劉 洪 李 超 王少新 王 薇 綜述 樊晉川 審校

腮腺多形性腺瘤外科術(shù)式的演變及發(fā)展*

劉 洪①李 超②王少新②王 薇②綜述 樊晉川②審校

腮腺腫瘤以多形性腺瘤居多，目前外科治療仍是主要的治療方式。20世紀(jì)時(shí)學(xué)者們由于對(duì)面神經(jīng)解剖和多形性腺瘤包膜病理特性缺乏了解，該病的主要術(shù)式為單純腫瘤剜除術(shù)，但術(shù)后容易導(dǎo)致復(fù)發(fā)；試圖通過(guò)擴(kuò)大切除的范圍控制復(fù)發(fā)率，于是包膜外切除術(shù)開(kāi)始運(yùn)用于臨床，雖然切除了腫瘤的包膜，但是復(fù)發(fā)率仍未能很好地控制。腮腺淺葉切除術(shù)和腮腺全切術(shù)明顯降低了復(fù)發(fā)率，但是伴隨著面神經(jīng)損傷的加重，似乎又矯枉過(guò)正。腮腺部分切除術(shù)作為新的腮腺手術(shù)形式，不但降低了復(fù)發(fā)率、面神經(jīng)損傷率，還得到病理學(xué)基礎(chǔ)研究證據(jù)的支持，是目前較為先進(jìn)的手術(shù)方式。但是在經(jīng)典的腮腺淺葉切除術(shù)與先進(jìn)的腮腺部分切除術(shù)之間仍存在爭(zhēng)議。經(jīng)過(guò)整形學(xué)、病理學(xué)、基因檢測(cè)法等方面探究這兩種手術(shù)的優(yōu)劣均各有差異。本文從腮腺術(shù)式的演變歷程探討腮腺術(shù)式發(fā)展的方向。

多形性腺瘤 手術(shù)方式 腮腺腫瘤 外科學(xué)

腮腺是唾液腺腫瘤最常見(jiàn)的發(fā)病部位，以多形性腺瘤為代表的良性腫瘤發(fā)病率最高［1-3］。雖然醫(yī)療在近幾年取得了較大的進(jìn)步，新型抗腫瘤藥物層出不窮，但對(duì)于腮腺良性腫瘤，手術(shù)仍是目前主要的治療措施。腮腺良性腫瘤的手術(shù)方式主要包括早期剜除術(shù)，后期包膜外切除術(shù)，以及現(xiàn)在常用的腮腺淺葉切除術(shù)、全葉切除術(shù)和部分切除術(shù)。目前對(duì)于腮腺良性腫瘤手術(shù)方式的選擇以及手術(shù)安全切緣范圍等問(wèn)題國(guó)內(nèi)外仍然存在較大的爭(zhēng)議［4-8］。本文對(duì)腮腺腫瘤治療術(shù)式的演變及優(yōu)缺點(diǎn)、未來(lái)發(fā)展方向予以綜述。

1 腮腺腫瘤手術(shù)術(shù)式的演變

1823年Bernard首次實(shí)施腮腺腫瘤切除術(shù)。然后Bailey對(duì)該術(shù)式進(jìn)行一系列改良［9-11］。腮腺腫瘤切除術(shù)至今已經(jīng)有近190年歷史。20世紀(jì)由于對(duì)面神經(jīng)解剖和多形性腺瘤包膜病理特性缺乏了解，術(shù)后引起面癱的發(fā)病率較高，該病的主要術(shù)式為單純腫瘤剜除術(shù)。由于該術(shù)式未完整切除腫瘤包膜，術(shù)后容易導(dǎo)致復(fù)發(fā)［12-15］。1956年P(guān)erzik等［12］提出反對(duì)單純性腮腺腫瘤剜除術(shù)，其原因是雖然剜除術(shù)有助于術(shù)中較好的保護(hù)面神經(jīng)，但對(duì)腮腺腫瘤的根治是遠(yuǎn)遠(yuǎn)不夠的，對(duì)周圍組織進(jìn)行微觀研究發(fā)現(xiàn)此類手術(shù)導(dǎo)致了腫瘤組織殘留，可引起復(fù)發(fā)。隨著解剖學(xué)的進(jìn)展，對(duì)腮腺及面神經(jīng)關(guān)系結(jié)構(gòu)的了解進(jìn)一步加深，人們開(kāi)始設(shè)想在保持面神經(jīng)低損傷率的前提下是否能通過(guò)擴(kuò)大切除的范圍來(lái)控制腫瘤的復(fù)發(fā)。1979年，Gleave等［16］首次提出對(duì)腮腺腫瘤進(jìn)行包膜外切除，其方法是沿腫瘤的包膜外壁分離切除腫瘤。Piekarski等［17］對(duì)98例進(jìn)行包膜外切除的患者進(jìn)行隨訪總結(jié)發(fā)現(xiàn)，進(jìn)行包膜外切除的患者術(shù)后腫瘤復(fù)發(fā)率為8.2%，該組患者術(shù)后面癱的發(fā)病率同樣為8.2%。當(dāng)時(shí)研究的主要方向是復(fù)發(fā)率的控制。Patey等［18］提出腮腺腫瘤的多中心性理論后，有學(xué)者認(rèn)為應(yīng)該行保留面神經(jīng)的腮腺腺葉全切以減少術(shù)后復(fù)發(fā)的可能。Orita等［19-20］對(duì)行此手術(shù)的術(shù)后復(fù)發(fā)率進(jìn)行統(tǒng)計(jì)學(xué)研究表明復(fù)發(fā)率可低至0.3%，然而腮腺全切術(shù)后暫時(shí)性和永久性面神經(jīng)麻痹的發(fā)生率分別是腮腺淺葉切除術(shù)的2.3倍和3.0倍，腮腺全切除術(shù)后味覺(jué)出汗綜合征的發(fā)生率是腮腺淺葉切除術(shù)的2.7倍，是腮腺區(qū)域切除術(shù)的4.7倍［20］。隨著面神經(jīng)解剖的不斷深入及外科技術(shù)的成熟，腮腺淺葉切除的并發(fā)癥大幅降低，而手術(shù)療效方面卻被大量的研究［15，21-22］證實(shí)，全腮腺切除術(shù)式受到了質(zhì)疑［23］。此時(shí)對(duì)于腮腺多形性腺瘤的基礎(chǔ)性研究表明腮腺多形性腺瘤很少多中心性生長(zhǎng)［12，24］，這也為腮腺淺葉術(shù)式作為腮腺當(dāng)時(shí)的經(jīng)典術(shù)式沿用至今奠定了理論基礎(chǔ)。

