Die primäre Verwendung des myofaszialen M. pectoralis-major-Lappens bei der Salvage-Laryngektomie

 

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Zusammenfassung

Hintergrund: Die Salvage-Laryngektomie (SLE) ist bei rezidivierenden Larynx- und Hypopharynxkarzinomen häufig die noch einzige kurative Option. Allerdings geht die SLE mit einem erhöhten Komplikationsrisiko, wie der Ausbildung von Speichelfisteln, einher. Zur Reduktion der Fistelquote ist die einzeitige Hebung eines myofaszialen M. pectoralis-major-Lappens (PMML) beschrieben. Ziel dieser Studie war es, die SLE mit und ohne gleichzeitigen Einsatz des PMML zur Prophylaxe einer Speichelfistel vergleichend zu untersuchen.

Patienten und Methode: 9 Patienten wurden eingeschlossen, die in den Jahren 2012 und 2013 wegen eines T4a-Rezidivtumors im Larynx oder Hypopharynx bei Z. n. Radiochemotherapie (RCT) mit einer SLE behandelt wurden. Eine zusätzliche PMML-Hebung wurde bei nachfolgenden Kriterien indiziert: Beendigung der RCT weniger als 1 Jahr zurückliegend, Tumorlokalisation außerhalb der Glottis, Infiltration des Schildknorpels und der prälaryngealen Muskulatur. Die Hebung des PMML erfolgte in klassischer Weise mit Aufnähen auf den durch Naht primär verschlossenen Pharynx.

Ergebnisse: 6 der 9 Patienten (2/3) erhielten im Rahmen der SLE eine Abdeckung des Pharynx mittels PMML. In keinem Fall kam es zur Ausbildung einer postoperativen Speichelfistel. Bei den verbliebenen 3 Patienten (1/3) wurde der Pharynx ebenfalls primär, jedoch ohne weitere Abdeckung mittels PMML, verschlossen. In dieser Patientengruppe zeigte sich in einem Fall eine pharyngokutane Speichelfistel.

Schlussfolgerung: Durch die einzeitige Anwendung des PMML im Rahmen der SLE konnte im eigenen Patientengut effektiv die Speichelfistelquote reduziert werden. Der PMML ist wegen seiner sicheren Hebetechnik, des fehlenden kutanen Sekundärdefekts im Thorax und der guten Modellierbarkeit im Empfängergebiet geeignet.

Abstract

Background: The salvage laryngectomy (SLE) is very often the only curative option in recurrent laryngeal or hypopharyngeal carcinomas. But the SLE is associated with an increased risk of complications such as the formation of salivary fistulas. To reduce the rate of fistulas a simultaneous elevation of the myofascial pectoralis major flap (PMML) is described. The aim of this study was to compare the SLE with and without the use of the PMML for prophylaxis of salivary fistulas.

Patients and Method: 9 patients were included, suffering from a T4a larynx or hypopharynx carcinoma recurrence after RCT in the years 2012 and 2013 and subsequently treated by a SLE. An additional elevation of PMML was indicated due to the following criteria: end of RCT less than one year ago, tumor localization outside the glottis, infiltration of thyroid cartilage and prelaryngeal muscles. After PMML elevation the flap was sewed onto a primary closed pharynx.

Results: 6 out of 9 patients (2/3) received an additional covering of the pharynx by the PMML during SLE. In no case a postoperative salivary fistula was seen. In the remaining 3 patients (1/3) the pharynx was primarily closed without an additional covering by the PMML. In this group of patients one postoperative salivary fistula was seen.

Conclusion: Due to the simultaneous application of the PMML in the context of SLE the rate of postoperative salivary fistula could be effectively reduced in our own patients. The PMML is suitable due to its safe elevation technique, the missing secondary thoracal cutaneous defect, and a good modelling possibility in the recipient area.

