Limitações da viabilidade do retalho miocutâneo de músculo grande peitoral em cabeça e pescoço: estudo de 72 casos

Yinde, Luis Alberto Bogado; Rapoport, Abrão; Fava, Antonio Sérgio; Andrade Sobrinho, Josias de; Denardin, Odilom Victor Porto; Carvalho, Marcos Brasilino de

doi:10.1590/S0100-69911999000200002

Resumos

O emprego do retalho miocutâneo do músculo peitoral maior é rotina nos procedimentos reconstrutivos no tratamento das neoplasias das vias aerodigestivas superiores nos estádios III e IV. Assim, no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Heliópolis, de 1983 a 1994, a utilização deste retalho foi necessária em 66 pacientes portadores de carcinoma epidermóide e em seis com outras neoplasias malignas. Quanto à localização, as lesões acometiam a cavidade oral em trinta pacientes (41,6%), a hipofaringe em 16 pacientes (22,2%), tegumentos em 13 pacientes (18,0%), a orofaringe em dez pacientes (13,8), a laringe em dois pacientes (2,7%), a rinofaringe em um paciente (1,3%). Para a reconstrução foram empregados 72 retalhos, sendo que em 49 casos (68,0%) ocorreram complicações, enquanto que, em 23 pacientes, houve evolução sem a ocorrência das mesmas. Do grupo de pacientes que evoluíram com complicações, em 45 deles (91,2%) não houve necessidade de procedimentos complementares. Quanto às complicações, tivemos 18 necroses parciais (27,2%), 34 deiscências parciais (51,5%), 28 fístulas (42,4%), 34 infecções (51,5%) e dois hematomas (3,0%), sendo na grande maioria dos casos concomitantes (X2 = 20; p=0,22). Quanto aos 49 pacientes que apresentaram complicações, três eram portadores de neoplasias malignas do estádio clínico III e 46 do estádio IV (x2=2; p=0,15), sendo que, em 70,6% dos casos, o tratamento radioterápico já havia sido indicado previamente (Teste de Fisher: p=0,0785). Concluem os autores que, como fatores de risco para o aparecimento de complicações, os níveis séricos de a1bumina abaixo de 3,5g% e hemoglobina 12mg% foram aqueles com significado estatístico (respectivamente p=0,0048 e 0,0037).

Reconstrução; Retalho Miocutâneo; Viabilidade

The increase 01 advanced head and neck squamous cell carcinoma, determines the need lor reconstructive procedures with pectoralis major myocütaneous flap. From 1983 to 1994 at the Head and Neck Service 01 Hospital Heliópolis, São Paulo, Brazil 72 patients with advanced squamous cell carcinoma 01 the head and neck were submitted to surgical resection 01 recurrent neoplasia plus reconstruction with pectoralis major myocutaneous flap. Carcinoma was localized at the oral cavity (30 cases), hypopharynx (13 cases), skin (13 cases), oropharynx (10 cases), larynx (2 cases) and rhinopharynx (I case). Determination 01 major or minor complications in these patients (49 cases or68.05%), showed that in 45 (91.28%), were not necessary rescue procedures. As risks factors 01 complications, we observed partial necrosis in 18 patients (27.27%), partial dehiscense in 34 cases (51.51%), fistulae in 28 cases (42.42%), infections in 34 cases (51.51%) and hematomas in 2 cases (3.03%). From the analysis between complication ocurrence and TNM stage, we observed that three patients were stage III and 46 ilz stage IV (xl =2; p=0.I5). A relation with previous radioterapy, was detected in 70.68% (Fisher test = 0.0785). Blood analysis related to risk factors associated complications were: albumine (3.5 g%) and hemoglobin (12 mg%) with a p value = 0.0048 and 0.0034), respectively.

