RU2556604C1 - Method for surgical management of oral or oropharyngeal cancer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used during posterior oral or oropharyngeal cancer surgeries. A cervical lymphadenectomy is performed; the external carotid artery is secured; that is followed by a mandibulotomy and a preventive tracheotomy. The neck skin is incised from a point 1.5 cm below the lower jaw margin from the involvement side to a point 1.5 cm below the lower jaw margin from the opposite side. The incision is made from an angle of the mouth of the opposite side to the neck incision. The anterior lower jaw is exposed. The mandibular body is cut along the vertical mid-line, starting from its upper edge 1.0 cm downwards, and then at an angle of 135° in relation to a cutting line towards the side opposite the tumour process localisation. The tumour is removed. Osteosynthesis is performed by bringing the lower jaw fragments together and fastening them with one titanium miniplate mounted at a right angle to an oblique cutting line. The wound is closed in layers.

EFFECT: method provides the optimum access to the tumour process and enables preserving lingual, speech, natural feeding functions by the reliable fixation of the jaw fragments without injuring, with minimum postoperative complications.

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Description

The invention relates to medicine, more specifically to surgery, and can be used during surgical interventions for cancer of the posterior parts of the bottom of the oral cavity, root of the tongue, retro-molar region and oropharynx.

A known method for the surgical treatment of cancer of the posterior parts of the oral cavity and oropharynx (see Paches A.I. Tumors of the head and neck. M .: Medicine, 2001). For better access to the tumor, the red border of the lower lip is dissected at a distance of 0.5-1.0 cm from the corner of the mouth, then the incision is continued along the border of the red border and skin to the corner of the mouth, then down the border of the lower lip and cheek to a level of 1 5 cm below the edge of the lower jaw. Next, the incision is made in the submandibular region parallel to the edge of the lower jaw 1.0-1.5 cm below it to the front edge of the sternocleidomastoid muscle. The mucous membrane of the lower lip is dissected vertically down from the section of the red border to a level of 1.0 cm from the alveolar part of the lower jaw.

The method of access to the areas of the oral cavity affected by the tumor, which is proposed by the author, facilitates surgical intervention in the anterior regions of the oral cavity and oropharynx. However, this technique does not provide the necessary access to remove the tumor process of the posterior parts of the oral cavity, as well as the posterior and lower parts of the oropharynx, the most difficult in technical implementation, due to topographic and anatomical features. This creates difficulties for the operation and does not allow for radical removal of the neoplasm.

A known method of median mandibulotomy, which consists in the fact that the cut of the lower jaw is carried out in the middle vertically down. Osteosynthesis is carried out using wire sutures or two or more titanium mini-plates (Fig. 1.) (see Kropotov M.A. Organ-preserving and reconstructive operations on the lower jaw in the combined treatment of cancer of the mucous membrane of the cavity: Abstract of thesis, doctor of medical sciences Moscow, 2004). This method allows you to approach the posterior parts of the bottom of the oral cavity and oropharynx. However, osteosynthesis during vertical cutting does not provide a stable fixation of jaw fragments, and the use of wire sutures increases the risk of lability of the edges of fastened fragments of the lower jaw, which leads to the development of osteomyelitis (41.7%), the formation of a false joint (12.5%). The use of several titanium miniplates improves osteosynthesis, but due to an increase in the mass of the metal, it worsens the result of radiation therapy.

Also known is a method of treating tumors of the bottom of the oral cavity, cheek and soft palate, proposed by J.F. Barbosa (1974) (see Paches A.I. Tumors of the head and neck. M .: Medicine, 2001. S. 337), adopted by us for the prototype. The method consists in conducting a mandibulotomy by two oblique cuts connected in the center of the middle section of the lower jaw (Fig. 2.). At the end of the operation, fragments of the jaw are fastened with two wire sutures.

This method allows you to approach the posterior parts of the bottom of the oral cavity and oropharynx. However, the upper cut, due to the oblique direction, always injures the roots of several teeth of the lower jaw, which makes them unviable. Osteosynthesis using wire does not provide strong fixation of jaw fragments.