• Literatur

• 1 Klozar J, Cada Z, Koslabova E. Complications of total laryngectomy in the era of chemoradiation. Eur Arch Otorhinolaryngol 2012; 269: 289-293
  CrossrefPubMedGoogle Scholar
• 2 Virtaniemi J, Kumpulainen E, Hirvikoski P, Johansson R, Kosma V. The incidence and etiology of postlaryngectomy pharyngocutaneous fistulae. Head & Neck 2001; 23: 29-33
  CrossrefPubMedGoogle Scholar
• 3 Relic A, Scheich M, Stapf J, Voelter C, Hoppe F, Hagen R, Pfreundner L. Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas. Eur Arch Otorhinolaryngol 2009; 266: 1799-1805
  CrossrefPubMedGoogle Scholar
• 4 Rothmeier N, Hoffmann TK, Lehnerdt G, Lang S, Mattheis S. Surgical management of persisting fistulas after salvage-laryngectomy. Laryngo-Rhino-Otol 2013; 92: 236-243
  PubMedGoogle Scholar
• 5 Mebeed AH, Hussein HA, Saber TK, Zohairy MA, Lotayef M. Role of pectoralis major myocutanuos flap in salvage laryngeal surgery for prophylaxis of pharyngocutaneuos fistula and reconstruction of skin defect. J Egypt Natl Canc Inst 2009; 21: 23-32
  PubMedGoogle Scholar
• 6 Sakai A, Okami K, Sugimoto R, Ebisumoto K, Yamamoto H, Maki D, Atsumi T, Iida M. Prevention of wound complications in salvage pharyngolaryngectomy by the use of well-vascularized flaps. Acta Otolaryngol 2012; 132: 778-782
  CrossrefPubMedGoogle Scholar
• 7 Sousa AA, Castro SM, Porcaro-Salles JM, Soares JM, de Moraes GM, Carvalho JR, Silva GS. The usefulness of a pectoralis major myocutaneous flap in preventing salivary fistulae after salvage total laryngectomy. Braz J Otorhinolaryngol 2012; 78: 103-107
  PubMedGoogle Scholar
• 8 Basheeth N, O’Leary G, Sheahan P. Pharyngocutaneous fistula after salvage laryngectomy: Impact of interval between radiotherapy and surgery, and performance of bilateral neck dissection. Head & Neck 2013; DOI: 10.1002/hed.23337.
  PubMedGoogle Scholar
• 9 Gil Z, Gupta A, Kummer B, Cordeiro PG, Kraus D, Shah JP, Patel SG. The role of pectoralis major muscle flap in salvage total laryngectomy. Arch Otolaryngol Head Neck Surg 2009; 135: 1019-1023
  CrossrefPubMedGoogle Scholar
• 10 Righini C, Lequeux T, Cuisnier O, Morel N, Reyt E. The pectoralis myofascial flap in pharyngolaryngeal surgery after radiotherapy. Eur Arch Otorhinolaryngol 2005; 262: 357-361
  CrossrefPubMedGoogle Scholar
• 11 Oosthuizen JC, Leonard DS, Kinsella JB. The role of pectoralis major myofascial flap in salvage laryngectomy: a single surgeon experience. Acta Otolaryngol 2012; 132: 1002-1005
  CrossrefPubMedGoogle Scholar
• 12 Patel UA, Keni SP. Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula. Otolaryngology-Head and Neck Surgery 2009; 141: 190-195
  PubMedGoogle Scholar
• 13 Leemans DR, Braakhuis BJM, Brakenhoff RH. The molecular biology of head and neck cancer. Nature Reviews 2011; 11: 9-22
  CrossrefPubMedGoogle Scholar
• 14 Fietkau R, Lautenschläger C, Sauer R, Dunst J, Becker A, Baumann M, Went T, Grüschow K, Hess C, Budach V, Iro H. Postoperative concurrent radiochemotherapy versus radiotherapy in high-risk SCCA of the head and neck: Results of the German phase III trial ARO 96-3. J Clin Oncol 2006; 24: 5507
  PubMedGoogle Scholar
• 15 Ariyan S. The pectoralis major myocutaneous flap. Plast Reconstr Surg 1979; 63: 73-81
  CrossrefPubMedGoogle Scholar
• 16 Patel UA, Moore BA, Wax M, Rosenthal E, Sweeny L, Militsakh ON, Califano JA, Lin AC, Hasney CP, Butcher RB, Flohr J, Arnaoutakis D, Huddle M, Richmon JD. Impact of pharyngeal closure technique on fistula after salvage laryngectomy. Otolaryngol Head Neck Surg 2013; 139: 1156-1162
  CrossrefPubMedGoogle Scholar
• 17 Gras R, Bouvier C, Guelfucci B, Robert D, Giovanni A, Zanaret M. The pectoralis myofascial flap in oropharyngeal and pharyngolaryngeal reconstruction in salvage surgery. Ann Otolaryngeal Chir Cervicofac 2000; 117: 378-382
  PubMedGoogle Scholar
• 18 Delaere PR, Ostyn F, Boeckx WD, Guelinckx P. Hypopharyngeal reconstruction with radial forearm flap. Acta Chir Belg 1990; 90: 132-135
  PubMedGoogle Scholar
• 19 Zaoui K, Federspil P, Plinkert PK, Simon C. Grafts with microvascular anastomosis. Their use in the head and neck region following radiotherapy and vessel depletion. HNO 2013; 61: 573-579
  CrossrefPubMedGoogle Scholar
• 20 Fung K, Teknos TN, Vandenberg CD, Lyden TH, Bradford CR, Hogikyan ND, Kim J, Prince ME, Wolf GT, Chepeha DB. Prevention of wound complications following salvage laryngectomy using free vascularised tissue. Head & Neck 2007; 29: 425-430
  CrossrefPubMedGoogle Scholar
• 21 Albirmawy OA. Prevention of postlaryngectomy pharyngocutaneous fistula using a sternocleidomastoid muscle collar flap. J Laryngol Otol 2007; 121: 253-257
  PubMedGoogle Scholar