Reconstruction; Myocutaneous flap; Risk lactors

ARTIGO ORIGINAL

Limitações da viabilidade do retalho miocutâneo de músculo grande peitoral em cabeça e pescoço: estudo de 72 casos

Limitations of viability of pectoralis major myocutaneous flap in head and neck: study of 72 cases

Luis Alberto Bogado Yinde^I; Abrão Rapoport, TCBC-SP^II; Antonio Sérgio Fava^III; Josias de Andrade Sobrinho^III; Odilom Victor Porto Denardin^IV; Marcos Brasilino de Carvalho^IV

^IEstagiário do Serviço de Cabeça e Pescoço, Hosphel/São Paulo

^IICoordenador do Curso de Pós-Graduação de Cirurgia de Cabeça e Pescoço do Hosphel/São Paulo

^IIICirurgião do Serviço de Cabeça e Pescoço, Hosphel/São Paulo

^IVDiretor da Divisão de Apoio Diagnóstico Terapêutico do Hosphel/São Paulo

^VChefe do Serviço de Cabeça e Pescoço, Hosphel /São Paulo

^{Endereço para correspondência} Endereço para correspondência: Prof. Abrão Rapoport Praça Amadeu Amaral, 47 cj.82 01327-010 - São Paulo-SP

RESUMO

O emprego do retalho miocutâneo do músculo peitoral maior é rotina nos procedimentos reconstrutivos no tratamento das neoplasias das vias aerodigestivas superiores nos estádios III e IV. Assim, no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Heliópolis, de 1983 a 1994, a utilização deste retalho foi necessária em 66 pacientes portadores de carcinoma epidermóide e em seis com outras neoplasias malignas. Quanto à localização, as lesões acometiam a cavidade oral em trinta pacientes (41,6%), a hipofaringe em 16 pacientes (22,2%), tegumentos em 13 pacientes (18,0%), a orofaringe em dez pacientes (13,8), a laringe em dois pacientes (2,7%), a rinofaringe em um paciente (1,3%). Para a reconstrução foram empregados 72 retalhos, sendo que em 49 casos (68,0%) ocorreram complicações, enquanto que, em 23 pacientes, houve evolução sem a ocorrência das mesmas. Do grupo de pacientes que evoluíram com complicações, em 45 deles (91,2%) não houve necessidade de procedimentos complementares. Quanto às complicações, tivemos 18 necroses parciais (27,2%), 34 deiscências parciais (51,5%), 28 fístulas (42,4%), 34 infecções (51,5%) e dois hematomas (3,0%), sendo na grande maioria dos casos concomitantes (X2 = 20; p=0,22). Quanto aos 49 pacientes que apresentaram complicações, três eram portadores de neoplasias malignas do estádio clínico III e 46 do estádio IV (x2=2; p=0,15), sendo que, em 70,6% dos casos, o tratamento radioterápico já havia sido indicado previamente (Teste de Fisher: p=0,0785). Concluem os autores que, como fatores de risco para o aparecimento de complicações, os níveis séricos de a1bumina abaixo de 3,5g% e hemoglobina 12mg% foram aqueles com significado estatístico (respectivamente p=0,0048 e 0,0037).

Unitermos: Reconstrução; Retalho Miocutâneo; Viabilidade.

ABSTRACT

The increase 01 advanced head and neck squamous cell carcinoma, determines the need lor reconstructive procedures with pectoralis major myocütaneous flap. From 1983 to 1994 at the Head and Neck Service 01 Hospital Heliópolis, São Paulo, Brazil 72 patients with advanced squamous cell carcinoma 01 the head and neck were submitted to surgical resection 01 recurrent neoplasia plus reconstruction with pectoralis major myocutaneous flap. Carcinoma was localized at the oral cavity (30 cases), hypopharynx (13 cases), skin (13 cases), oropharynx (10 cases), larynx (2 cases) and rhinopharynx (I case). Determination 01 major or minor complications in these patients (49 cases or68.05%), showed that in 45 (91.28%), were not necessary rescue procedures. As risks factors 01 complications, we observed partial necrosis in 18 patients (27.27%), partial dehiscense in 34 cases (51.51%), fistulae in 28 cases (42.42%), infections in 34 cases (51.51%) and hematomas in 2 cases (3.03%). From the analysis between complication ocurrence and TNM stage, we observed that three patients were stage III and 46 ilz stage IV (xl =2; p=0.I5). A relation with previous radioterapy, was detected in 70.68% (Fisher test = 0.0785). Blood analysis related to risk factors associated complications were: albumine (3.5 g%) and hemoglobin (12 mg%) with a p value = 0.0048 and 0.0034), respectively.

