RESUMO
A patent internal carotid artery (ICA) is essential in most patients. Management of skull base lesions often requires translocation, balloon embolization, or resection of this vessel. Preoperative tests to assess the availability of collateral flow have not been uniformly accurate. A new test that significantly increases the safety of surgical removal of the ICA is described. One hundred thirty-six patients were studied with temporary balloon occlusion (TBO) of the ICA and determination of stable xenon-enhanced computed tomography cerebral blood flow (Xe/CT CBF) measurements. Eleven patients failed TBO and were determined to be at very high risk of stroke with loss of the ICA. Ninety-six of the patients were predicted to be at minimal risk with permanent loss of the ICA by Xe/CT CBF studies. Twenty-one patients in this group had either permanent balloon occlusion (PBO) or surgical resection of the ICA with no permanent neurologic sequelae. Our studies show that the combination of preoperative TBO and Xe/CT CBF studies significantly increases the safety of ICA resection.
Assuntos
Artéria Carótida Interna/cirurgia , Cateterismo , Infarto Cerebral/prevenção & controle , Circulação Cerebrovascular , Neoplasias de Cabeça e Pescoço/cirurgia , Cuidados Pré-Operatórios , Adolescente , Adulto , Idoso , Velocidade do Fluxo Sanguíneo , Pressão Sanguínea , Artéria Carótida Interna/diagnóstico por imagem , Cateterismo/normas , Criança , Pré-Escolar , Circulação Colateral , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Lactente , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Risco , Fatores de Risco , Tomografia Computadorizada por Raios X , XenônioRESUMO
Use of enteric grafts is a popular method for reconstruction of the cervical esophagus and hypopharynx. Free jejunal transfer (FJT) and gastric pull-up (GP) are the most popular methods used. This discussion is a retrospective review of our experience with 50 cases of free jejunal transfer and 15 cases of gastric pull-up. The graft survival rate was 94 percent (47 of 50) for free jejunal transfer and 87 percent (13 of 15) for gastric pull-up. Successful swallowing was achieved in 88 percent (44 of 50) of free jejunal transfers and 87 percent (13 of 15) of gastric pull-ups. Patients with free jejunal transfers were able to swallow and leave the hospital sooner: 10.6 versus 16.0 days and 22.3 versus 29.0 days, respectively. Fistulas occurred in 16 percent (8 of 50) of free jejunal transfers, most of which (6 of 8) healed spontaneously. Fistulas occurred in 20 percent (3 of 15) of gastric pull-ups, only one of which healed spontaneously. Stricture was the most common late complication for free jejunal transfers, 22 percent (11 of 50), whereas reflux was most common in gastric pull-ups, 20 percent (3 of 15). In patients with advanced cancer, extensive esophageal resection into the chest is often required, and gastric pull-up seems to be an easier and more direct form of reconstruction. In limited resection of the hypopharynx and esophagus, especially with proximal lesions, free jejunal transfer is simpler and avoids mediastinal dissection. This concept as well as other advantages and disadvantages of both techniques will be discussed.
Assuntos
Esofagoplastia/métodos , Jejuno/transplante , Estômago/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-OperatóriasRESUMO
Gastric pull-up or free jejunal interposition was used for reconstruction after total laryngopharyngectomy in 31 patients. Complications and functional outcomes of the two methods are compared. Primary swallowing was achieved in 86% of patients after gastric pull-up and in 82% of patients after jejunal interposition. Patients who underwent jejunal interposition were able to swallow sooner and had a shorter hospital stay than patients who underwent gastric pull-up. Esophageal tumor recurrence after jejunal interposition was not observed. Hepatic failure occurred in two gastric pull-up patients, leading to perioperative death in one. Flap necrosis occurred in two jejunal interposition patients and one gastric pull-up patient. Two additional fistulas occurred in jejunal interposition patients as a result of microvascular complications. Stricture developed in four jejunal interposition patients, requiring revision surgery in two. Minor complications were more common in the gastric pull-up group. Long-term speech and swallowing function are compared. Our current choice of jejunal interposition or gastric pull-up for reconstruction after total laryngopharyngectomy primarily depends on the location of the tumor.
Assuntos
Hipofaringe/cirurgia , Idoso , Deglutição , Neoplasias Esofágicas/cirurgia , Feminino , Humanos , Jejuno/transplante , Neoplasias Laríngeas/cirurgia , Laringectomia , Masculino , Métodos , Pessoa de Meia-Idade , Neoplasias Faríngeas/cirurgia , Faringectomia , Complicações Pós-Operatórias , Estudos Retrospectivos , Fala , Estômago/cirurgiaRESUMO
Teratoma is the most common nasopharyngeal tumor in neonates. The tumor is usually limited to the oropharynx and is manifest by stridor and respiratory distress. Complete excision affects a cure. An unusual case of nasopharyngeal teratoma extending into the temporal bone, causing facial paralysis and conductive hearing loss, in addition to stridor, is presented. Stridor was relieved by transoral partial excision shortly after birth. Complete removal of the tumor by way of a subtemporal and infratemporal fossa approach was performed at 14 months of age. The defect was filled with a rectus abdominis muscle graft with microvascular anastomoses. The facial nerve was reconstructed secondarily with a sural nerve graft. The patient has no recurrence tumor and has good facial function at 30 months. This case demonstrates the first known case of facial paralysis due to nasopharyngeal teratoma. The surgical approach for tumor removal: lateral infratemporal fossa dissection, and the method of reconstruction: free rectus abdominis muscle flap with microvascular anastomoses, had so far not been described in a patient this young.
Assuntos
Neoplasias Nasofaríngeas/patologia , Neoplasias Cranianas/patologia , Osso Temporal/patologia , Teratoma/patologia , Humanos , Lactente , Masculino , Invasividade NeoplásicaRESUMO
Curability of skull base tumors is related to the ability to achieve a complete resection. Resection of the internal carotid artery with the tumor puts the patient at risk for catastrophic cerebral injury. Autogenous vein grafting is not always technically or physiologically possible. We present eight patients with tumors eroding the cranial base who underwent safe resection or occlusion of the internal carotid artery as predicted by three tests: 1. carotid arteriography, 2. temporary balloon occlusion of the internal carotid artery, and 3. xenon computerized tomography cerebral blood flow mapping. No patient suffered permanent central nervous system injury.