RU2706031C1 - Method for reconstruction of oral cavity defects in case of oral mucosa and submandibular cancer mucosa - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine and can be used for reconstructing defects of the oral cavity bottom in cancer of the oral cavity and submandibular gland. Primary focus is removed. Lymph node dissection is performed on primary tumor. In the presence of one-sided regional metastases, the upper lateral pole of submandibular salivary gland is separated from the facial artery to the point of retraction of the sub-artery from the contralateral side along the lower edge of the lower jaw arch with one-sided inclusion of the anterior abdomen of the digastric muscle, maxillofacial muscle. Further, the defect is replaced in the oral cavity with a skin site of the flap.

EFFECT: method enables reducing complications in reconstruction of defects in cancer of the oral cavity and submandibular gland due to inclusion of the anterior abdomen of the digastric muscle and mandibulohyoid muscle into the flap.

1 cl, 2 ex

Description

The invention relates to medicine, namely to methods for reconstructing defects in the bottom of the oral cavity for cancer of the mucous membrane of the oral cavity and submandibular gland.

In modern reconstructive surgery of the oral cavity and oropharynx, there is a method for replacing postoperative defects (1 - F. Bussu et al. Contemporary role of pectoralis major regional flaps in head and neck surgery / Acta Otorhinolaryngol Ital. 2014; 4: 327-341). This method is taken as an analog.

There is also a method of reconstruction of defects in cancer of the oral mucosa and cancer of the submandibular gland by using a radiation flap, moreover, this method is characterized by a surgically simple cutting process, good blood supply and a relatively low number of complications from the donor bed (2 - Soutar DS et al. The radial forearm flapza versatile method for intrairal reconstruction. Brit. J. Plast. Surg. 1983; 86: 1). This method is adopted as a prototype.

However, this method is difficult to apply in the presence of unilateral metastases in the regional (submandibular) lymph nodes.

The aim of the invention is to reduce complications in the reconstruction of defects in cancer of the mucous membrane of the oral cavity and submandibular gland.

The technical result is achieved by removing the primary lesion, performing lymphodissection on the side of the primary tumor, and in the presence of unilateral regional metastases, the upper lateral pole of the submandibular salivary gland with the facial artery is isolated to the point of departure of the submental chin artery from the contralateral side along the lower edge of the lower jaw arch with unilateral inclusion the abdomen of the biceps muscle, maxillary hyoid muscle, followed by the replacement of the defect in the oral cavity with the skin site of the flap.

The method is as follows.

Upon admission, patients complain of education on the lateral surface of the tongue, oral mucosa, dull pain in the oral cavity during a conversation.

Anamnesis of the disease: patients periodically experience episodes of voice loss, hoarseness appears. Diagnose a neoplasm of the vocal fold, chronic hyperplastic laryngitis. A routine medical examination revealed a tumor-like formation of the submandibular gland and a neoplasm of the oral mucosa. Surgical treatment was performed with removal of the neoplasm of the vocal fold, puncture biopsy of the neoplasm of the submandibular salivary gland. Cytological examination revealed adenolymphoma. Extirpation of the submaxillary salivary gland was performed. After 8-10 years, diskeratosis of squamous epithelium, reactive changes in part of the cells, the presence of elements of inflammation, abundant flora were found. Over time, patients began to notice the growth of tumors of the tongue, submandibular gland, oral mucosa with increased pain. Consulted by an oncologist. Biopsies of these neoplasms were taken. According to a histological study: small pieces of an ulcerated tumor are a highly differentiated keratinizing squamous cell carcinoma. Consulted by an anesthetist, there are no contraindications for surgical intervention. Hospitalized for planned surgical treatment.

Diagnosis justification: - based on complaints (on the formation of the lateral surface of the tongue, dull pain in the oral cavity during conversation) and the clinical picture (facial contour is not changed. Opening the mouth in full. When examining the oral cavity in the area of the lateral surface of the tongue, a tuberous tumor is determined , surrounded by an infiltrate shaft) was diagnosed with:

Diagnosis: cancer of the submandibular salivary gland. Cancer of the tongue and oral mucosa.