The technical result of the invention is to achieve optimal access to the tumor process.

The objective of the invention is to preserve the function of the tongue, providing nutrition with natural food, speech, reduce postoperative complications, improve the quality of life of patients.

The goal is achieved by making an incision in the skin of the neck from a point located 1.5 cm below the edge of the lower jaw on the affected side, I to a point located 1.5 cm below the edge of the lower jaw on the opposite side, then making an incision from the corner of the mouth of the opposite side to the cut on the neck, the front of the lower jaw is exposed, the lower jaw body is cut along the vertical midline, first 1.0 cm from its upper edge, and then at an angle of 135 ° relative to the cut line in the opposite direction localization tion of tumor, the tumor was removed, osteosynthesis is carried out by reduction and bonding the fragments a titanium mandibular miniplates reinforced at right angles to the oblique cutting line, whereupon the wound sutured by layers.

Performing mandibulotomy according to the proposed method allows to achieve optimal access to the tumor process. Osteosynthesis achieved by a single titanium mini-plate reduces postoperative complications from pre- and postoperative radiation therapy and improves the quality of life of the patient.

A comparative analysis of the known methods of surgical treatment of cancer of the organs of the oral cavity and oropharynx and the proposed method allows us to ascertain the presence of novelty in the proposed method and significant differences of the latter.

The novelty of the proposed “Method for the treatment of cancer of the organs of the oral cavity and oropharynx” lies in the original version of the dissection of the lower jaw followed by osteosynthesis of one titanium miniplate, which makes it possible to maximally visualize the surgical field, radically remove the tumor, reconstruct the soft tissue defect, all of the above can improve the immediate postoperative effect , reduce postoperative complications, increase the duration of disease-free survival and restore speech and hl functions otania.

In open sources of information in Russia, the CIS countries and abroad, methods similar to the proposed were not found.

To explain the invention, the proposed drawings:

- Figure 1 shows a diagram of the cut of the body of the lower jaw (1) with the orientation of titanium miniplates (2) when fastening fragments of the jaw (according to Kropotov M.A. Doctor of Medical Sciences, Moscow, 2004);

- Figure 2 shows a diagram of the cut of the body of the lower jaw according to the method of J.F. Barbosa (1) with the orientation of wire seams (2) when fastening fragments of the jaw;

- figure 3 shows the access to perform operations according to the proposed method;

- Figure 4 shows a diagram of the cutting of the body of the lower jaw according to our proposed method (1) with the orientation of the titanium mini-plate (2) when fastening fragments of the jaw.

The method is as follows.

Under intravenous combined anesthesia with mechanical ventilation, a neck skin is cut from a point located 1.5 cm below the edge of the lower jaw on the affected side to a point located 1.5 cm below the edge of the lower jaw on the opposite side. Next, a cut is made from the corner of the mouth of the opposite side to the cut on the neck, the front part of the lower jaw is exposed, the lower jaw body is cut along the vertical midline, first 1.0 cm from its upper edge, and then at an angle of 135 ° relative to cut lines in the direction opposite to the localization of the tumor process. The edges of the lower jaw mobilize from the muscles of the diaphragm of the bottom of the oral cavity, part. An audit of the surgical wound is carried out, the boundaries of the tumor of the tongue and the bottom of the oral cavity are determined. The tumor is removed within healthy tissues. Then, reconstruction and closure of the postoperative defect of the bottom of the oral cavity, tongue with local tissues, a skin-fatty buccal flap, or in another way are performed. Hemostasis. Osteosynthesis of the lower jaw is achieved by reducing the edges of the lower jaw and fixing them using a titanium mini-plate located at right angles to the oblique cut line. The wound is sutured in layers. Next, a preventive tracheostomy is performed: a skin incision is made on the front surface of the neck from the lower edge of the thyroid cartilage to the jugular notch. Dissect the rectus muscles of the neck. When performing an average tracheostomy, the isthmus of the thyroid gland is crossed between the clamps and stitched. The trachea is exposed and opened by Bjork. Hemostasis. Stitches. At the end of the operation, a tracheotomy tube is inserted. Dressing according to the standard method.

