Objective: To explore the value and limitation of transverse cervical artery flap in laryngeal function preservation surgery of hypopharyngeal carcinoma.
Methods: Between January 2013 and December 2019, 18 male patients with hypopharyngeal carcinoma were admitted. The patients' age ranged from 48 to 77 years, with a median age of 65 years. The disease duration ranged from 3 to 8 months (mean, 5 months). All patients were diagnosed as squamous cell carcinoma by biopsy before operation. According to the American Joint Committee on Cancer (AJCC) guidelines (2017, 8th ed), TNM staging was T2N0M0 in 9 cases, T2N1M0 in 2 cases, and T3N0M0 in 7 cases, and cTNM staging was stage Ⅱ in 9 cases and stage Ⅲ in 9 cases. The lesions of 15 cases were located in the piriform fossa of hypopharynx on one side, among which the esophageal entrance was involved in 4 cases. The lesions of 3 cases were located in the posterior wall of the hypopharynx with esophageal entrance involvement. After partial pharyngo- laryngectomy and bilateral neck lymph node dissection, the hypopharyngeal and laryngeal defects were repaired with transverse cervical artery flaps, the size of the flap ranged from 4 cm×3 cm to 6 cm×4 cm. The accompanying vein of transverse cervical artery (7 cases), external jugular vein (6 cases), and combination of both (5 cases) served as venous reflux. Retrograde external jugular venous reflux exercise was performed in 2 flaps with venous reflux obstruction during operation. The incisions at donor sites were directly sutured or via relaxed incision sutured. Radiotherapy and chemotherapy were supplemented within 3 months after operation. Tracheal cannula with air bag was used to prevent patients from aspiration in the early postoperative stage.
Results: The operation time was 4-6 hours, with an average of 4.5 hours. All patients were followed up 1-5 years (mean, 2 years and 6 months). Postoperative pathological examination showed that 7 cases had cervical lymph node metastases on the affected side, and there was no lymph node metastasis in cervical region Ⅴ; the remaining 11 cases had no lymph node metastasis. After operation, 16 flaps survived successfully, and 2 flaps with external jugular vein reflux were covered with white pseudomembrane, no flap necrosis was found after the pseudomembrane fell off. Four cases had no obvious accidental aspiration after operation; 14 cases had obvious accidental aspiration, of which 13 cases were significantly reduced at 3 months after operation, and 1 case still had obvious accidental aspiration at 6 months after operation, and the accidental aspiration decreased significantly after pulling out the gastric tube. All patients had no aspiration pneumonia. One case developed upper mediastinal lymph node metastasis at 1 year and 2 months after operation, and died of recurrence and pulmonary infection at 1 year and 3 months after operation. No recurrence or metastasis was found in the remaining 17 cases during follow-up. Tracheal cannula was successfully removed in 7 cases at 2-5 months after operation. Different degrees of accidental aspiration in 11 patients were confirmed by esophagography, so the tracheal cannula was retained. All patients had pronunciation function after operation. All incisions at the donor sites healed by first intention, and the shoulder joint function was normal.
Conclusion: Using transverse cervical artery flap to repair the hypopharyngeal and laryngeal defects during hypopharyngeal carcinoma surgery in patients without lymph node metastasis in cervical region Ⅴ, can achieve good results of laryngeal function preservation. In cases with suspected lymph node metastasis in cervical region Ⅴ or venous dysplasia of accompanying vein of transverse cervical artery, there is a risk of tumor recurrence or flap necrosis, and the repair method needs to be cautiously employed.
目的: 探讨颈横动脉皮瓣在下咽癌喉功能保存术中的应用价值及局限性。.
方法: 2013年1月—2019年12月，收治18例下咽癌男性患者。患者年龄48～77岁，中位年龄65岁。病程3～8个月，平均5个月。术前经活检病理诊断为鳞状细胞癌。根据2017年第8版美国癌症联合委员会（AJCC）指南标准，TNM分期：T2N0M0 9例、T2N1M0 2例、T3N0M0 7例，cTNM分期：Ⅱ期9例、Ⅲ期9例。15例病变位于一侧下咽梨状窝，其中4例累及食道入口；3例病变位于下咽后壁，累及食道入口。采用气管切开+部分下咽-喉肿瘤切除+双侧颈淋巴结清扫术，术中切除下咽肿瘤及累及的部分喉组织后，以颈横动脉皮瓣修复缺损，皮瓣切取范围为4 cm×3 cm～6 cm×4 cm。皮瓣回流静脉为颈横动脉伴行静脉（7例）、颈外静脉（6例）及颈横动脉伴行静脉联合颈外静脉（5例）。术中2例皮瓣静脉回流不畅，行颈外静脉逆行回流锻炼以促进皮瓣经颈外静脉回流。供区切口直接缝合或作松弛切口缝合。术后3个月内均行放化疗治疗。采用带气囊气管套管防止患者术后早期误咽。.
结果: 手术时间4～6 h，平均4.5 h。患者均获随访，随访时间1～5年，平均2年6个月。术后病理检查示7例患侧颈淋巴结转移，颈Ⅴ区无淋巴结转移；余11例无淋巴结转移。术后16例皮瓣顺利成活；2例以颈外静脉回流的皮瓣被白色假膜覆盖，假膜脱落后未见皮瓣坏死。术后4例患者无明显误咽；14例出现明显误咽，其中13例3个月后明显减轻，1例6个月时仍误咽明显，拔除胃管后明显减轻。所有患者均无吸入性肺炎发生。1例术后1年2个月上纵膈淋巴结转移，1年3个月时死于肿瘤复发及肺部感染；余17例随访期间未见肿瘤复发或转移。7例患者于术后2～5个月顺利拔除气管套管，11例患者有不同程度误咽并经食道造影证实，保留气管套管。术后所有患者发音功能均保留。供区切口均Ⅰ期愈合，肩关节功能正常。.
结论: 对于颈Ⅴ区淋巴结无转移的下咽癌患者，采用颈横动脉皮瓣修复下咽-喉缺损可较好地保留喉功能；对于颈Ⅴ区淋巴结有可疑转移或颈横动脉伴行静脉发育不良患者，存在肿瘤复发或皮瓣坏死风险，该修复方法需谨慎使用。.
Keywords: Transverse cervical artery flap; hypopharyngeal carcinoma; laryngeal function; repair and reconstruction.