The reconstruction of defects that occur during the surgical treatment of cancer of the oral mucosa and submandibular salivary gland is carried out by using a skin-fascial displaced submental chin flap on a vascular pedicle, characterized in that the primary focus is removed, lymph node dissection is performed on the side of the primary tumor, and in the presence of unilateral regional metastases superior lateral pole of the submaxillary salivary gland with the facial artery to the site of discharge of the submental chin artery with contralate the left side along the lower edge of the arch of the lower jaw with the unilateral inclusion of the anterior abdomen of the biceps muscle, maxillary hyoid muscle, followed by the replacement of the defect in the oral cavity with the skin area of the flap.

The primary lesion is removed and lymph nodes with metastases are excised. The process of cutting a submental chin flap consists of first marking a skin incision along the upper cervical fold, usually approximately at the level of the upper edge of the thyroid cartilage in the lateral neck, with a gradual rise of the incision line at the midline to the body of the hyoid bone. Next, between the lower edge of the body of the lower jaw and the body of the hyoid bone, according to the size of the alleged defect, the skin area of the submental flap is marked. When a flap is mobilized on the contralateral feeding vessels, a skin incision is first performed along the upper cervical fold of the opposite half of the neck, with dissection of the subcutaneous tissue and subcutaneous muscle as well, the upper skin flap is mobilized up to the level of the lower jaw. The vascular leg of the flap is mobilized to the edge of the skin site. Next, the skin and subcutaneous tissue are dissected along the distal part of the skin site, mobilized to the midline and then the hyoid-mandibular muscle intersects along the midline suture, is cut off from the hyoid bone, then the anterior abdomen of the biceal muscle at the edge of the lower jaw and hyoid bone intersects and is included in the l , which is then bluntly mobilized from surrounding tissues on the supply vessels, which are branches of the facial artery and vein. After the intersection of the latter above the place of discharge of the supply vessels, the leg of the flap is significantly lengthened. With the formed flap, the defect in the bottom of the oral cavity is closed

That is, in the method for reconstructing defects that occur during surgical treatment of cancer of the oral mucosa, the primary lesion is removed, lymph node dissection is performed on the side of the primary tumor, and in the presence of unilateral regional metastases, the upper lateral pole of the submaxillary salivary gland with the facial artery is isolated to the point where the submental chin artery leaves the contralateral side along the lower edge of the arch of the lower jaw with the unilateral inclusion of the anterior abdomen of the biceps muscle, maxillary hyoid muscle with after uyuschim replacement defect in the mouth area of the skin flap.

Diagnosis at discharge: cancer of the submandibular salivary gland. Cancer of the tongue, condition after surgical treatment: half resection of the tongue, resection of the tissues of the bottom of the oral cavity, functional cervical lymphadenectomy, plastic surgery of the defect with a submental chin flap, tracheostomy (С02.1), pT2N0M0, stage II, III class.

Of the advantages of this method, it should be noted the simplicity of cutting, a small number of local complications, an inconspicuous scar in the submandibular region after taking the flap and minimal disturbance of facial expressions.

If it is impossible to use the flap due to the accumulation of unilateral regional metastasized nodes from the homolateral side, a submental chin flap was cut out on the supply vessels from the contralateral side. When the facial artery and vein crosses above the point of departure of the vessels supplying the flap, the latter becomes mobile enough to replace defects in the bottom of the oral cavity of central and anterolateral localization. This approach was carried out not only with the defeat of the lymph nodes of the submandibular region of the homolateral side, but also in the presence of sialadenitis of the submandibular salivary gland, due to the spread of the primary tumor to the excretory duct and, as a result, the difficulty in mobilizing the feeding leg of the flap, as well as during previous surgical interventions on the neck in the amount of lymphatic dissection and removal of the submandibular salivary gland over the tumor. Thus, in the proposed method, a contralateral submental flap was used.

