓣修復(fù)局部中晚期舌癌術(shù)后缺損,并發(fā)癥少,皮瓣成活率高,對供區(qū)外形及功能的損傷小,修復(fù)效果理想,患者的語音功能和吞咽功能均可獲得良好的恢復(fù)。與常規(guī)股前外側(cè)皮瓣修復(fù)方法相比,帶有感覺神經(jīng)重建的皮瓣修復(fù)局部中晚期舌癌術(shù)后缺損,有助于患者吞咽功能的恢復(fù),而對語音功能的恢復(fù)無明顯影響。并且,帶有神經(jīng)吻合的患者術(shù)后感覺功能的恢復(fù)優(yōu)于常規(guī)股前外側(cè)皮瓣修復(fù)的患者,患者滿意度增高,進(jìn)而提高了患者的生存質(zhì)量。隨著帶感覺神經(jīng)的股前外側(cè)皮瓣臨床療效得到越來越多的肯定,可能將成為股前外側(cè)皮瓣修復(fù)舌癌術(shù)后缺損的常規(guī)術(shù)式。
[Abstract]:Objective To observe the effect of the application of the anterolateral skin flap in the repair of the defect after the operation of the tongue cancer, and to investigate the defect of the front lateral skin flap with the nerve reconstruction and the anterolateral skin flap of the non-line nerve to repair the postoperative defect of the tongue cancer and the voice function of the patient. The difference of the sensory function of the swallowing function and the reconstructive tongue was used to evaluate the postoperative quality of life of the patients with the defect of the tongue cancer after using the University of Washington head and neck quality-of-life questionnaire (UW-QOL). To compare the difference of the quality of life between the patients with the neuroreconstruction and the non-linear neuroanastomosis. Methods A total of 52 patients with locally advanced (T3-4N0-3M0) tongue cancer were collected and divided into the test group and the control group. In the patients with internal jugular vein, it is necessary to reserve the external jugular vein for the vascular anastomosis.2. Preparation of the anterolateral myocutaneous flap: make a connection with the outer edge of the patella along the outer edge of the upper spinous process of the patella, and make a second connection from the midpoint of the connecting line to the middle point of the inguinal ligament, This line is equivalent to the body surface projection of the lateral femoral artery. The size and thickness of the skin flap were designed according to the condition of the tissue defect and the condition of the blood vessel, and the branch of the lateral skin nerve of the thigh was retained on the test group. An end-to-end anastomosis or end-to-end anastomosis is used to anastomose the blood supply vessel to the region of the subject. In the test group, the lateral skin nerve was found to be in agreement with the nerve of the tongue. The flaps were used for the repair of the skin defects of the tongue and the submucous membrane of the oral cavity and the part of the facial skin, and the flap was needed to be folded for repair as necessary.4. The flap monitoring and the function test of the patient: the color of the skin flap of the patient was observed after operation, and whether the flap was swollen or not, and the blood vessel patency of the flap was evaluated by Doppler flow detection. The postoperative healing was also observed. The voice function and swallowing function of the patient were detected 6 months after operation, and the reconstructive tongue sensation was detected in 3 and 6 months after operation. The quality of life of the two groups was evaluated by the University of Washington's Quality of Life Questionnaire (UW-QOL). Results: Of the 52 patients,25 of the test group, the repair of the soft tissue and the nerve of the lateral skin and the nerve of the tongue were performed, and in the control group, the soft tissue was repaired only after the operation of the tongue cancer. The survival rate of the flap was 98.1%. One patient with the test group had a blood vessel crisis after 1 day after the operation, and the blood was recovered after the operation. The postoperative 9-day partial flap of the skin flap was pale and necrotic, and some survived. In two cases, the lymphatic leakage occurred after the operation, and the wound was healed after the operation of the debridement and suture. The wound of the remaining patients was well healed. In 2,10 of the 52 patients were treated with radiotherapy for about 4 months after operation.2 patients were lost to follow-up after operation, and 3 of the patients died due to the recurrence of the tumor and 1 case had a recurrence of the primary tumor. The remaining 46 patients were tested in 6 months after operation,24 in the test group and 22 in the control group. The results showed that both the voice function and the swallowing function of the two groups recovered well. The voice function score of the test group was 4.13 and 0.68, and the voice function score of the control group was 3.73 and 0.70, and there was no significant difference in the voice function of the two groups. The swallowing function of the test group was 5.50 and 0.51, and the score of the swallowing function in the control group was 5.10 to 0.75. The swallowing function of the test group was superior to that of the control group (P = 0.04). The cold and hot sensation was found in only 4 patients in the control group, and the cold and hot sensation in 21 patients in the test group was found in the control group, and the pain of pain was detected in 20 patients in the test group. In the 6-month post-operation, the flap of the control group had no two-point discrimination, and 20 of the patients in the trial group were able to detect two-point discrimination (5.15 mm and 3.20); and, with the extension of the post-operative recovery time, the two-point discrimination ability was enhanced.3. The quality of the patient's life was evaluated at 6 months after the operation. The results showed that the total survival quality of the lateral skin flap of the thigh was 907.39. Among them, the three sub-items with the highest score were shoulder function, anxiety and pain, and the lowest score of three sub-items was chewing, taste and language. The scores of life quality of the patients in the test group were higher than that of the control group (t = 3.07, P = 0.00). Conclusion The anterolateral skin flap can be used to repair the postoperative defects of the local and advanced tongue cancer, the complication is little, the survival rate of the skin flap is high, the damage to the shape and function of the donor area is small, the repair effect is ideal, and the voice function and the swallowing function of the patient can be recovered well. Compared with the conventional anterolateral skin flap repair method, the skin flap with the sensory nerve reconstruction is used for repairing the postoperative defect of the local middle and late-stage tongue cancer, which is helpful for the recovery of the swallowing function of the patient, and has no obvious effect on the restoration of the voice function. And the recovery of the sensory function after the operation of the patients with the nerve anastomosis is superior to that of the patients who are repaired by the conventional anterolateral skin flap, and the satisfaction of the patients is increased, and the survival quality of the patients is further improved. As the clinical effect of the anterolateral skin flap with sensory nerve is more and more positive, it is possible to be a conventional method for repairing the postoperative defect of the tongue cancer by the anterolateral skin flap.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R739.86
