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北京大学学报（医学版） ›› 2022, Vol. 54 ›› Issue (2): 363-368. doi: 10.19723/j.issn.1671-167X.2022.02.026

• 论著 • 上一篇    下一篇

头颈部游离组织瓣移植术后预防性气管切开的临床分析

蔡天怡,章文博,于尧,王洋,毛驰,郭传瑸,俞光岩,彭歆()   

  1. 北京大学口腔医学院·口腔医院口腔颌面外科,国家口腔医学中心,国家口腔疾病临床医学研究中心,口腔生物材料和数字诊疗装备国家工程研究中心,口腔数字医学北京市重点实验室,国家卫生健康委员会口腔医学计算机应用工程技术研究中心,国家药品监督管理局口腔生物材料重点实验室,北京 100081
  • 收稿日期:2019-03-20 出版日期:2022-04-18 发布日期:2022-04-13
  • 通讯作者: 彭歆 E-mail:pxpengxin@263.net

Clinical analysis of selective tracheostomy necessary for patients undergoing head and neck surgery with free flap reconstruction

CAI Tian-yi,ZHANG Wen-bo,YU Yao,WANG Yang,MAO Chi,GUO Chuan-bin,YU Guang-yan,PENG Xin()   

  1. Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology & NHC Research Center of Engineering and Technology for Computerized Dentistry & NMPA Key Laboratory for Dental Materials, Beijing 100081, China
  • Received:2019-03-20 Online:2022-04-18 Published:2022-04-13
  • Contact: Xin PENG E-mail:pxpengxin@263.net

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摘要：

目的: 探讨头颈部游离组织瓣移植患者术后行预防性气管切开的影响因素。方法: 选择2015—2016年北京大学口腔医院口腔颌面外科同一手术团队连续完成的533例头颈部游离组织瓣移植术患者的病例资料进行回顾性分析,患者平均年龄(49.3±16.6)岁,其中321例患者行预防性气管切开术,占全部患者的60.2%。记录患者基本信息、手术因素、治疗史、患有共病、个人史及术后并发症发生情况。结果: 手术伴有舌、口底、口咽部、双侧下颌骨缺损,行单侧及双侧颈淋巴清扫术,既往有放疗史、吸烟史者,以及应用较臃肿软组织皮瓣的患者,术后气道梗阻风险较大,更倾向于行预防性气管切开。有1例未行预防性气管切开术的患者术后出现气道梗阻行紧急气管切开。预防性气管切开术患者中,8.39%出现气管切开相关并发症,以肺部感染、切口出血为主。结论: 并非所有行头颈部游离组织瓣移植修复的患者均需行预防性气管切开术,头颈部游离组织瓣移植术患者是否行预防性气管切开术需根据具体情况综合判断,以保证患者的术后气道安全。

关键词: 气管切开, 气道管理, 游离组织瓣移植, 头颈部

Abstract:

Objective: To discover the factors that may affect the use of selective tracheostomy among patients who have undergone head and neck surgeries with free flap reconstruction, so that the patients will not need tracheostomy nor receive the unnecessary treatment. Methods: Five hundred and thirty-three patients who had undergone head and neck surgery with free flap reconstruction operated by the same team of surgery at Department of Oral and Maxillofacial Surgery at Peking University School of Stomatology from 2015 to 2016 were reviewed. Three hundred and twenty-one (60.2%) of these patients underwent selective tracheostomy. All the patients’ demographic information, operation-related information, prior treatments, comorbidities and complications were recorded and analyzed. Results: The patients with defects of the tongue, mouth floor, oropharynx and bilateral mandible, who underwent neck dissection and with previous radiotherapy and smoking habit were more likely to get selective tracheostomy. Usage of bulky soft tissue flap might also add to the risk of airway obstruction and the need of selective tracheostomy, while other factors were not significantly related to the risk of postoperative airway obstruction and the patients could be kept safe without selective tracheostomy. Most cases without tracheostomy were kept safe except one case, while 8.39% of the patients with tracheostomy suffered from tracheostomy related complications, mainly pneumonia and hemorrhage of the tracheostomy wound, yet none led to serious consequences or even death. Conclusion: Selective tracheostomy is not necessary for patients who have undergone head and neck surgeries with free flap reconstruction except that there are defects at the tongue, oropharynx and mandible. Neck dissection, bulky soft tissue flap reconstruction, previous radiotherapy and smoking habit may also add to the risk of postoperative airway obstruction, while a favorable decision would involve a combination of all the above factors to assure the safety of the postoperative airway for the patients undergone head and neck surgeries with free flap reconstruction.