This method of cutting out a sub-selection flap on the contralateral tumor process of the half of the neck eliminates manipulation in the area where localization of regional metastases is possible, which is favorable both from the oncological point of view and from the surgical one, as it simplifies manipulations in the area of passage of the supply vessels. This method was applied in 18 patients.

The method is further explained by examples of its implementation.

Example 1

Patient K., 55 years old. Received with complaints of the formation of the left lateral surface of the tongue, dull pain in the left half of the oral cavity during a conversation, radiating to the left ear. In a clinical study, the facial contour is not changed. Opening the mouth in full.

Anamnesis of life: Tuberculosis, viral hepatitis B and C, HIV, syphilis denies. Injury denies. Blood transfusion denied.

Allergic history: drug intolerance denies. Expert history: Bad habits: smoking (up to 10 cigarettes per day, 30 years).

Hereditary history: Mother (uterine cancer). Epidemiological history: not burdened. Transfusion history: not burdened.

Takes medications: Concor (2.5 mg, 1 t 1 r / d), Adravel (150 mg, 1 t 1 r / d), Lerkamen (10 mg, 1 t 1 r / d). Glucophage (850 mg per 1 ton in the evening).

General condition is satisfactory. General examination: skin and visible mucous membranes of physiological color. Peripheral lymph nodes are not enlarged. Subcutaneous fat is moderately developed. Musculoskeletal system: there is no deformation of the joints, the skin above them is not changed, the movement in full. Height 160 cm, Weight 85 kg. Temperature 36.6 ° C. Mental state: in time, space, self-oriented. Neurological status: focal neurological symptoms not detected. Respiratory organs: vesicular breathing in the lungs, is carried out in all departments, wheezing is not heard. Percussion - a clear pulmonary sound. BH: 17 engine / min. Circulatory system: heart sounds are clear, rhythmic. Swelling on the legs. Blood pressure: 120/80 mmHg, heart rate: 70 beats / min, pulse: 70 beats / min. Digestive system: tongue moist, clean. The abdomen is not swollen, palpation is soft, painless in all departments. The liver is not enlarged, the edge of the liver is smooth, painless. The gall bladder is not palpable. There is no dullness in the sloping places of the abdomen. There are no peritoneal symptoms. The peristalsis is even. Single chair, decorated, feces brown, without pathological impurities. Genitourinary system: the kidneys are not palpable. There is no dysuria. The "striking" symptom is negative on both sides. Diuresis is sufficient. The urine is light yellow.

When examining the oral cavity, a tumor of the oral mucosa is determined up to 4 cm in size, the surface is covered with a yellow fibrin coating, surrounded by an infiltrate shaft, and the total size (tumor-infiltrate) is about 5.5 cm. Palpation is painful. Regional lymph nodes are not enlarged. From the anamnesis it is known that six months ago I independently discovered a painful reddish spot on the oral mucosa. Asked for medical help. Scraped education taken. According to a cytological study of scraping: epithelial dyskeratosis, reactive changes in part of the cells, some elements of inflammation, copious flora, there are elements of a fungus such as Candida. No malignant cells were found. Received antifungal therapy - no effect. Over time, the patient began to notice an increase in the formation of the oral mucosa with an increase in pain. Consulted by an oncologist. A biopsy of the formation of the oral mucosa was taken.

Laboratory and instrumental examination data.

Ultrasound of the lymph nodes and soft tissues of the neck: lymph nodes of reduced echogenicity are determined on the left side of the neck and in the submandibular region. the shape is closer to round, actively circulating, without internal differentiation, from 5-4 mm to 16-9 mm in size. On the right submandibular and cervical lymph nodes of the usual echostructure. Conclusion: Y3-signs of pathologically altered cervical submandibular lymph nodes of the neck on the left.

Histological examination: small pieces of an ulcerated tumor with the structure of highly differentiated cancer.