Key words: Reconstruction; Myocutaneous flap; Risk lactors.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

REFERÊNCIAS

1. Waitzberg DN - Nutrição enteral e parenteral na prática. In: Waitzberg DN - Desnutrição, Editora Atheneu, São Paulo, 1990.

2. Kroll S, Goepfert H, Jones M, et al- Analysis of complications in 168 pectoralis major myocutaneous fIap in head and neck reconstruction. Ann Plast Surg 1990;225:93-7.

3. Aryan S - The pectoralis major myocutaneous flap. A versaitile flap for reconstruction in head neck. Plast Reconst Surg 1979;63:78-81.

4. Azevedo JF - Pectoralis minor flap: an experimental study and clinical aplications of osteomuscular, osteomyocutaneous and myocutaneous models. Head & Neck Surg 1987; 9:211-22.

5. Brussatti R, Collini M, Bozzetti A, et al - The pectoralis major flap: experience of 100 consecutives cases. Cranio Max Fac Surg 1988;16:35-39.

6. Chew CI, Stanley R, Peck R, et al - Pectoralis major myocutaneous flap, reconstruction in head and neck surgery, experience with 90 cases. Ann Acad Med Singapore 1991;20:570-80.

7. SchuIler DE - Limitations of pectoralis major myocutaneous flap in head and neck reconstruction. Arch Otolaryngol I980;106:709-14.

8. Arnold PG, Pairolero PC- Use of pectoralis major muscle flap to repair defects of anterior chest wall. Plast Reconst Surg 1979;63:205-13.

9. Shah IP, Haribhakti V, LoreeTR, Sutaria P - Complications of pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1990;160:352-5.

10. Johnson JT, Bloomer WD - Effect of prior radiotherapy on post surgical wound infection. Head & Neck Surg 1989;132:132-6.

11. Silver CE, Molsa II, Stein WBR - Pectoralis major myocutaneous fIap In Ferlito A - Surgical therapy of the larynx. Edit Churchul & Livingstone, Padua, 1993,Itália.

12. Aryan S, Cuono CH - Use of pectora1is major myocutaneous flap for reconstruction of large cervical racial and cranial defects. Am J Surg 1980;140:506-6.

13. Azevedo OJF - Modified pectoralis major myocutaneous flap with partial preservation of the muscle: a study of 55 cases. Head & Neck Surg 1986;3327-31.

14. Huang RD, Silver SM, Hussain A, et al - Pectoralis major myocutaneous fIap analysis of complications. Head & Neck SurgI992;14:102-6.

15. Tincani AJ, Martins AS, Barreto G, et al - O retalho miocutâneo pediculado de peitoral na recontrução em cabeça e pescoço. Rev Col Bras Cir 1993;3:118-22.

16. Marcial VA, Gelber R, Kraner S, et al - Does preoperative irradiation increase the rate of surgical complications in carcinoma of the head and neck? Cancer 1982;49:1.294-1.301.

17. Vasconez LO, Mc Graw JB, Hall EJ - Complication of musculocutaneous flap. Clin Plast Surg 1980;7:123-132.

18. Lefebvre J, Vanktmme LB, Merynadier J, et al- L'apport du lambeau musculocutané de grand pectoral en chirurgie cervicofaciale et buccopharingeé. Bull Cancer 1984;71 :35-9.

