RU2714593C1 - Method for reconstruction of larynx and pharynx in locally advanced tumours - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to reconstructive laryngology. Method comprises three steps. At the first stage, general anaesthesia is performed, lower tracheostoma is applied, neck skin is cut from mastoid process on affected side to projection of upper pole of thyroid on opposite side. Then the skin flaps are diluted to the sides, lymphadenectomy is performed, lateral pharyngotomy is performed, and the front muscles of the neck are cut on the right - sternum-sublingual and sternum-thyroid. Using the electric coagulum, the hyoid bone and the edge of the thyroid cartilage are extracted, isolating and dissecting the greater horn of the hyoid bone, separating and cutting off the upper horn of the thyroid cartilage, posterior wall of laryngopharynx is exposed and larynx and tongue root are lifted, mucous membrane of posterior pharyngeal wall is separated from prevertebrate fascia. After opening the pharynx under direct visualization, the tumour is removed with a single unit, retreating 1 cm from the visible border in laryngopharynx and 0.5 cm in the larynx. At second stage transverse and longitudinal size of defect formed in hypopharynx and larynx is determined, in accordance with size of defect, skin area is marked in projection of large pectoral muscle. Transverse and longitudinal size of the skin flap must exceed the size of the defect in the laryngopharynx by at least 1 cm; then, the electrocoagulator is used to mobilize the marked skin flap together with a greater pectoral muscle and pass through the skin tunnel into a postoperative wound - a laryngopharyngeal defect. Wound on the chest involves thorough haemostasis; wound is closed with leaving aspiration drainage. At the third stage, an internal laryngopharynx is formed. Musculocutaneous flap is rotated and a nasopharyngeal tube is inserted. Then, the skin turned into a laryngopharyngeal lumen is anchored to the remaining mucosa in a circle by interrupted sutures of the absorbable material, thus ensuring tightness. Muscular portion of graft is anchored to local tissues, creating additional sealing and filling the volume of formed defect of soft tissues of neck after lymphadenectomy.

EFFECT: using the method enables preserving the larynx by avoiding complete removal of the larynx and laryngopharynx.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, mainly to reconstructive plastic surgery for tumors of the larynx and pharynx.

In the global practice, several basic methods of organ-preserving operations on the larynx are known.

Resection of the posterior pharyngeal wall by the method of Pogosov-Antoniv (Atlas of operative otorhinolaryngology. / Ed. By Prof. B.C. Pogosov.-M .: Medicine, 1983, p. 321). With tumors of the posterior pharyngeal wall, the intervention begins with a tracheotomy, which is performed under local anesthesia. Through the tracheostomy, the patient is intubated and the operation continues already under anesthesia. As access use sublingual or sublingual pharyngotomy with bilateral lateral. The front wall of the pharynx with the hyoid bone is pulled hook down. The back wall becomes visible to the level of arytenoid cartilage. An operational microscope can be used to clarify the boundaries of the neoplasm.

In addition to determining the spread of the tumor over the surface, it is very important to establish the depth of tumor infiltration. Some idea of the infiltration of the underlying tissues can be obtained by introducing a 1% solution of novocaine under the prevertebral fascia. The free stratification of tissues without seepage of novocaine to the surface through the tumor tissue to a certain extent indicates the integrity of the fascia.

The neoplasm is excised within healthy tissues, departing from the visible boundaries of the tumor focus by at least 1.5-2 cm. If after removal of the tumor at least 30% of the area of the posterior pharyngeal wall remains covered with mucous membrane, then plastic surgery can be omitted. With extensive postoperative defects, plastic surgery of the posterior pharyngeal wall requires a skin flap on the leg. Two options are possible: using a free flap of the forearm or a skin-muscle flap on the pectoralis major muscle, which is used much less often due to its size.

In this case, there is a need for the formation of lateral pharyngostomy. In the postoperative period, the patient is fed through a nasophageal tube.

The disadvantages of the method is that this operation is indicated in the case of tumors bounded by the posterior or inferior pharyngeal wall without spreading into the piriform sinus or larynx.

Known operation for the defeat of the outer surface of the scoopalonadhortan fold (Atlas of operative otorhinolaryngology. / Ed. Prof. B.C. Pogosov. - M .: Medicine, 1983, p. 321-322)

With limited (Ti) neoplasms of this localization, horizontal resection of the larynx with preservation of the vestibular and scooped palatine folds on the opposite side of the tumor process is permissible. This operation, as well as the intervention for tumors of the posterior pharyngeal wall, has very limited indications, although their effectiveness and functional treatment results are quite high.