Diagnosis. Primary: PMZO: cancer of the oral mucosa. Condition after combined treatment. cTZNXMO. Concomitant disease: 1) Impaired carbohydrate tolerance. Fasting glycemia. (R73.0); 2) I obesity, exogenous constitutional. (E66.0)

Consulted, recommended planned surgical treatment. Outpatiently examined. Consulted by an anesthesiologist, there are no contraindications for surgery, there is no intervention in the conditions of COA. Hospitalized for planned surgical treatment.

The primary lesion is removed and lymph nodes with metastases are excised. Cutting out of the submental flap begins with a skin incision along the upper cervical fold, usually approximately at the level of the upper edge of the thyroid cartilage in the lateral neck, with a gradual rise of the incision line at the midline to the body of the hyoid bone. Next, between the lower edge of the body of the lower jaw and the body of the hyoid bone, the skin area of the submental flap is marked according to the size of the alleged defect. When a flap is mobilized on the contralateral supply vessels, a skin incision is first performed along the upper cervical fold of the opposite half of the neck, with dissection of the subcutaneous tissue and subcutaneous muscle, and the upper skin flap is mobilized up to the level of the lower jaw. The vascular leg of the flap is mobilized to the edge of the skin site. Next, the skin and subcutaneous tissue are dissected along the distal part of the skin site, mobilized to the midline and then cross the hyoid-mandibular muscle along the midline suture, cut off from the hyoid bone, then the anterior abdomen of the biceal muscle is crossed at the edge of the lower jaw and hyoid bone and included in , which is then bluntly mobilized from surrounding tissues on the supply vessels, which are branches of the facial artery and vein. After crossing the latter above the place of discharge of the supply vessels, the flap leg is significantly lengthened. The formed flap closes the defect in the bottom of the oral cavity

The diagnosis at discharge. Primary: PMZO: cancer of the oral mucosa. Condition after combined treatment, resection of the tissues of the bottom of the oral cavity, functional cervical lymphatic dissection on the left, plastic surgery of the defect with a submental chin flap, tracheostomy (С02.1), pT2N0M0, stage II, III class. Concomitant disease: 1) Impaired carbohydrate tolerance. Fasting glycemia. (R73.0). 2) I obesity, exogenous constitutional. (E66.0)

Discharge Status

The general condition is satisfactory, operated on, resection of the tissues of the bottom of the oral cavity, functional cervical lymphadenectomy on the left, plastic surgery of the defect with a submental flap, tracheostomy. The course of the postoperative period without complications. Conducted a comprehensive conservative therapy, daily dressings. The tracheostomy tube and nasophageal tube were removed on the 10th day. The wounds healed by primary intention. Discharged in satisfactory condition

Biochemical study. Total protein 66.8 (64.0-83.0) g / l: Albumin 37.0 (34.0-48.0) g / l; ALT 39.0 (7.0-35.0) U / L; ACT 27.9 (13.0-35.0) U / L; Bilirubin total 11.0 (5.0-21.0) mmol / l; Direct bilirubin 2.1 (0.0-3.4) μmol / L; Indirect bilirubin 8.8 (0.0-15.9) mmol / l; Glucose 5.47 (4.10-5.90) mmol / L; Creatinine 69 (53-97) μmol / L. Urea 4.89 (2.10-7.10) mmol / l; Potassium 4.66 (3.50-5.10) mmol / L; Sodium 141.6 (136.0-145.0) mmol / L; Chlorine 102.7 (98.0-107.0) mmol / l; Alpha-amylase 32 (28-100) U / L.

Hematology. Initial determination of blood group AB0 (test in the department) 0 (1); Blood type AB0 0 (1); Rhesus factor Rb - positive. (Rb +); The red blood cell antigen is negative. Anti-erythrocyte antibodies were not detected.

