Grundlagen und klinische Bedeutung der klassischen transzervikalen Chirurgie von Kopf-Hals-Tumoren – Teilresektionen, Laryngektomie, Rekonstruktionstechniken, Rettungschirurgie

Zusammenfassung

Die Versorgung von Malignomen im Larynx/Hypopharynx stellt den behandelnden Arzt vor eine große Herausforderung, die gewählte Therapiemodalität muss häufig die Brücke schlagen zwischen onkologisch geforderter Radikalität und Erhaltung der Organfunktion. In den letzten Jahren ist aufgrund der Zunahme der transoralen Laserchirurgie bei Karzinomen im Stadium T1 und T2 sowie der Radiochemotherapie bei fortgeschrittenen Karzinomen die Anwendung der offenen Zugänge zu Larynx und Hypopharynx stark zurückgegangen. Gleichzeitig wurde in den letzten Jahren der Ruf nach einem funktionserhaltenden chirurgischen Ansatz mit Erhalt einer möglichst hohen Lebensqualität lauter. Vor diesem Hintergrund werden Grundlagen und Stellenwert der traditionellen transzervikalen Chirurgie von Larynx und Hypopharynx erläutert und in einen zeitgemäßen Zusammenhang gestellt.

Die offenen Larynxresektionen bieten bei der Therapie des Larynxkarzinoms ein wichtiges Werkzeug des Kopf-Hals-Chirurgen mit Funktionserhalt des Larynx, das im Falle der anatomisch bedingten mangelhaften Übersicht des Larynx mit dem starren Rohr bei frühen und fortgeschrittenen Karzinomen zum Einsatz kommen kann. Offene Teilresektionen bieten insbesondere im Bereich der vorderen Kommissur exzellente Übersicht und onkologische Sicherheit, vor allem in der Rezidivsituation. Bei ausgewählten fortgeschrittenen Karzinomen und im Salvage-Setting bietet die supracricoidale Laryngektomie ein wertvolles Werkzeug zur onkologisch sicheren larynxerhaltenden chirurgischen Therapie, jedoch auf Kosten hoher postoperativer Morbidität und hohen Anforderungen an die postoperative Schluckrehabilitation.

Bedingt durch die Zunahme der transoralen Laserchirurgie wird im Hypopharynxbereich die Indikation zur transzervikalen Tumorentfernung über partielle Pharyngektomie mit Partieller Laryngektomie in frühen Tumorstadien nur in Ausnahmesituationen gestellt. Die Totale Laryngektomie mit Partieller Pharyngektomie bietet zuverlässige onkologische Ergebnisse bei fortgeschrittenen Tumoren des Sinus piriformis und der Postcricoidregion mit Larynxbeteiligung. Die radikale chirurgische Therapie mittels Zirkumferenter Laryngopharyngektomie mit oder ohne Ösophagektomie ist indiziert im Salvage-Setting bei Patienten mit ausgedehnten Rezidiven nach Radiatio und als primäre chirurgische Maßnahme bei Patienten mit ausgedehnten Befunden, bei denen eine Radiochemotherapie keine ausreichende onkologische Kontrolle und keine ausreichenden funktionellen Ergebnisse garantiert. Bei erforderlicher Rekonstruktion scheinen bei Nichtbeteiligung des zervikalen Ösophagus fasziocutane Lappen (Anterolateral Thigh Flap, Radialislappen) enterischen Lappen überlegen was die Stimmrehabilitation angeht, die Komplikationsrate ist niedriger und die Morbidität ist postoperativ reduziert durch die Vermeidung der Laparotomie. Im Salvage-Setting hat sich der Gastroomental Free Flap als wertvolles Werkzeug erwiesen.

Insgesamt bleibt die Wahl der chirurgischen Therapiemodalität beeinflusst von der Anatomie des Patienten, der Tumorausdehnung und -lokalisation sowie vor allem der Expertise des behandelnden Chirurgen.

Abstract

Traditional Transcutaneous Approaches In Head & Neck Surgery

The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background.

The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon’s armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing.

In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function.

In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool.

In conclusion, the choice of a surgical treatment modality is influenced by the patient’s anatomy, tumor size and location as well as the surgeon’s personal expertise.

Schlüsselwörter

Larynxerhaltende Chirurgie - Partielle Laryngektomie - Rettungschirurgie - Larynxcarcinom - Hypopharynxcarcinom

Key words

partial laryngectomy - salvage surgery - glottic carcinoma - hypopharyngeal carcinoma - laryngeal cancer

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