19. Cho HT, Mignogna F, Garay Y, et al - Delayed failure of myocutaneous fIap in the head and neck reconstruction. Laryngoscope 1983; 93:17-9.

20. Moloy PJ, Gonzales FE - Vascular anatomy of the pectoralis major myocutaneous fIap. Head & Neck Surg 1986;112:62-9.

21. Lavelle RJ, MAR - The ethiology of post laryngectomy pharyngocutaneous fistulae. J Laryngol Otol 1972;88:785-793.

22. Hier M, Black MJ, Lafond G - Pharyngocutaneous fistulae after total laryngectomy: incidence, etiology and outcome analysis. J Othorrinolaryngol 1993;22:164-6.

23. Leon X, Quer M, Orus C, et al - Complications deI miocutáneo de pectoral major em reconstruction cervical. Acta Othorrinolaring (Espana), 1993;44:375-80.

24. Biller HF, Baek SM, Lawson W; et al- Pectoralis myocutaneous island flap in head and neck surgery: analysis of complications in 42 cases. Arch Otolaryngol 1981;107:23-6.

25. Cussomano RJ, Silver CE, Braner J E, et al - Pectoralis myocutaneous flap for replacement of cervical esophagus. Head & Neck Surg 1.989;5:450-6.

26. Sisson GA, Straehley CJ, Johnson NE - Mediastinal dissection for recurrent cancer after laryngectomy. Cancer 1962; 22:1.060-77.

Recebido em 4/9/98

Aceito para publicação em 11/1/99

Trabalho realizado no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Heliópolis, São Paulo, Brasil.