Acid-base condition of the blood. pH / blood basics; pH 7.389 (7.260-7.360) units. pH p0 ₂ - Part. C02 pressure 45.7 (46.0-58.0) mm. Hg; p02 - Part. pressure 02 39.0 (37.0-42.0) mm. Hg: Oximetry; SNV - Hemoglobin 137.0 (120.0-160.0) g / l: p02 - Saturation 02 71.8 (70.0-76.0)%: F02HB - Oxyhemoglobin 69.5 (40.0-70.0)%; FCOHB-Carboxyhemoglobin 2.1%; FHHB - Deoxyhemolobin 27.3%; PFmetHB - Methemoglobin 1.10 (0.40-1.50)%; Hct - Hematocrit 42.0 (36.0-48.0)%;

Blood analysis. Hemoglobin 13.1 (12.0-14.0) g / dl; Red blood cells 4.07 (3.90-4.70) 10 ⁶ μl; Wed erythrocyte hemoglobin content 32.2 (27.0-31.0) pg; The average volume of the red blood cell 93.5 (80.0 -100.0) fl; Wed erythrocyte hemoglobin concentration 34.5 (30.0-38.0) g / dl; Hematocrit 38.1 (36.0-42.0) g / l; Platelets 352 (180 320) 10 ³ / μl; The average platelet volume is 8.30 (7.40-12.00) fl; White blood cells 9.27 (4.00 • 9.00) 10 ⁹ / l; Neutrophils 73.50 (48.00-78.00)%; Eosinophils 2.1 (0.5-5.0)%; Monocytes 4.6 (3.0-11.0)%; Lymphocytes 18.00 (19.00-37.00)%; Basophils 0.5 (0.0-1.0)%; Neutrophils abs. 6.81 (2.00-7.50) 10 ⁹ l; Eosinophils abs. 0.20 (0.02-0.30) 10 ⁹ / l; Monocytes abs. 0.43 (0.09-0.60) 10 ⁹ / l: Lymphocytes abs. 1.67 (1.20-3.00) 10 ⁹ / l; Basophils abs. 0.05 (0.00-0.07) 10 ⁹ / l; The erythrocyte sedimentation rate according to Westergren 84 (0-20) mm / h; Leukocyte Formula; Band neutrophils 6.0 (1.0-6.0)% "; Segmented neutrophils 63.0 (47.0-72.0)%: Eosinophils 3.0 (0.5-5.0)%; Lymphocytes 20.0 (19.0-37.0)%; Monocytes 7.0 (3.0-11.0)%; Basophils 1.0 (0.0-1.0)%;

Coagulogram APTTV 24.8 sec; Prothrombin according to Quick 98.5 (70.0-130.0)%; MHO 1.02 (0.90-1.20); Prothrombin time 12.2 sec.

X-ray examination. Conducted 1) Rg-graphy of the chest Dose: 0.2 mSv. Number of shots: 2. in two projections. X-ray picture of moderate diffuse pneumosclerosis. Effective dose 0.2 mSv.

Conclusion on functional diagnostics. Conducted 1) ECG (12 holes), 2) Decoding of the ECG sinus rhythm 84 per min, compared with the previous ECG without dynamics.

Morphological conclusion Highly differentiated carcinoma of the oral cavity, without reliable signs of vascular (LVO) and perineural (PnO) invasion, moderate perigumoral lymphoid infiltration. The maximum depth of invasion (DOI) is 7.0 mm. The surgical edge of the resection is intacten (R0). Fragments of the salivary glands are determined in the surrounding soft tissues.

In 16 examined lymph nodes (15 from the lateral tissue of the neck on the left. 1 submandibular lymph node) - sinus histiocytosis, no metastases were detected.

Surgical treatment: Resection of the tissues of the bottom of the oral cavity, functional cervical lymphadenectomy on the left, plastic defect submental chin flap.

Example 2

Patient K., 55 years old, was admitted with complaints of pain in the left oral cavity with radiation to the ear. When examining the oral cavity, a tumor of the mucous membrane with a diameter of 5 cm is determined, surrounded by an infiltrative shaft.

Operation. Half tongue resection, tissue resection of the bottom of the oral cavity. functional cervical lymphadenectomy on the left, plastic surgery of the defect with a submental chin flap, tracheostomy [A16.07.071]

Intraoperative Diagnosis

C01 PMZO: cancer of the left submandibular salivary gland. Condition after combined treatment. Cancer of the tongue. T3NXMO. Stage not installed.