Disadvantages - the operation is indicated for cancer bounded by the medial wall of the pear-shaped sinus.

A known method of operation - resection of the posterior pharyngeal wall according to Seifert (Seiffert). (Portmann G. Traite de technique operatoire oto-rhino-laryngologique, P., 1931). With a limited tumor in the region of the posterior pharyngeal wall, an isolated pharyngeal resection is performed without removing the larynx. Surgery consists of two stages:

The first stage - preparatory - is reduced to a transplant after separation of the posterior pharyngeal wall into the pharyngeal space of the skin flap. After lymphadenectomy on the neck, on the side of the lesion, the tissues are bluntly stratified and penetrated into the pharyngeal space, where the back wall of the pharynx is removed from the prevertebral fascia with a finger or raspator, which is covered by the Thiersch method using a skin flap taken from the hip. Form a pharyngostomy. The flap is fixed in the attached position with a swab, which takes root within 7-10 days; after that proceed to the second stage of the operation.

The second stage - opening the pharynx and removing the neoplasm - begins with the removal of the tampon, opening with a vertical section of the lateral wall of the pharynx. Formed defect of the pharynx corresponds to a transplanted and already accustomed flap. The wound is left open. Appearing discharge passes through the pharyngostoma and the channel in the soft tissues formed during the first operation. They do not constitute a danger for soft tissue infection due to the presence of an already formed granulation shaft in the surgical wound.

The disadvantages of the method is the possibility of its use only in patients with localized forms of laryngeal pharyngeal tumors, a multi-stage operation, as well as a significant duration of treatment with subsequent rehabilitation.

The prototype of the invention is a method of combined resection of the piriform sinus with simultaneous reconstruction (E.I. Trofimov, V.I. Chissov, I.V. Reshetov. Surgical treatment. / Laryngeopharynx cancer. M., 2005. - 300 s. .) Progress of the operation: lower tracheostomy, endotracheal anesthesia. After separation of the tissues, the upper laryngeal neurovascular bundle is isolated and doped. Throat compressors cross and expose its submucosal layer. The lumen of the larynxopharynx is opened in the region of the lingual vecule, the point farthest from the tumor. Resection of the piriform sinus affected by the tumor is performed together with the posterior-upper fragment of the thyroid cartilage, thereby providing access to the bottom of the piriform sinus and the lower border of the tumor lesion. The large horn of the hyoid bone is resected. The posterior wall of the piriform sinus is isolated from the elements of the larynx in an acute way. Part of the arytenoid cartilage is resected, the pharyngeal-pharyngeal folds are scooped, departing from the edge of the tumor by 0.5-1.5 cm.The restoration of the medial wall of the piriform sinus is performed due to the scapular-hyoid muscle while maintaining its fixation with the hyoid bone. The latter is moved to a bed of scooped-epiglottis folds. To the bed of the arytenoid cartilage fix the tendon part of the scapular-hyoid muscle along with the part of the distal leg. Due to the mobile mucous membrane of the posteriorpaloid region and the medial wall of the esophagus, the final formation of the resected wall with volumetric replacement of the partially removed arytenoid cartilage is performed. To restore the bottom, the front and outer walls of the piriform sinus, the mucous membrane of the posterior wall of the larynx and the lateral opposite pear-shaped sinus is displaced, and the mucous membrane of the oropharynx and esophagus is mobilized. Displaced tissue after insertion of the nasophageal probe is sutured with a two-row suture. Then, the sternum-hyoid muscle is mobilized, it is shifted downward at a right angle and fixed to the thyroid hyoid muscle with the tissues of the sutured larynxopharynx grasped, due to which the bottom and walls (front and side) of the recreated pear-shaped sinus are formed. The proximal sternum-hyoid muscle is sutured to the inner edge of the muscle in the plane of the resected thyroid cartilage plate. A stent is inserted into the larynx for 10-14 days. The naso-esophageal probe is removed on the 14-20th day of the postoperative period. The act of swallowing is restored on the 30-60th day. The question of the timing of removal of the tracheotomy tube is decided individually.