An example of a specific implementation of the method can serve as an extract from the medical history.

1. Patient G., was admitted to the Department of head and neck tumors of the RNII on 09.21.2012 with a diagnosis of Cancer of the tongue with spreading to the mucosa of the bottom of the oral cavity, St. III, T3NxM0, class column 2.

I have not received treatment before.

Local status: lymph nodes are not palpable. The face is symmetrical. Opening the mouth is painful, but in full. When oropharyngoscopy in the area of the right lateral surface of the tongue with a transition beyond the midline and in the posterior parts of the bottom of the oral cavity, a tumor infiltrate of 5.0 × 3.5 cm is determined, with ulceration on the lower surface of the tongue up to 1.5 cm.The tongue is limitedly mobile.

10/01/2012 11 ¹⁰ -14 ⁰⁰ - Operation: 1) Cervical lymphadenectomy on the right;

2) Mandibulotomy, hemiglosectomy with reconstructive plastic component, osteosynthesis; 3) Tracheostomy.

Under intravenous combined anesthesia with artificial lung ventilation, an incision was made in the skin of the neck in the right submandibular region, located 1.5 cm below the edge of the lower jaw, to a point located 1.5 cm below the edge of the lower jaw on the left side. Then a cut was made from the corner of the mouth on the left to a cut on the neck, the anterior part of the lower jaw was exposed, the lower jaw was cut along the vertical midline, first 1.0 cm from its upper edge down, and then at an angle of 135 ° relative to the line saw cut to the left side (opposite to the localization of the tumor process). The edges of the lower jaw are mobilized from the muscles of the diaphragm of the bottom of the oral cavity, divorced. An audit of the surgical wound was carried out, the boundaries of the tumor of the tongue and the bottom of the oral cavity were determined. The tumor is removed within healthy tissues. Then, the reconstruction and closure of the postoperative defect in the bottom of the oral cavity, tongue with local tissues was performed. Hemostasis. Osteosynthesis of the lower jaw was carried out by reducing the edges of the lower jaw and fixing them using a titanium mini-plate located at right angles to the oblique cut line. The wound is sutured in layers. Next, a preventive tracheostomy was performed: a skin incision was made on the front surface of the neck from the lower edge of the thyroid cartilage to the jugular notch. The rectus muscles of the neck are dissected. The trachea is exposed and opened by Bjork above the isthmus of the thyroid gland. Hemostasis. Stitches. A tracheotomy tube was inserted. Dressing according to the standard method.

The postoperative period without complications. Sutures were removed on the ninth day.

The patient is in satisfactory condition.

October 18, 2012 the patient was discharged at the place of residence under the supervision of an oncologist. It is under outpatient supervision.

Last inspection 04/23/2013, i.e. 6 months after surgery.

The patient is in satisfactory condition, usually eats, the function of chewing, swallowing and speech without difficulty.

This method operated on 6 patients.

Thus, the present invention allows: to carry out radical surgical treatment of cancer of the posterior portions of the oral cavity, oropharynx, root of the tongue and retro-molar region.

The developed method is industrially applicable, as it can be reproduced and repeated many times in surgical clinics of the general medical network, specialized oncological institutions.

Claims (1)

A method for surgical treatment of cancer of the organs of the oral cavity and oropharynx, including performing cervical lymphadenectomy, ligation of the external carotid artery, performing mandibulotomy and preventive tracheostomy, characterized in that the neck skin is cut from a point located 1.5 cm below the edge of the lower jaw on the affected side , to a point located 1.5 cm below the edge of the lower jaw of the opposite side, then make a cut from the corner of the mouth of the opposite side to the cut on the neck, expose the front of the lower jaw, cut the body of the lower jaw is carried out along the vertical midline, first from its upper edge down by 1.0 cm, and then - at an angle of 135 ° relative to the cut line to the side opposite to the localization of the tumor process, the tumor is removed, osteosynthesis is carried out by mixing and fastening fragments of the lower the jaw with one titanium miniplate fixed at right angles to the oblique cut line, after which the wound is sutured in layers.

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