Protocol. After processing the surgical field three times with antiseptic solutions, a transverse section was made at the neck from the angle of the lower jaw from left to front through the midline in the projection of the sublingual to right. From the fascial case, the left sternocleidomastoid muscle was isolated and laterally retracted, sequential extraction of accessory fiber was performed along the internal jugular vein from the scapular-hyoid muscle to the base of the skull and the fascial case was separated along the anterior surface of the neck, the drug is in a single block summed up to the submandibular region, and removed. During wound revision, the facial artery is visualized. When crossing the latter, blood flow is determined (bandaged during a previous surgery). The upper thyroid artery was visualized, the latter was atherosclerotically altered, slight blood flow was observed at the intersection, the artery was found unsuitable for microvascular reconstruction. The superior laryngeal artery is highlighted. When crossing the blood flow is satisfactory, however, the length of the artery is considered insufficient for microvascular reconstruction. Given the intraoperative picture, it was decided to perform plastic surgery of the defect in the oral cavity with a submental chin flap. In the sub-chin area, lines for cutting a sub-chin flap 3x4 cm in size are outlined. In this case, the incision on the neck is extended to the angle of the lower jaw on the right. The skin with the subcutaneous muscle is dissected and set aside. The upper lateral pole of the right submandibular salivary gland is highlighted, over which the facial artery is highlighted to the point of departure of the submental chin artery. The latter is traced to the level of the skin site of the flap. At the same time, one lymph node with dimensions up to 1.5 cm, soft-elastic consistency, was visualized and removed. Removed by acute route, sent for routine histological examination. Continued to cut the flap from the lateral left side along the lower edge of the arch of the lower jaw with the inclusion of the anterior abdomen of the biceps muscle on the right um. Melyhoideus on the right. The skin-fascial-muscular flap was isolated with vascular tracing to the level of the facial vein and set aside.

Change of the surgical field. Treatment of the oral cavity with antiseptic solutions, pharyngeal plugging. With the help of a monopolar coagulator, the boundaries of the resection along the tissues of the tongue are outlined, the bottom of the oral cavity deviating 1.5 cm from the tumor infiltrate. Using an electrocoagulator, resection of the antero-lateral parts of the tissues of the oral cavity was performed, half the resection of the tongue with ligation of the hyoid on the left. The drug in a single block is deleted. A submental chin flap is inserted through the diaphragm of the bottom of the oral cavity, adapted in the oral cavity and adapted to the edges of the defect along the mucosa. Layer wound closure with silicone drainage through contra-holes. Two silicone graduates are installed in the submandibular region. Single nodal sutures on the wound. Wound treatment with an antiseptic solution. Dissected skin over the jugular notch. The trachea was visualized and opened at the level of 4 half rings. Tracheotomy tube No. 8.

This method is used in 18 patients and allows to achieve the goal of the invention is to reduce complications in the reconstruction of defects in cancer of the oral mucosa and submandibular gland.

Information sources:

1 - F. Bussu et al. Contemporary role of pectoralis major regional flaps in head and neck surgery / Acta Otorhinolaryngol Ital. 2014; 4: 327-341

2 - Soutar D.S. et al. The radial forearm flapza versatile method for intrairal reconstruction Brit J. Plast. Surg. 1983; 86: 1

Claims (1)

A method for reconstructing defects that occur during surgical treatment of cancer of the oral mucosa and submandibular gland by using a skin-fascial displaced submental chin flap on a vascular pedicle, characterized in that the primary focus is removed, lymphadenectomy is performed on the side of the primary tumor, and in the presence of unilateral regional metastases, the upper lateral pole of the submaxillary salivary gland with the facial artery to the point of departure of the submental artery from the contralateral sides s along the lower edge of the arch of the lower jaw with the one-sided inclusion of the anterior abdomen of the biceps muscle, the jaw-hyoid muscle, followed by the replacement of the defect in the oral cavity with the skin area of the flap.