The disadvantages of the prototype is the possibility of its use only in patients with the prevalence of tumors of the larynxopharynx stage I or II, the technical complexity of the intervention and not entirely satisfactory rehabilitation of patients. Thus, according to the authors, only 58% of patients were decanulated in the period from 1 to 3 months. The digestive function of the larynxopharynx was restored in 90% of patients.

The technical result of the proposed solution is to preserve such a socially significant organ as the larynx, and especially its dividing function, while the standard of modern treatment for this category of patients is surgery in the amount of laryngarynectomy, i.e. complete removal of the larynx and larynx.

The essence of the proposed method includes three stages. At the first stage, general anesthesia is performed, the lower tracheostomy is applied, the neck skin is cut from the mastoid process on the affected side to the projection of the upper thyroid pole on the opposite side, the skin flaps are pulled apart, lymphadenectomy is performed, lateral pharyngotomy is performed and the front neck muscles are cut to the right - the sternum-hyoid and sternum-thyroid, with the help of an electrocoagulator, the hyoid bone and the edge of the thyroid cartilage are isolated, the large horn of the hyoid bone is isolated and cut off, and the upper horn of the thyroid cartilage is cut off, the posterior wall of the larynopharynx is exposed and the larynx and root of the tongue are lifted, the mucous membrane of the posterior pharyngeal wall is separated from the prevertebral fascia, after opening the pharynx under direct visualization, the tumor is removed in a single block, retreating 1 cm from the visible border in the larynopharynx and 0.5 see in the larynx.

Second phase. The transverse and longitudinal dimensions of the defect formed in the larynx and pharynx are measured. In accordance with the size of the defect markup of the skin in the projection of the pectoralis major muscle. The transverse and longitudinal size of the skin flap should exceed the size of the defect in the larynx and pharynx by at least 1 cm.The mobilized skin flap is mobilized along with the pectoralis major muscle according to the generally accepted method and is pulled through the skin tunnel into the area of the postoperative wound - larynopharynx defect. In the wound on the chest, thorough hemostasis is performed. The wound is sutured leaving an aspiration drainage.

The third stage. The inner lining of the larynxopharynx is formed. A musculocutaneous flap is rotated almost 180 degrees. A naso-esophageal tube is inserted. The skin is hemmed to the remaining mucous membrane in a circle with interrupted sutures from absorbable material. The seam should be airtight. The skin should be turned into the lumen of the larynx and to replace the removed part of the larynx. A muscle portion of the flap is sutured to local tissues, creating additional sealing and filling the volume of the resulting soft tissue defect in the neck after lymphadenectomy. The wound is sutured with the suction drainage left.

Enumeration of figures.

FIG. 1: rear view of the area of tumor lesion: 1 - the edge of the epiglottis, 2 - scapulonadhortane fold, 3 - the vestibular part of the larynx, 4 - pear-shaped sinus, 5 - the posterior-lateral wall of the pharynx.

FIG. 2: top view: 1 - the edge of the epiglottis, 2 - scooped palatine fold, 3 - the vestibular part of the larynx, 4 - pear-shaped sinus, 5 - the posterior-lateral wall of the pharynx.

FIG. 3. The position of the graft at the site of the removed tumor: 6 - graft, 7 - epiglottis, 8 - scooped, 9 - tongue root, 10 - esophagus, 11 - trachea.

FIG. 4. The position of the transplant: 6 - transplant, 7 - epiglottis, 8 - scooped, 9 - the root of the tongue.

The order of implementation of the method.

Indications for surgery: a larynxopharyngeal tumor with a prevalence of stage IVa with a lesion of the vestibular or vestibular-median part of the larynx, lateral and posterior walls of the larynx, of the tongue, provided that there is no lesion and the mobility of the opposite half of the larynx is completely preserved. Using an electrocoagulator

The operation consists of three stages.

First stage. Carry out general anesthesia. Impose the lower tracheostomy according to the standard method. A J-shaped incision is made of the skin of the neck from the mastoid process on the affected side to the projection of the upper pole of the thyroid gland on the opposite side. Skin flaps are bred to the sides. Perform lymphadenectomy (various options) by a standard technique. A lateral pharyngotomy is performed and the anterior neck muscles on the right (sternum-hyoid and sternum-thyroid) are cut. Using an electrocoagulator, the hyoid bone and the edge of the thyroid cartilage are isolated. A large horn of the hyoid bone is isolated and cut off. The upper horn of the thyroid cartilage and the edge of the cartilage are isolated and cut off (up to 2/3). The back wall of the larynxopharynx is exposed and, for adequate visualization of the surgical field, the larynx and tongue root are raised. The mucous membrane of the posterior pharyngeal wall is separated from the prevertebral fascia. After opening the pharynx under direct visualization, the tumor is removed in a single block, departing 1 cm from the visible border in the larynx and 0.5 cm in the larynx.

