全喉切除术后的咽部与颈部重建及瘘管管理：当代策略与证据

文献信息

中文摘要

背景： 全喉切除术（TL）仍是晚期喉癌和下咽癌的标准治疗方法，而咽部重建是决定预后的一个具有挑战性的因素。方法：我们检索了PubMed/MEDLINE、Scopus和Web of Science从建库至2026年7月的文献，纳入报告TL后咽部重建技术或瘘管结局的研究。本叙述性综述综合了当前关于TL后重建的证据，涵盖三个领域：咽皮瘘（PCF）的预防、重建和管理。结果：将缺损分类为微小、部分和环周类别可指导重建决策，每一类均有不同的证据流支持。风险分层确定既往放疗、营养状况差、肌少症和挽救性手术背景是最强的PCF预测因素。对于微小缺损，吻合器辅助闭合可降低原发性TL中的PCF风险，双层手工闭合优于单层修补。挽救性手术背景下的部分缺损可从带血管组织加强中获益，带蒂覆盖皮瓣的瘘管发生率低于直接闭合或游离皮瓣修补。对于环周缺损，网状荟萃分析数据提示游离空肠瓣在预防瘘管方面排名最高。比较性队列数据表明，股前外侧皮瓣可能提供更好的长期言语结局。最佳选择取决于所优先考虑的结局。唾液旁路管是预防瘘管和狭窄方面支持最为一致的辅助措施。结论：PCF的管理遵循基于分期的策略：早期瘘管采用保守治疗，亚急性病例采用负压伤口治疗作为过渡，慢性或难治性瘘管采用带血管皮瓣重建。

英文摘要

Total laryngectomy (TL) is still the standard treatment for advanced laryngeal and hypopharyngeal cancer, with pharyngeal reconstruction being a challenging determinant of outcomes. We searched PubMed/MEDLINE, Scopus, and Web of Science from inception to July 2026 for studies reporting pharyngeal reconstruction techniques or fistula outcomes after TL. This narrative review synthesizes current evidence on reconstruction following TL across three domains: prevention, reconstruction, and management of pharyngocutaneous fistula (PCF). Defect classification into minimal, partial, and circumferential categories guides reconstructive decision-making, each supported by a distinct evidence stream. Risk stratification identifies prior radiotherapy, poor nutritional status, sarcopenia, and salvage setting as the strongest PCF predictors. For minimal defects, stapler-assisted closure reduces PCF risk in primary TL, and double-layer manual closure outperforms single-layer repair. Partial defects in the salvage setting benefit from vascularized tissue augmentation, with pedicled onlay flaps associated with lower fistula rates than primary closure or free flap patching. For circumferential defects, network meta-analytic data suggest that the free jejunal flap ranks highest for fistula prevention. Comparative cohort data indicate that anterolateral thigh flaps may offer better long-term speech outcomes. The optimal choice depends on the outcome prioritized. Salivary bypass tubes represent the most consistently supported adjunct for fistula and stenosis prevention. PCF management follows a stage-based approach: conservative care for early fistulas, negative pressure wound therapy as a bridge in subacute cases, and vascularized flap reconstruction for chronic or refractory fistulas.