RU2759323C1 - Method for preventing the divergence of the pharyngeal sutures after total glosssectomy with plasty of the defect with a pectoral musculocutaneous flap - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to oncology and surgery. After total glossectomy, the defect is repaired with a pectoral musculocutaneous flap by suturing. Additionally, the pectoral musculocutaneous flap is fixed to the hyoid bone. In this case, a pectoral musculocutaneous flap, soft tissues of the pre-epiglottis space and the body of the hyoid bone are captured in one suture.EFFECT: method allows improving the results of surgical treatment, to prevent the divergence of sutures between the pectoral musculocutaneous flap and the soft tissues of the pre-epiglottis region, to prevent the development of purulent-necrotic complications, to reduce the risk of life-threatening arrosive bleeding from the neck vessels, to quickly proceed to the next stage of patient treatment - radiation therapy, to reduce the length of stay of the patient in the hospital and the cost of treatment, improve the quality of life of patients.1 cl, 1 dwg, 1 ex

Description

The invention relates to medicine, namely to oncology and surgery in the surgical treatment of patients with tumors of the oropharyngeal zone.

After surgical interventions in the oropharyngeal zone, extensive tissue defects are formed, causing a violation of very important functions: the act of breathing, speech, the process of chewing and swallowing. That is why radical removal of the tumor itself is only the first stage of surgical treatment. Next, it is necessary to operatively solve another problem - to perform the plasty of the post-resection defect, which is the key to the successful rehabilitation of this category of patients.

Attempts to plasty the pharynx are often doomed to failure due to the development in the postoperative period of incompetence of the pharyngeal suture (Ogoltsova E.S. Malignant tumors of the upper respiratory tract. M .: Medicine, 1984, 221 S.). The risk of postoperative complications depends on various reasons, including the method of suturing the pharynx (Paches A.I. Tumors of the head and neck. M .: Medicine, 1983. S. 351-355), and the disadvantage of different methods is considered a sufficiently strong tension the edges of the pharyngeal defect, which leads to excessive stretching and fragility of the seams (RF Patent No. 2028085, RU, A61B 17/00, 1994; Patent No. 2229850 RU, A61B 17/00, A61L 17/00, 2004).

In the course of a glossectomy performed for locally advanced or recurrent tumors, in accordance with the principles of oncological radicalism and ablasty, the tongue and lymphatic collectors of the neck are removed in a single block, i.e. a radical or functional cervical dissection is performed. In this case, an extensive tissue defect is formed, which is not compatible with the patient's life.

When reconstructing such a post-resection defect, it is important to isolate the neck tissues and great vessels isolated from the fascial sheaths from the aggressive environment of the oral cavity and pharynx in order to prevent a life-threatening complication - profuse arrosive bleeding from the large vessels of the neck.

The most dangerous complication is the divergence of the sutures between the pectoral flap and the tissues of the pharynx anterior to the epiglottis. The volume of soft tissues remaining after total glossectomy anterior to the epiglottis (tissue of the pre-epiglottis space anterior to the thyroid-hyoid membrane) is extremely small, which often leads to the eruption of these tissues with suture material after reconstruction with a pectoral flap. As a result of eruption, the sutures diverge, as a result of which the contents of the pharynx enters the postoperative wound on the neck and purulent-necrotic complications develop with the threat of arrosive bleeding. This clinical situation is complicated by the impossibility of swallowing after glossectomy, and the site of suture divergence is the lower point of the oropharynx, where saliva and wound discharge accumulate, which prevents healing at the site of suture divergence.

The technical result of the proposed application for the invention is to improve the results of surgical treatment and the quality of life of patients by preventing purulent-necrotic complications caused by the divergence of the sutures between the pectoral musculocutaneous flap and the soft tissues of the pre-epiglottis region, by grasping the hyoid bone into the suture, the mechanical properties of which prevent eruption of sewn fabrics.

Let us explain the implementation of the method reception with graphic material in Fig. 1, where:

1 - pectoral musculocutaneous flap,

2 - subcutaneous fat,

3 - the muscular leg of the pectoral flap,

4 - the body of the hyoid bone,

5 - larynx (thyroid cartilage),

6 - neck tissue.

With the usual method of tissue fixation, the pectoral musculocutaneous flap (1) is sutured to the neck tissues (6), in the proposed method, the pectoral musculocutaneous flap (1) with a muscle component is captured in one suture and the pectoral flap is fixed through the body of the hyoid bone (4 ).

The proposed method consists in the fact that, in addition to the insufficient volume of the indicated soft tissues of the pre-epiglottis region (6), the body of the hyoid bone (4), located anatomically under these tissues, is captured in the seams, and which, preventing the eruption of the stitched tissues of the pharynx, keeps the soft tissues of the pre-epiglottis region next to the lower point of the pectoral codomuscular flap, which prevents suture divergence.

This reduces the frequency of purulent-necrotic complications, life-threatening arrosive bleeding from the vessels of the neck, therefore, reduces the length of hospital stay and the cost of treatment. It also makes it possible to start the next phase of the patient's treatment (radiation therapy) more quickly.

Clinical example.

Patient P., 57 years old. Diagnosis: squamous cell carcinoma of the tongue with spread to the tissues of the floor of the oral cavity and the periosteum of the lower jaw, T4aN1M0, IVa stage. Condition after chemoradiation therapy (total dose 66 Gy, taxanes, carboplatin, 5-fluorouracil). Continued tumor growth, complicated by stage II dysphagia, chronic pain syndrome, stage I. ECOG 1.

Concomitant diagnosis: chronic ischemic heart disease, atherosclerotic cardiosclerosis, HF I, grade III arterial hypertension, risk 4.

Local status: an ulcerated tumor with a total lesion of the tongue, spreading to the tissues of the floor of the oral cavity, not displaced relative to the periosteum of the lower jaw. Dense displaceable level III lymph node (right carotid triangle). The posterior border of the tumor runs at the mushroom papillae.

Operation: total glossectomy with resection of the tissues of the floor of the oral cavity, segmental resection of the lower jaw "from corner to corner". The distal border of the resection passed at the base of the lingual part of the epiglottis. Fascial-sheath excision of the neck tissue (functional level III cervical dissection). Tracheostomy.

The post-resection defect is incompatible with life. A pectoral musculocutaneous flap was formed, which was moved to the neck to cover the defect. Since the volume of the tissues of the pre-epiglottis space, which received a radical dose of radiation therapy, is insufficient to suture the pectoral flap with the skin area without the threat of their eruption, in addition to these soft tissues, the body of the hyoid bone, located anatomically under these tissues, was captured in the sutures.

As a result, the eruption of the stitched tissues of the pharynx, the divergence of the sutures, and purulent-necrotic complications were prevented.

Claims (1)

A method of preventing the divergence of the pharyngeal sutures after total glosssectomy with plastic defect with a pectoral musculocutaneous flap by suturing, characterized in that the pectoral musculocutaneous flap is additionally fixed to the hyoid bone, while the pectoral musculocutaneous flap is captured in one suture, the soft tissues of the pre-epiglottis spaces and body of the hyoid bone.

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