Second phase. The transverse and longitudinal dimensions of the defect formed in the larynxopharynx and larynx are measured. Corresponding to these sizes, a marking of the skin area in the projection of the pectoralis major muscle is performed. The transverse and longitudinal size of the skin flap should exceed the size of the defect in the larynx and pharynx by at least 1 cm. Using an electrocoagulator, the marked skin flap is mobilized together with the pectoralis major muscle according to the generally accepted method and is pulled through the skin tunnel into the area of the postoperative wound - defect of the larynx. In the wound on the chest, thorough hemostasis is performed. The wound is sutured, leaving a suction drainage.

The third stage. The inner lining of the larynxopharynx is formed. The musculocutaneous flap rotates almost 180 degrees. A naso-esophageal tube is inserted. The skin is sutured to the remaining mucous membrane in a circle with interrupted sutures from absorbable material. The seam should be airtight. The skin should be turned into the lumen of the larynx and to replace the removed part of the larynx. The muscle portion of the flap is sutured to local tissues, creating additional sealing and performing the volume of the resulting soft tissue defect in the neck after lymphadenectomy. The wound is sutured, leaving a suction drainage.

In the case of a favorable course of the postoperative period, the naso-esophageal probe is removed 16 days after the operation.

After complete healing of the wounds on the neck, postoperative radiation therapy is performed. The patient is decanulated one month after the end of radiation treatment.

Clinical example.

Patient K., born 1981

Main disease: laryngopharyngeal cancer cT4aN2M0. IV A stage.

Histological examination No. 11971/17 of 11.24.2017: in the finished preparations, fragments of the mucous membrane with the growth of squamous keratinizing cancer.

Cytological examination of nodes on the right and left No. 2017/186 11.28.2017 2017 1.2 Cytogram of metastasis of squamous cell cancer in the lymph node.

The history of this disease: sick since July 2017. At the place of residence, a larynxopharyngeal tumor was detected, a biopsy was performed, the diagnosis was verified. He independently applied to the MRRC and was further examined.

SKT of the neck with iv contrast from 12/14/2017 on the left neck, located outward from the carotid artery, the lymph node of an inhomogeneous structure and density is determined, up to 14 mm. At the level of the lower third of the neck adjacent to the jugular vein, a similar lymph node of 20.15.25 mm is determined.

Ultrasound of the neck November 21, 2017 - on the right along the vascular bundle of the neck, a chain of lymph nodes up to 23 mm. On the left along the vascular bundle is a chain of nodes up to 19 mm. Bilateral lymphadenopathy of the cervical nodes.

At the first stage, given the prevalence of the disease, surgical treatment is indicated.

On December 13, 2017, an operation was performed: expanded radical lymphadenectomy on the neck of both sides with reconstructive plastic component, resection of the larynx, pharynx with plastic surgery of the defect by a displaced musculoskeletal flap from the pectoralis major muscle.

Histology p / o material 13217/17 from 12/22/17

1. fiber of the neck on the right - in 4 of 33 lymph nodes of adipose tissue metastases of squamous cell carcinoma;

2. neck tissue on the left - in 1 of 22 lymph nodes of adipose tissue, cancer metastasis of a similar structure;

3. tumor - in the area of macroscopically described exophytic formation, invasive growth of keratinizing squamous cell cancer to a depth of 9 mm.

Status localis primary: the tumor affects the right side wall of the pharynx, the vestibular part of the larynx on the right, the epiglottis on the right. On the neck on both sides, level IIa-III, a chain of enlarged nodes on the right up to 3 cm, on the left up to 2 cm, displaceable.

