顺行法分叶背阔肌皮瓣在LABC切除术后胸壁修复重建中的应用

doi:10.3760/cma.j.cn441417-20240827-12025

摘要/Abstract

摘要：

目的　分析顺行法设计分叶背阔肌皮瓣在局部晚期乳腺癌（LABC）切除后胸壁缺损即刻修复重建术中的应用效果。方法　采用回顾性分析，选取2021年1月至2023年10月西安国际医学中心医院接收的乳腺癌根治术和即刻胸壁修复重建术的LABC女性患者59例，根据胸壁缺损修复重建方式不同分为观察组、对照组。观察组28例，年龄（53.1±6.4）岁；对照组31例，年龄（52.6±6.5）岁。观察组采用顺行法设计分叶背阔肌皮瓣修复缺损，对照组采用带蒂腹直肌皮瓣修复缺损。比较两组围手术期相关指标（手术时长、术中失血量、淋巴结清扫数、皮肤缺损面积、术后引流时间及住院时间）、并发症发生率、外观满意度以及生存分析指标［总生存率（OS）和无病生存率（DFS）］。采用t检验、χ2检验、Kaplan-Meier生存分析法和Log-Rank检验进行统计学分析。结果　观察组手术时间和术后引流时间均短于研究组［（231.4±30.7）min比（249.3±36.8）min、（4.3±0.4）d比（4.5±0.3）d）］，术中失血量低于对照组［（86.9±19.5）ml比（98.7±24.4）ml］，差异均有统计学意义（均P<0.05）。观察组淋巴结清扫数为（15.2±1.1）枚、术后住院时间为（8.7±0.7）d，对照组分别为（14.8±1.5）枚、（9.1±1.2）d，差异均无统计学意义（均P>0.05）。观察组并发症总发生率低于对照组［10.7%（3/28）比32.3%（10/31）］，差异有统计学意义（χ2=3.975，P=0.046）。随访6个月观察组非常满意占比显著高于对照组［（60.7%（17/28）比32.3%（10/31））］，差异有统计学意义（P<0.05）；两组整体满意度无显著差异（χ2=1.650，P>0.05）。观察组3年DFS率为71.4%（20/28），对照组为67.7%（21/31）；OS率观察组为82.1%（23/28），对照组为77.5%（24/31）。Log-Rank检验显示，两组DFS（χ2=0.142，df=1，P=0.706）和OS（χ2=0.171，df=1，P=0.679），差异均无统计学意义。结论　顺行法设计的双叶背阔肌皮瓣用于LABC患者术后即刻胸壁重建，可显著优化手术流程（降低操作难度、缩短手术时间及减少术中出血），同时确保皮瓣血供可靠并降低供区并发症，临床疗效确切，值得推广应用。

关键词: 乳腺癌, 胸壁重建, 分叶背阔肌皮瓣, 腹部皮瓣

Abstract:

Objective　To analyze the effect of anterograde design of lobular latissimus dorsi flap in immediate reconstruction of chest wall defect after resection of locally advanced breast cancer (LABC). Methods　A retrospective analysis was conducted. Fifty-nine female patients with LABC who underwent radical mastectomy for breast cancer and immediate chest wall repair and reconstruction at Xi 'an International Medical Center Hospital from January 2021 to October 2023 were selected and divided into an observation group and a control group according to different methods of chest wall defect repair and reconstruction. There were 28 cases in the observation group, with an age of (53.1±6.4) years. There were 31 cases in the control group, with an age of (52.6±6.5) years. The observation group used the anterograde method to design lobulated latissimus dorsi flap for defect repair, while the control group used the pedicled rectus abdominis flap for defect repair. The perioperative related indicators (operation duration, intraoperative blood loss, number of lymph node dissections, skin defect area, postoperative drainage time ,and hospital stay), complication rates, appearance satisfaction ,and survival analysis indicators [overall survival rate (OS) and disease-free survival rate (DFS)] of the two groups were compared. Statistical analyses were performed using t-tests, χ² tests, Kaplan-Meier survival analysis methods and Log-Rank tests.. Results　The operation time and postoperative drainage time in the observation group were both shorter than those in the observation group [(231.4±30.7) min vs. (249.3±36.8) min and (4.3±0.4) d vs. (4.5±0.3) d)], and the intraoperative blood loss was lower than that in the control group [(86.9±19.5) ml vs. (98.7±24.4) ml]; the differences were all statistically significant (all P<0.05). The number of lymph node dissections in the observation group was 15.2±1.1, and the postoperative hospital stay was (8.7±0.7) , while those in the control group were 14.8±1.5 and (9.1±1.2) days, respectively; there were no statistically significant differences (both P>0.05). The total incidence of complications in the observation group was lower than that in the control group [10.7% (3/28) vs. 32.3% (10/31)], and the difference was statistically significant (χ²=3.975, P=0.046). After a 6-month follow-up, the proportion of very satisfied individuals in the observation group was significantly higher than that in the control group [(60.7% (17/28) vs. 32.3% (10/31))], and the difference was statistically significant (P<0.05). There was no statistical difference in the overall satisfaction between the two groups (χ²=1.650, P>0.05). The 3-year DFS rate was 71.4%（20/28） in the observation group, and 67.7%（21/31） in the control group. The OS rate was 82.1%（23/28） in the observation group, and 77.5%(24/31) in the control group. The Log-Rank test showed that there were no statistically significant differences in DFS (χ²=0.142, df=1, P=0.706) and OS (χ²=0.171, df=1,P=0.679) between the two groups. Conclusion　The anterior-designed bilateral latissimus dorsi muscle flap for immediate chest wall reconstructions in patients with LABC can significantly optimize the surgical process (reduce operational difficulty, shorten operation time, and reduce intraoperative bleeding), while ensuring reliable blood supply to the flap and reducing complications in the donor area. The clinical efficacy is definite and worthy of promotion and application.

