中华胸部外科电子杂志 ›› 2024, Vol. 11 ›› Issue (02) : 91 -95. doi: 10.3877/cma.j.issn.2095-8773.2024.02.03 × 扫一扫
论著
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Qijue Lu1, Bin Li2, Chao Yang3, Rong Hua2, Chunguang Li2, Zhigang Li2,†()
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卢琪珏, 李斌, 杨超, 华荣, 李春光, 李志刚. 改良Grillo气管重建术在颈段食管癌挽救性食管切除术中的应用[J]. 中华胸部外科电子杂志, 2024, 11(02): 91-95.
Qijue Lu, Bin Li, Chao Yang, Rong Hua, Chunguang Li, Zhigang Li. Modified tracheal reconstruction as a substitute for the Grillo procedure in salvage esophagectomy of cervical esophageal cancer[J]. Chinese Journal of Thoracic Surgery(Electronic Edition), 2024, 11(02): 91-95.
Grillo手术通过切除胸骨以及采用带蒂的肌皮瓣重建气管缺损，已成为颈段食管癌挽救性手术后气道重建的标准方法。但是大范围的前胸壁骨性组织的切除和随后的感染可能导致致命性大出血，本研究拟评价改良Grillo气管重建术在颈段食管癌挽救性食管切除术中的安全性和有效性。
回顾性分析上海市胸科医院食管外科12例气管膜部受侵犯且已接受化疗、放疗的颈段食管癌患者。所有患者接受改良的Grillo手术，手术通过楔形切除受累的气管膜部以保留胸骨，然后选择带血管蒂的胸大肌皮瓣修复缺损的气道。对所有患者围手术期的临床资料及预后进行统计分析。
12例患者接受了胸大肌皮瓣重建气管后壁并完成了气管造口术。12例患者中，10例男性，2例女性，平均年龄62.6岁，手术时间（395.5±75.7）min，出血量（231.8±44.1）mL，住院时间（23.8±14.1）天，ICU住院时间（6.7±9.8）天。术后4例患者发生严重的并发症，包括2例残留气管前壁坏死；1例发生咽胃吻合口瘘；另1例患者在手术后21天死于突发的颈部血管大出血。其余患者长期存活，无造口狭窄或相关气管狭窄。随访中统计患者术后第1、3、6个月的卡氏功能状态（KPS）评分，6例（50%）患者术后3个月KPS评分≥60，9例患者（75%）术后6个月KPS评分≥60。
改良的气管重建术有效避免了Grillo手术因为前纵隔气管造口引起的大范围胸骨及其周围组织的损伤。同时良好的胸大肌皮瓣的血液供应可以有效降低纵隔感染和大出血的发生率。因此单侧带蒂胸大肌皮瓣重建气管后壁在颈段食管癌挽救手术中具有良好的可行性和较高的安全性。
The Grillo procedure, involving a laterally bipedicled flap and sternum removal, has historically served as the standard approach for airway reconstruction following salvage resection of cervical esophageal cancer. However, the creation of an anterior mediastinal stoma can result in significant trauma, and subsequent infection may precipitate catastrophic bleeding. The study aimed to evaluate the safety and effectiveness of modified tracheal reconstruction.
We retrospectively analyzed 12 patients with cervical esophageal cancer involving the trachea who underwent chemoradiotherapy at the Shanghai Chest Hospital Esophageal Surgery Department. We developed a novel technique utilizing unilateral pectoralis major myocutaneous flap for tracheal defect reconstruction. Wedge resection of the involved tracheal membrane was conducted to preserve the sternum, opting for a pedicled pectoralis major myocutaneous flap for airway repair. The perioperative clinical data and prognosis of all patients were statistically analyzed.
Twelve patients underwent reconstruction of the posterior tracheal wall using the pectoralis major muscle flap and underwent tracheostomy. Among them, 10 were male and 2 were female, with an average age of 62.6 years. The surgical duration was (5.5±75.7) min, blood loss volume (231.8±44.1) mL, hspitalization stay (23.8 ± 14.1) days, ICU stay (6.7±9.8) days. Four patients experienced severe postoperative complications, including two cases of residual necrosis of the anterior tracheal wall, one case of pharyngogastric anastomotic fistula, and one case of sudden cervical vascular bleeding resulting in death 21 days post-surgery. The remaining patients experienced long-term survival without stoma stenosis or related tracheal stenosis. During follow-up, the Karnofsky Performance Status (KPS) scores at 1-, 3-, and 6-months post-surgery were statistically analyzed. Six patients (50%) scored ≥60 at 3 months post-surgery, and nine patients (75%) scored ≥60 at 6 months post-surgery.
Utilizing a unilateral pectoralis major pedicled myocutaneous flap to reconstruct the posterior tracheal wall proves effective in salvage surgery for cervical esophageal cancer. This improved technique effectively avoids damage to the sternum and surrounding tissues caused by Grillo’s mediastinal stoma, while the rich blood supply of the pectoralis major flap can effectively prevent mediastinal infection and catastrophic bleeding. Unilateral pectoralis major pedicled myocutaneous flap to reconstruct the posterior wall of the trachea is an effective technical in salvage surgery for cervical esophageal cancer.