Description of convenient operation: U-shaped (or J-shaped) neck skin incision. Separated skin flaps and taken to the holders. The front edge of the sternocleidomastoid is mobilized to the right, the neurovascular bundle is exposed. During the audit in the upper third of the neck revealed paravasal altered nodes. In the area of the venous angle, a metastatically changed lymph node up to 2 cm. Using an electrocoagulator, paravasal tissue was mobilized and removed from the venous angle to the base of the skull, the lateral triangle of the neck with the above nodes c (level I-V). Hemostasis during the operation. The front edge of the sternocleidomastoid is mobilized to the left of the neurovascular bundle. During the audit, in the area of the venous angle, the metastatically changed lymph node is up to 2 cm. The paravasal tissue from the venous angle to the base of the skull of the lateral surface of the neck with the above nodes was mobilized and removed in an acute and blunt way (level I-V). Hemostasis during the operation.

Lateral pharyngotomy. The hyoid bone and the edge of the thyroid cartilage on the left are sharply and bluntly highlighted. A large horn of the hyoid bone was isolated and cut off. The upper horn of the thyroid cartilage and the edge of the cartilage of about 0.5 cm were isolated and cut off. The pharynx was opened. The tumor affects the right side wall of the pharynx, the vestibular part of the larynx on the right, the epiglottis on the right. The boundaries of the resection are outlined, 0.5 cm indent from the visible edge of the tumor. The drug is removed. A skin-muscle flap was mobilized with the inclusion of fibers of the pectoralis major muscle according to the accepted method, it was moved to the neck in the tunnel, a skin-muscle flap was spread over the resulting wound surface, thereby forming an inner lining and trays and covering the remaining elements of the larynx. Layered seams on the wound with the left 3x PVC drainage. Aseptic dressing.

The postoperative period was uneventful, the wound healed by first intention, the sutures were removed on the 12th day. With laryngoscopy, the displaced flap is viable, the glottis is wide.

At the second stage, from January 12, 2018 to March 7, 2018, a postoperative course of radiation therapy was carried out at 2 Gy., 5 r / week., SOD 50 Gy.

Decanulated one month after completion of radiation therapy. The patient was observed every 3 months. The laryngeal dividing function is fully restored, speech is satisfactory. Last examination in January 2019, data on the progression of the disease was not received.

Confirmation of the achievement of the technical result

The positive effect of the invention makes it possible to preserve the vital and socially significant organ like the larynx in case of a widespread lesion - T4a. The above data, the proposed solutions confirm the achievement of the planned technical result. When implementing the method does not require special equipment. The moved musculocutaneous flap promotes rapid epithelialization of the postoperative wound and a decrease in the number of postoperative complications. The method is very economical.

Claims (1)

A method for reconstructing the larynx and pharynx in locally advanced tumors, consisting of three stages, at the first stage performing general anesthesia, applying a lower tracheostomy, cutting the skin of the neck from the mastoid process on the affected side to the projection of the upper thyroid pole on the opposite side, skin the flaps are spread apart, they perform lymphadenectomy, they conduct lateral pharyngotomy and cut the front muscles of the neck on the right - the sternum-hyoid and sternum-thyroid, using an electrocoagulator the hyoid bone and the edge of the thyroid cartilage are extracted, the large hyoid bone horn is isolated and cut, the upper horn of the thyroid cartilage is isolated and cut, the posterior wall of the larynopharynx is exposed and the larynx and root of the tongue are raised, the mucous membrane of the posterior pharyngeal wall is separated from the forevertebral fascia, by visualization, the tumor is removed in a single block, departing 1 cm from the visible border in the larynx and 0.5 cm in the larynx; at the second stage, the transverse and longitudinal size of the defect formed in the larynx and pharynx and larynx is determined, in accordance with the size of the defect, a section of the skin is projected in the projection of the pectoralis major muscle, while the transverse and longitudinal size of the skin flap must exceed the size of the defect in the larynx and pharynx by at least 1 cm, then, with the help of an electrocoagulator, a marked skin flap is mobilized along with the pectoralis major muscle and pulled through the skin tunnel into the area of the postoperative wound - a defect of the larynx, in the wound and the breasts undergo thorough hemostasis, the wound is sutured with the suction drainage left; at the third stage, the inner lining of the larynopharynx is formed, while a skin-muscle flap is rotated and a nasophageal probe is inserted, then the skin turned into the lumen of the larynxopharynx is sutured to the remaining mucous membrane in a circle with interrupted sutures from absorbable material, ensuring tightness, the muscular portion of the flap is sutured to local tissues creating additional sealing and filling the volume of the resulting defect in the soft tissues of the neck after lymphadenectomy.

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