Key words: Breast cancer, Chest wall reconstruction, Lobulated latissimus dorsi muscle flap, Abdominal flap

任杰汪阳席儒兴. 顺行法分叶背阔肌皮瓣在LABC切除术后胸壁修复重建中的应用 [J]. 国际医药卫生导报, 2025, 31(12): 2056-2061.

Ren Jie, Wang Yang, Xi Ruxing.

The application of anterograde lobed latissimus dorsi flap in the reconstruction of chest wall after LABC resection [J]. International Medicine and Health Guidance News, 2025, 31(12): 2056-2061.

参考文献

[1]Xu Y, Gong M, Wang Y, et al. Global trends and forecasts of breast cancer incidence and deaths[J]. Sci Data, 2023,10(1):334-335. DOI:10.1038/s41597-023-02253-5.

[2]高艳多,阎炯,赵胜,等. 1990-2019年中国女性乳腺癌发病和死亡趋势的年龄-时期-队列模型分析[J].中国预防医学杂志, 2022, 23(12):909-916. DOI: 10.16506/j.1009-6639. 2022.12.005.

[3]陈晴纪楠,何珊珊,丁泊文,等.局部晚期乳腺癌行即刻乳房再造术的远期生存及预后因素研究[J].中国肿瘤临床,2023,50(12):606-611.DOI: 10.12354/j.issn.1000-8179. 2023.20221526.

[4]陈晴纪楠,何珊珊,尹健.自体皮瓣在整形保乳术和局部晚期乳腺癌胸壁重建中的应用进展[J].中华整形外科杂志,2023,39(11):1161-1165. DOI:10.3760/cma.j.cn114453-20220527-00165.

[5]黄毅,程腾,吴晓东,等.乳腺癌乳房切除术后即刻重建的研究进展[J].安徽医学,2024,45(4):511-515. DOI: 10.3969/j.issn.1000-0399.2024.04.021.

[6]马建勋,夏有辰,李比,等.乳腺癌改良根治术后即刻乳房重建的方式选择[J].北京大学学报(医学版),2023,55(4):612-618. DOI: 10.19723/j.issn.1671-167X.2023.04.007.

[7]胡清,龚建平,李淳一,等.腹部皮瓣在乳房重建中的应用[J].中国肿瘤外科杂志,2020,12(4):371-374. DOI: 10.3969/j.issn.1674-4136.2020.04.017.

[8]Ahmed GA, Aseem R, Osman H. Latissimus dorsi flap revisited: coverage of large chest wall defects following mastectomy for locally advanced breast carcinoma and angiosarcoma[J]. Cureus, 2024,16(2):e53759-53742. DOI: 10.7759/cureus.53759..

[9]Sakamoto A, Noguchi T, Matsuda S. Thoracoabdominal flap reconstruction after resection of superficial soft-tissue sarcomas in the chest wall[J]. J Surg Case Rep, 2021, 2021(1):571-582. DOI: 10.1093/jscr/rjaa571.

[10]中国抗癌协会乳腺癌专业委员会.中国抗癌协会乳腺癌诊治指南与规范(2021年版)[J].中国癌症杂志, 2021, 31(10):954-1040. DOI:10.19401/j.cnki.1007-3639. 2021.10.013.

[11]Huang J, Chan PS, Lok V, et al. Global incidence and mortality of breast cancer: a trend analysis[J]. Aging (Albany NY), 2021,13(4):5748-5803. DOI: 10.18632/aging.202502.

[12]Dhanushkodi M, Sridevi V, Shanta V, et al. Locally advanced breast cancer (LABC): real-world outcome of patients from cancer institute, chennai[J]. JCO Glob Oncol, 2021,31(7):767-781. DOI: 10.1200/GO.21.00001.

[13]胡志伟.整形外科修复在局部晚期乳腺癌切除术后的应用效果[J].医学美学美容,2022,31(13):98-100.