Key words: Tracheostomy, Airway management, Free flap reconstruction, head and neck

中图分类号: 

  • R782

表1

患者的人口学及病因学资料"

Items Tracheostomy Non-tracheostomy
Median age/years 55 45
Male/female 220 ∶101 109 ∶103
Etiology
Benign tumor 28 99
Malignant tumor 270 99
Inflammation 17 7
Tissue defect 6 12

表2

患者组织缺损部位相关因素"

Items Tracheostomy Non-tracheostomy P
Maxilla
Unilateral 7 33 <0.001
Bilateral 8 11 0.100
Mandible
Unilateral 38 98 <0.001
Bilateral 37 9 0.003
Cutaneous, lip and buccal 15 3 <0.001
Tongue 55 2 <0.001
Mouth floora 48 17 0.017
Oropharynxa 126 27 <0.001

表3

患者的颈淋巴结清扫相关因素"

Items Tracheostomy Non-tracheostomy P
Unilateral 143 77 <0.001
Bilateral 97 6 <0.001

表4

患者的修复重建方式相关因素"

Items Tracheostomy Non-tracheostomy P
Thin soft-tissue flap 0.416
Radial forearm flap 47 38
Lateral upper-arm flap 1 0
Gastrocnemius flap 1 0
Total 49 38
Thick soft-tissue flap <0.001
Anterolateral thigh flap 89 35
Posteromedial thigh flap 10 0
Total 99 35
Osseous tissue flap 0.015
Fibula myocutaneous flap 171 128
Iliac Flap 4 10
Total 175 138

表5

患者的既往史、个人史相关因素"

Items Tracheostomy Non-tracheostomy P
History of surgery 112 83 0.358
History of radiotherapy 41 15 0.029
History of chemotherapy 18 5 0.068
Diseases of respiratory system 24 4 0.004
High blood pressure 76 34 0.027
Diabates 30 12 0.108
Cardio & cerebrovascular diseases 34 18 0.404
Hepatopathy 8 4 0.633
Nephropathy 1 0 0.412
Hemopathy 6 3 0.945
Smoking 133 43 <0.001
Alcohol abusing 101 25 <0.001

表6

对潜在影响因素的Logistic回归分析"

Items OR 95%CI P
Lower Upper
Defect Unilateral maxilla 0.500 0.126 1.984 0.335
Unilateral mandible 1.470 0.454 4.755 0.520
Bilateral mandible 18.640 4.863 71.454 <0.001
Cutaneous, lip and buccal 0.417 0.070 2.470 0.335
Tongue 15.484 7.578 72.999 <0.001
Mouth floor 4.818 1.403 16.547 0.013
Oropharynx 10.632 3.373 33.512 <0.001
Neck dissection Unilateral 3.345 1.884 5.939 <0.001
Bilateral 12.931 4.360 38.346 <0.001
Reconstructiona Thick soft-tissue flap 2.623 1.176 5.850 0.018
Osseous tissue flap 1.469 0.661 3.263 0.345
Others Radiotherapy 3.180 1.386 7.297 0.006
Respiratory diseases 3.115 0.772 12.564 0.110
High blood pressure 0.871 0.425 1.600 0.657
Smoking 1.998 1.108 3.602 0.021
Alcohol abusing 1.176 0.816 1.695 0.386
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