1. Waitzberg DN - Nutriçăo enteral e parenteral na prática. In: Waitzberg DN - Desnutriçăo, Editora Atheneu, Săo Paulo, 1990.
2. Kroll S, Goepfert H, Jones M, et al- Analysis of complications in 168 pectoralis major myocutaneous fIap in head and neck reconstruction. Ann Plast Surg 1990;225:93-7.
3. Aryan S - The pectoralis major myocutaneous flap. A versaitile flap for reconstruction in head neck. Plast Reconst Surg 1979;63:78-81.
4. Azevedo JF - Pectoralis minor flap: an experimental study and clinical aplications of osteomuscular, osteomyocutaneous and myocutaneous models. Head & Neck Surg 1987; 9:211-22.
5. Brussatti R, Collini M, Bozzetti A, et al - The pectoralis major flap: experience of 100 consecutives cases. Cranio Max Fac Surg 1988;16:35-39.
6. Chew CI, Stanley R, Peck R, et al - Pectoralis major myocutaneous flap, reconstruction in head and neck surgery, experience with 90 cases. Ann Acad Med Singapore 1991;20:570-80.
7. SchuIler DE - Limitations of pectoralis major myocutaneous flap in head and neck reconstruction. Arch Otolaryngol I980;106:709-14.
8. Arnold PG, Pairolero PC- Use of pectoralis major muscle flap to repair defects of anterior chest wall. Plast Reconst Surg 1979;63:205-13.
9. Shah IP, Haribhakti V, LoreeTR, Sutaria P - Complications of pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1990;160:352-5.
10. Johnson JT, Bloomer WD - Effect of prior radiotherapy on post surgical wound infection. Head & Neck Surg 1989;132:132-6.
11. Silver CE, Molsa II, Stein WBR - Pectoralis major myocutaneous fIap In Ferlito A - Surgical therapy of the larynx. Edit Churchul & Livingstone, Padua, 1993,Itália.
12. Aryan S, Cuono CH - Use of pectora1is major myocutaneous flap for reconstruction of large cervical racial and cranial defects. Am J Surg 1980;140:506-6.
13. Azevedo OJF - Modified pectoralis major myocutaneous flap with partial preservation of the muscle: a study of 55 cases. Head & Neck Surg 1986;3327-31.
14. Huang RD, Silver SM, Hussain A, et al - Pectoralis major myocutaneous fIap analysis of complications. Head & Neck SurgI992;14:102-6.
15. Tincani AJ, Martins AS, Barreto G, et al - O retalho miocutâneo pediculado de peitoral na recontruçăo em cabeça e pescoço. Rev Col Bras Cir 1993;3:118-22.
16. Marcial VA, Gelber R, Kraner S, et al - Does preoperative irradiation increase the rate of surgical complications in carcinoma of the head and neck? Cancer 1982;49:1.294-1.301.
17. Vasconez LO, Mc Graw JB, Hall EJ - Complication of musculocutaneous flap. Clin Plast Surg 1980;7:123-132.
18. Lefebvre J, Vanktmme LB, Merynadier J, et al- L'apport du lambeau musculocutané de grand pectoral en chirurgie cervicofaciale et buccopharingeé. Bull Cancer 1984;71 :35-9.
19. Cho HT, Mignogna F, Garay Y, et al - Delayed failure of myocutaneous fIap in the head and neck reconstruction. Laryngoscope 1983; 93:17-9.
20. Moloy PJ, Gonzales FE - Vascular anatomy of the pectoralis major myocutaneous fIap. Head & Neck Surg 1986;112:62-9.
21. Lavelle RJ, MAR - The ethiology of post laryngectomy pharyngocutaneous fistulae. J Laryngol Otol 1972;88:785-793.
22. Hier M, Black MJ, Lafond G - Pharyngocutaneous fistulae after total laryngectomy: incidence, etiology and outcome analysis. J Othorrinolaryngol 1993;22:164-6.
23. Leon X, Quer M, Orus C, et al - Complications deI miocutáneo de pectoral major em reconstruction cervical. Acta Othorrinolaring (Espana), 1993;44:375-80.
24. Biller HF, Baek SM, Lawson W; et al- Pectoralis myocutaneous island flap in head and neck surgery: analysis of complications in 42 cases. Arch Otolaryngol 1981;107:23-6.
25. Cussomano RJ, Silver CE, Braner J E, et al - Pectoralis myocutaneous flap for replacement of cervical esophagus. Head & Neck Surg 1.989;5:450-6.
26. Sisson GA, Straehley CJ, Johnson NE - Mediastinal dissection for recurrent cancer after laryngectomy. Cancer 1962; 22:1.060-77.

Endereço para correspondência:

Prof. Abrão Rapoport

Praça Amadeu Amaral, 47 cj.82

01327-010 - São Paulo-SP

Datas de Publicação

Publicação nesta coleção
09 Fev 2010
Data do Fascículo
Abr 1999

Histórico

Aceito
11 Jan 1999
Recebido
04 Set 1998

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Waitzberg DN - Nutriçăo enteral e parenteral na prática. In: Waitzberg DN - Desnutriçăo, Editora Atheneu, Săo Paulo, 1990.

[2] 2. Kroll S, Goepfert H, Jones M, et al- Analysis of complications in 168 pectoralis major myocutaneous fIap in head and neck reconstruction. Ann Plast Surg 1990;225:93-7.

[3] 3. Aryan S - The pectoralis major myocutaneous flap. A versaitile flap for reconstruction in head neck. Plast Reconst Surg 1979;63:78-81.

[4] 4. Azevedo JF - Pectoralis minor flap: an experimental study and clinical aplications of osteomuscular, osteomyocutaneous and myocutaneous models. Head & Neck Surg 1987; 9:211-22.

[5] 5. Brussatti R, Collini M, Bozzetti A, et al - The pectoralis major flap: experience of 100 consecutives cases. Cranio Max Fac Surg 1988;16:35-39.