本文編號：2484456
[Abstract]:Objective To observe the effect of the application of the anterolateral skin flap in the repair of the defect after the operation of the tongue cancer, and to investigate the defect of the front lateral skin flap with the nerve reconstruction and the anterolateral skin flap of the non-line nerve to repair the postoperative defect of the tongue cancer and the voice function of the patient. The difference of the sensory function of the swallowing function and the reconstructive tongue was used to evaluate the postoperative quality of life of the patients with the defect of the tongue cancer after using the University of Washington head and neck quality-of-life questionnaire (UW-QOL). To compare the difference of the quality of life between the patients with the neuroreconstruction and the non-linear neuroanastomosis. Methods A total of 52 patients with locally advanced (T3-4N0-3M0) tongue cancer were collected and divided into the test group and the control group. In the patients with internal jugular vein, it is necessary to reserve the external jugular vein for the vascular anastomosis.2. Preparation of the anterolateral myocutaneous flap: make a connection with the outer edge of the patella along the outer edge of the upper spinous process of the patella, and make a second connection from the midpoint of the connecting line to the middle point of the inguinal ligament, This line is equivalent to the body surface projection of the lateral femoral artery. The size and thickness of the skin flap were designed according to the condition of the tissue defect and the condition of the blood vessel, and the branch of the lateral skin nerve of the thigh was retained on the test group. An end-to-end anastomosis or end-to-end anastomosis is used to anastomose the blood supply vessel to the region of the subject. In the test group, the lateral skin nerve was found to be in agreement with the nerve of the tongue. The flaps were used for the repair of the skin defects of the tongue and the submucous membrane of the oral cavity and the part of the facial skin, and the flap was needed to be folded for repair as necessary.4. The flap monitoring and the function test of the patient: the color of the skin flap of the patient was observed after operation, and whether the flap was swollen or not, and the blood vessel patency of the flap was evaluated by Doppler flow detection. The postoperative healing was also observed. The voice function and swallowing function of the patient were detected 6 months after operation, and the reconstructive tongue sensation was detected in 3 and 6 months after operation. The quality of life of the two groups was evaluated by the University of Washington's Quality of Life Questionnaire (UW-QOL). Results: Of the 52 patients,25 of the test group, the repair of the soft tissue and the nerve of the lateral skin and the nerve of the tongue were performed, and in the control group, the soft tissue was repaired only after the operation of the tongue cancer. The survival rate of the flap was 98.1%. One patient with the test group had a blood vessel crisis after 1 day after the operation, and the blood was recovered after the operation. The postoperative 9-day partial flap of the skin flap was pale and necrotic, and some survived. In two cases, the lymphatic leakage occurred after the operation, and the wound was healed after the operation of the debridement and suture. The wound of the remaining patients was well healed. In 2,10 of the 52 patients were treated with radiotherapy for about 4 months after operation.2 patients were lost to follow-up after operation, and 3 of the patients died due to the recurrence of the tumor and 1 case had a recurrence of the primary tumor. The remaining 46 patients were tested in 6 months after operation,24 in the test group and 22 in the control group. The results showed that both the voice function and the swallowing function of the two groups recovered well. The voice function score of the test group was 4.13 and 0.68, and the voice function score of the control group was 3.73 and 0.70, and there was no significant difference in the voice function of the two groups. The swallowing function of the test group was 5.50 and 0.51, and the score of the swallowing function in the control group was 5.10 to 0.75. The swallowing function of the test group was superior to that of the control group (P = 0.04). The cold and hot sensation was found in only 4 patients in the control group, and the cold and hot sensation in 21 patients in the test group was found in the control group, and the pain of pain was detected in 20 patients in the test group. In the 6-month post-operation, the flap of the control group had no two-point discrimination, and 20 of the patients in the trial group were able to detect two-point discrimination (5.15 mm and 3.20); and, with the extension of the post-operative recovery time, the two-point discrimination ability was enhanced.3. The quality of the patient's life was evaluated at 6 months after the operation. The results showed that the total survival quality of the lateral skin flap of the thigh was 907.39. Among them, the three sub-items with the highest score were shoulder function, anxiety and pain, and the lowest score of three sub-items was chewing, taste and language. The scores of life quality of the patients in the test group were higher than that of the control group (t = 3.07, P = 0.00). Conclusion The anterolateral skin flap can be used to repair the postoperative defects of the local and advanced tongue cancer, the complication is little, the survival rate of the skin flap is high, the damage to the shape and function of the donor area is small, the repair effect is ideal, and the voice function and the swallowing function of the patient can be recovered well. Compared with the conventional anterolateral skin flap repair method, the skin flap with the sensory nerve reconstruction is used for repairing the postoperative defect of the local middle and late-stage tongue cancer, which is helpful for the recovery of the swallowing function of the patient, and has no obvious effect on the restoration of the voice function. And the recovery of the sensory function after the operation of the patients with the nerve anastomosis is superior to that of the patients who are repaired by the conventional anterolateral skin flap, and the satisfaction of the patients is increased, and the survival quality of the patients is further improved. As the clinical effect of the anterolateral skin flap with sensory nerve is more and more positive, it is possible to be a conventional method for repairing the postoperative defect of the tongue cancer by the anterolateral skin flap.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R739.86
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