[14]Schaverien MV, Singh P, Smith BD, et al. Premastectomy radiotherapy and immediate breast reconstruction: a randomized clinical trial[J]. JAMA Netw Open, 2024, 7(4):e245217. DOI: 10.1001/jamanetworkopen.2024.5217.

[15]宋达疆.自体组织乳房再造胸壁重建[J/OL].中华普通外科学文献(电子版),2024,18(2):118-120.https://med.wanfangdata.com.cn/Paper/Detail/PeriodicalPaper_zhptwkxwx202402008. DOI: 10.3877/cma.j.issn.1674-0793.2024.02.020.

[16]吴祥虎,陈春龙,丁皓,等.乳腺癌超象限切除术联合背阔肌皮瓣转移乳房重建术对乳腺癌患者美容效果和预后的影响[J].黑龙江医学,2023,47(12):1416-1420.DOI: 10.3969/j.issn.1004-5775.2023.12.002.

[17]张辉,张颖,华江伟,等.不同部位皮瓣移植对乳腺癌保乳术患者肿瘤学安全性及乳房缺损修复效果的影响[J].中国性科学,2022,31(7):95-98.DOI:10.3969/j.issn.1672- 1993.2022.07.025.

[18]Li L, Yang Y, Li W, et al. Latissimus dorsi myocutaneous flap repair is effective after neoadjuvant chemotherapy for locally advanced breast cancer[J]. World J Surg Oncol, 2022, 20(1):134-140. DOI: 10.1186/s12957-022-02598-y.

[19]宋达疆,李赞,章一新.带蒂腹直肌皮瓣联合游离腹壁下动脉穿支皮瓣移植重建胸壁巨大缺损的手术策略[J].组织工程与重建外科杂志,2022,18(5):386-392. DOI: 10.3969/j.issn.1673-0364.2022.05.003.

[20]宋达疆,李赞,章一新.分叶带蒂腹直肌皮瓣修复巨大胸壁缺损的疗效观察[J].中国修复重建外科杂志,2023,37(4):473-477.

[21]谢欣彤,林栋材,谢丽,等.双血管蒂腹壁下动脉穿支皮瓣在即刻乳房重建中的应用[J].中国现代手术学杂志,2023,27(5):356-360. DOI: 10.16260/j.cnki.1009-2188. 2023.05.002.

[22]Whalen K, Liu L, Rejano CJ, et al. Reverse abdominoplasty for mastectomy defect closure in advanced breast cancer[J]. Ann Plast Surg, 2023,90(3):204-208. DOI: 10.1097/SAP.0000000000003439.

[23]许文婷,欧江华,王虎,等.乳腺癌术后带蒂降支背阔肌肌皮瓣即刻乳房重建临床效果研究[J].中国实用外科杂志,2024,44(7):832-835. DOI: 10.19593/j.issn.2095- 0721.2024.09.017.

[24]Tanaka K, Oura S, Yasuda K, et al. Abrupt aggravation of encapsulated seroma after breast reconstruction with、extended latissimus dorsi muscle flap[J]. Case Rep Oncol, 2021, 14(1):290-295. DOI: 10.1159/000513491.

[25]张迈,宋达疆,张永林,等.自体组织乳房重建用于修复乳腺叶状肿瘤术后胸壁缺损[J/OL]. https://med.wanfangdata.com.cn/Paper/Detail?id=PeriodicalPaper_zhrxbzz202303006&dbid=WF_QK.中华乳腺病杂志(电子版),2023,17(3):163-166. DOI:10.3877/cma.j.issn.1674- 0807.2023.03.006.

[26]俞楠泽,孙怡馨,张海林,等.基于多学科综合治疗模式的胸壁肿瘤术后巨大复合组织缺损的修复策略[J].中国美容整形外科杂志,2022,33(11):688-692. DOI:10.3969/j.issn.1673-7040.2022.11.013.

[27]Fraisse J, Gangloff D, Meresse T, et al. Muscle sparing latissimus dorsi flap for reconstruction of a large chemo-necrosis of the chest wall: A case report[J]. Ann Chir Plast Esthet, 2022,67(2):105-110. DOI: 10.1016/j.anplas.2022.01.001.

[28]关山.乳腺癌术后乳房重建的意义及常用方法[J].中国医刊,2024,59(5):475-477. DOI:10.3969/j.issn.1008- 1070.2024.05.003

[29]纪登峰,张鹏,赵玉亭.背阔肌肌皮瓣与腹直肌皮瓣移植修复乳腺癌根治术后创面的效果观察[J].中国医疗美容,2024,14(2):40-46.DOI:10.19593/j.issn.2095-0721. 2024.02.010.

[30]Oda G, Nakagawa T, Uemura N, et al. Axillary lymph node recurrence in patients with breast cancer who underwent breast reconstruction using a latissimus dorsi flap after mastectomy[J]. Mol Clin Oncol, 2021, 14(3):49.DOI: 10.3892/mco.2021.2211.