[6] 6. Chew CI, Stanley R, Peck R, et al - Pectoralis major myocutaneous flap, reconstruction in head and neck surgery, experience with 90 cases. Ann Acad Med Singapore 1991;20:570-80.

[7] 7. SchuIler DE - Limitations of pectoralis major myocutaneous flap in head and neck reconstruction. Arch Otolaryngol I980;106:709-14.

[8] 8. Arnold PG, Pairolero PC- Use of pectoralis major muscle flap to repair defects of anterior chest wall. Plast Reconst Surg 1979;63:205-13.

[9] 9. Shah IP, Haribhakti V, LoreeTR, Sutaria P - Complications of pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1990;160:352-5.

[10] 10. Johnson JT, Bloomer WD - Effect of prior radiotherapy on post surgical wound infection. Head & Neck Surg 1989;132:132-6.

[11] 11. Silver CE, Molsa II, Stein WBR - Pectoralis major myocutaneous fIap In Ferlito A - Surgical therapy of the larynx. Edit Churchul & Livingstone, Padua, 1993,Itália.

[12] 12. Aryan S, Cuono CH - Use of pectora1is major myocutaneous flap for reconstruction of large cervical racial and cranial defects. Am J Surg 1980;140:506-6.

[13] 13. Azevedo OJF - Modified pectoralis major myocutaneous flap with partial preservation of the muscle: a study of 55 cases. Head & Neck Surg 1986;3327-31.

[14] 14. Huang RD, Silver SM, Hussain A, et al - Pectoralis major myocutaneous fIap analysis of complications. Head & Neck SurgI992;14:102-6.

[15] 15. Tincani AJ, Martins AS, Barreto G, et al - O retalho miocutâneo pediculado de peitoral na recontruçăo em cabeça e pescoço. Rev Col Bras Cir 1993;3:118-22.

[16] 16. Marcial VA, Gelber R, Kraner S, et al - Does preoperative irradiation increase the rate of surgical complications in carcinoma of the head and neck? Cancer 1982;49:1.294-1.301.

[17] 17. Vasconez LO, Mc Graw JB, Hall EJ - Complication of musculocutaneous flap. Clin Plast Surg 1980;7:123-132.

[18] 18. Lefebvre J, Vanktmme LB, Merynadier J, et al- L'apport du lambeau musculocutané de grand pectoral en chirurgie cervicofaciale et buccopharingeé. Bull Cancer 1984;71 :35-9.

[19] 19. Cho HT, Mignogna F, Garay Y, et al - Delayed failure of myocutaneous fIap in the head and neck reconstruction. Laryngoscope 1983; 93:17-9.

[20] 20. Moloy PJ, Gonzales FE - Vascular anatomy of the pectoralis major myocutaneous fIap. Head & Neck Surg 1986;112:62-9.

[21] 21. Lavelle RJ, MAR - The ethiology of post laryngectomy pharyngocutaneous fistulae. J Laryngol Otol 1972;88:785-793.

[22] 22. Hier M, Black MJ, Lafond G - Pharyngocutaneous fistulae after total laryngectomy: incidence, etiology and outcome analysis. J Othorrinolaryngol 1993;22:164-6.

[23] 23. Leon X, Quer M, Orus C, et al - Complications deI miocutáneo de pectoral major em reconstruction cervical. Acta Othorrinolaring (Espana), 1993;44:375-80.

[24] 24. Biller HF, Baek SM, Lawson W; et al- Pectoralis myocutaneous island flap in head and neck surgery: analysis of complications in 42 cases. Arch Otolaryngol 1981;107:23-6.

[25] 25. Cussomano RJ, Silver CE, Braner J E, et al - Pectoralis myocutaneous flap for replacement of cervical esophagus. Head & Neck Surg 1.989;5:450-6.

[26] 26. Sisson GA, Straehley CJ, Johnson NE - Mediastinal dissection for recurrent cancer after laryngectomy. Cancer 1962; 22:1.060-77.