口腔癌游離皮瓣修復(fù)術(shù)后早期喂養(yǎng)的研究

劉曉霞 劉 潔 黃 燕 趙 珊 譚 娟 楊 舟

口腔癌游離皮瓣修復(fù)術(shù)后早期喂養(yǎng)的研究

劉曉霞 劉 潔 黃 燕 趙 珊 譚 娟 楊 舟

目的探討口腔癌切除術(shù)后游離皮瓣修復(fù)術(shù)患者早期經(jīng)口進(jìn)流食對(duì)患者傷口愈合的影響。方法分析32例口腔癌游離皮瓣修復(fù)術(shù)患者的資料，記錄術(shù)后經(jīng)口進(jìn)水、進(jìn)流食、拔除鼻飼管的時(shí)間、平均住院天數(shù)及并發(fā)癥，并歸納總結(jié)。結(jié)果32例患者均于術(shù)后6 h進(jìn)食溫開水，其中29例術(shù)后第5天9 Am經(jīng)口進(jìn)流食無不適后，于術(shù)后第5天10 Pm拔除鼻飼管；其余3例患者術(shù)后第7天9 Am經(jīng)口進(jìn)食，術(shù)后第7天10 Pm拔除鼻飼管。所有患者未出現(xiàn)皮瓣壞死、皮膚瘺管等并發(fā)癥。盡管平均住院天數(shù)為12.8(范圍10～19)天，但并非因?yàn)檫M(jìn)食問題而推遲。住院超過14天主要因?yàn)榈却g(shù)前確認(rèn)病理結(jié)果(n=1)以及家屬對(duì)手術(shù)的支持不足(n=2)。結(jié)論口腔癌切除游離皮瓣修復(fù)術(shù)后早期經(jīng)口進(jìn)流食不影響皮瓣的成活及傷口的愈合。

口腔癌；皮瓣修復(fù)；早期喂養(yǎng)

口腔癌切除后組織缺損的游離皮瓣修復(fù)重建術(shù)后的并發(fā)癥主要有皮瓣壞死、傷口裂開、皮膚瘺管的形成等。有的學(xué)者認(rèn)為口腔癌游離皮瓣修復(fù)重建術(shù)后早期經(jīng)口進(jìn)食會(huì)增加口內(nèi)傷口的張力，可能導(dǎo)致傷口裂開，并可能污染傷口甚至形成皮膚瘺管。因此多數(shù)外科醫(yī)生仍采用術(shù)后6～12天不能經(jīng)口進(jìn)食的傳統(tǒng)方式[1]。近年來，國內(nèi)外有報(bào)道提出早期經(jīng)口進(jìn)食是安全、可耐受的[2-3]。

迄今為止，對(duì)于口腔癌切除游離皮瓣修復(fù)重建患者手術(shù)后早期喂養(yǎng)的報(bào)道還比較少。我們對(duì)32例口腔癌切除游離皮瓣修復(fù)重建患者術(shù)后行早期經(jīng)口進(jìn)流食，對(duì)經(jīng)口進(jìn)流食的時(shí)間、拔除鼻飼管時(shí)間、傷口愈合情況、住院天數(shù)等進(jìn)行觀察和分析，現(xiàn)報(bào)告如下。

1 資料與方法

1.1 一般資料

南昌大學(xué)附屬口腔醫(yī)院口腔頜面外科2014年1月至2015年12同一醫(yī)療小組實(shí)施口腔癌游離皮瓣修復(fù)重建術(shù)患者32例，患者平均年齡54(32～75)歲，其中鱗狀細(xì)胞癌患者30例，成釉細(xì)胞癌患者2例；腫瘤分期以3期為主(18例)，腫瘤部位位于舌(前2/3段)19例，上下頜骨、口底區(qū)各5例，頰粘膜3例；行前臂皮瓣修復(fù)術(shù)患者30例，腓骨瓣修復(fù)患者2例；單側(cè)頸清29例，雙側(cè)3例。所有患者除所治療疾病外并未合并其他系統(tǒng)疾病。

1.2 進(jìn)食方法

所有患者術(shù)后6 h全麻清醒后開始經(jīng)口進(jìn)食溫開水(36 ℃～38 ℃，過冷易致血管痙攣影響皮瓣存活，過熱易致傷口出血)每次50 ml，每天7 Am至9 Pm，每2小時(shí)1次；術(shù)后第1天9 Am插鼻飼管注流食(無渣流質(zhì)飲食，且經(jīng)過嚴(yán)格篩選以保證充足熱量)，溫度36 ℃～38 ℃，每天7 Am至9 Pm，每2小時(shí)1次。術(shù)后第5天9 Am經(jīng)口進(jìn)流食，初次給予經(jīng)口進(jìn)食流質(zhì)100 ml，鼻飼注入100 ml，患者無不適癥狀后逐漸加大口腔進(jìn)食量，每2小時(shí)進(jìn)食1次，如無不適術(shù)后第5天10 Pm拔除鼻飼管。

2 結(jié)果

32例患者均于術(shù)后6 h全麻清醒后經(jīng)口進(jìn)食溫開水(36 ℃～38 ℃)，術(shù)后第1天9 Am插鼻飼管注流食。其中29例患者術(shù)后第5天9 Am經(jīng)口進(jìn)食無不適，并于術(shù)后第5天10 Pm拔除鼻飼管；其余3例患者術(shù)后第7天9 Am經(jīng)口進(jìn)食，術(shù)后第7天10 Pm拔除鼻飼管。所有患者進(jìn)食的食物均為無渣流質(zhì)飲食，溫度36 ℃～38 ℃，且經(jīng)過嚴(yán)格篩選以保證充足熱量。32例患者均未出現(xiàn)感染、皮瓣壞死、皮膚瘺管等并發(fā)癥?；颊咂骄≡禾鞌?shù)為12.8(10～19)天。住院超過14天的主要原因是等待術(shù)前確認(rèn)病理結(jié)果(n=1)以及家屬對(duì)手術(shù)的支持程度(n=2)，并非因?yàn)檫M(jìn)食問題而推遲。

3 討論

大量研究表明口腔癌切除游離皮瓣重建術(shù)后并發(fā)癥的發(fā)生主要?dú)w因于腫瘤的位置、范圍以及重建的類型[4-6]。有學(xué)者認(rèn)為口腔癌游離皮瓣重建術(shù)后早期經(jīng)口進(jìn)食會(huì)增加出現(xiàn)皮膚瘺管的風(fēng)險(xiǎn)[1]。自上世紀(jì)90年代以來，由于圍手術(shù)期多種護(hù)理模式的引入，這種推遲功能恢復(fù)的說法已逐漸被取代。Guidera等發(fā)現(xiàn)，口腔癌游離皮瓣重建術(shù)后第5天經(jīng)口進(jìn)食流質(zhì)飲食與術(shù)后第6天后進(jìn)食相比并發(fā)癥的發(fā)生率并未增加[7]。同時(shí)，在喉頭切除手術(shù)后第6天進(jìn)食流質(zhì)可以保持和促進(jìn)吞咽能力的恢復(fù)，且皮膚瘺或潛在并發(fā)癥的發(fā)生并沒有增加[8-9]。本組病例中，患者術(shù)后6 h麻醉清醒后經(jīng)口進(jìn)食溫水，術(shù)后第5天經(jīng)口進(jìn)食流質(zhì)并拔除鼻飼管，所有病例均未見傷口裂開、皮瘺等并發(fā)癥的發(fā)生。

許多研究表明，患者可在術(shù)后第5天進(jìn)食流質(zhì)[7]。我們的研究表明，患者術(shù)后6 h麻醉清醒后進(jìn)溫開水，術(shù)后第5天經(jīng)口進(jìn)流食，早期經(jīng)口進(jìn)食水、流食不僅可以補(bǔ)充水分、清潔傷口，還能促進(jìn)患者唾液腺分泌，避免口腔內(nèi)菌群失調(diào)，使腭咽功能得到早期恢復(fù)。喉切除術(shù)后早期拔除胃管經(jīng)口進(jìn)食的優(yōu)勢(shì)早有報(bào)道，該法可以讓患者更舒適，比起胃管進(jìn)食，口腔進(jìn)食也可以增加患者的攝入量，且降低成本[8]。

總之，口腔癌游離皮瓣重建術(shù)后早期經(jīng)口進(jìn)流食不影響皮瓣的成活及傷口的愈合，不會(huì)增加并發(fā)癥發(fā)生的風(fēng)險(xiǎn)，同時(shí)能使患者的舒適度和滿足感顯著提升。

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StudyofEarlyOralFeedingafterFreeFlapReconstructionforOralCancer

LIUXiaoxia,LIUJie,HUANGYan,etal.

AffiliatedStomatologicalHospitalofNanchangUniversity,Nanchang,330006

ObjectiveTo discuss the impact of early oral feeding on wound healing after free flap reconstruction for oral cancer.MethodsThe postoperative records of 32 patients who had undergone surgical resection and free flap reconstruction for oral cancer were analyzed.Details including the commencement of water and fluids,duration of nasogastric intubation and hospital stay,postoperative complication were also recorded and analyzed.ResultsAll patients were started on water 6 hours after the operation,by 9 am of the fifth day after surgery，29 patients could tolerate fluids orally and their nasogastric tubes were removed by 10 pm of day 5.Only 3 patients,who could take fluids until 9 Am of day 7,got their nasogastric tubes removed by 10 pm of the same day.There were no complications such as flap necrosis,fistulas and so on.Although the mean duration of hospital stay after operation was 12.8 days(range 10～19),discharge was not delayed by problems of feeding.The main reasons for a stay of more than 14 days were the delay of preoperative pathological report(n=1) and insufficient support for surgery from family members(n=2).ConclusionEarly oral feeding after free flap reconstruction for oral cancer does not affect the flap survival and wound healing.

Oral cancer;Flap reconstruction;Early oral feeding

(ThePracticalJournalofCancer,2017,32:1953～1954)

330006 南昌大學(xué)附屬口腔醫(yī)院

10.3969/j.issn.1001-5930.2017.12.012

R739.8

A

1001-5930(2017)12-1953-02

2017-03-01

2017-08-29)

(編輯：甘艷)