2 腮腺多形性腺瘤的安全邊界研究及腮腺腫瘤術(shù)式革新

近年來(lái)隨著患者對(duì)生存質(zhì)量要求不斷提高，許多研究顯示腮腺淺葉切除雖降低腫瘤復(fù)發(fā)率，但相比包膜外切除卻增加了面神經(jīng)損傷率、Frey綜合征發(fā)生率［4-5，25］。又因腮腺淺葉的徹底切除造成了耳垂下區(qū)凹陷影響了患者術(shù)后的顏面外觀。因此，如何在減少?gòu)?fù)發(fā)率的基礎(chǔ)上提高患者生存質(zhì)量已經(jīng)成為目前腮腺腫瘤外科治療研究的熱點(diǎn)。因其并發(fā)癥顯著，人們開(kāi)始思考對(duì)于腮腺多形性腺瘤這種臨界腫瘤進(jìn)行腮腺淺葉切除是否矯枉過(guò)正。由此，腮腺部分切除術(shù)被提出并開(kāi)始應(yīng)用于臨床，腮腺淺葉部分切除術(shù)為腮腺淺葉切除和腮腺剜除術(shù)的折中切除術(shù)式，近似于包膜外切除，但切除范圍較包膜外切除術(shù)稍寬。有研究［6，26-27］顯示腮腺淺葉部分切除術(shù)可以減低術(shù)后并發(fā)癥，其療效得到肯定?；A(chǔ)研究方面，通過(guò)對(duì)多形性腺瘤的連續(xù)切片觀察發(fā)現(xiàn)腫瘤具有包膜外浸潤(rùn)和出芽生長(zhǎng)的特點(diǎn)，但這種浸潤(rùn)和出芽距腫瘤包膜均在1 cm以內(nèi)［28］。

本研究組前期研究發(fā)現(xiàn)直徑＜4 cm的腮腺多形性腺瘤腫瘤的浸潤(rùn)和出芽均局限在包膜3.127～8.476 mm，與傳統(tǒng)的手術(shù)相比改良術(shù)式組在Frey綜合征、耳廓區(qū)麻木感、面部外形發(fā)生率明顯降低。因而認(rèn)為直徑＜4 cm的腫瘤，安全切緣為1 cm，而直徑＞4 cm的腫瘤行腮腺淺葉切除為腮腺手術(shù)的標(biāo)準(zhǔn)術(shù)式［29-30］。這也為腮腺腫瘤個(gè)體化的治療提供了理論和實(shí)驗(yàn)依據(jù)。

腮腺淺葉部分切除術(shù)是目前一種成熟的外科治療腮腺良性腫瘤術(shù)式，無(wú)論從理論還是臨床術(shù)后效果角度均可認(rèn)為是腮腺淺葉腫瘤的最佳選擇術(shù)式。雖然目前也有文獻(xiàn)報(bào)道對(duì)包膜外切除持支持意見(jiàn)，認(rèn)為對(duì)術(shù)后復(fù)發(fā)率無(wú)影響，但根據(jù)基礎(chǔ)研究，安全邊界明顯不夠。之所以這些文獻(xiàn)通過(guò)對(duì)患者的隨訪報(bào)道其復(fù)發(fā)率未增高，考慮主要原因?yàn)殡S訪的年限不足和新技術(shù)的發(fā)展降低了復(fù)發(fā)率。

3 新技術(shù)在腮腺外科治療中的應(yīng)用

近年來(lái)，各種先進(jìn)的技術(shù)和方法應(yīng)用于腮腺手術(shù)以增加療效和減少術(shù)后并發(fā)癥。

3.1 超聲刀在腮腺手術(shù)中的應(yīng)用

超聲刀（US）是一種振動(dòng)頻率可達(dá)55 500 HZ的超聲波，是組織蛋白氣化，氫鍵斷裂而達(dá)到的切割止血效果。超聲刀在刀鋒邊1 mm的溫度為40℃，5 mm測(cè)不出溫度變化，散熱非常有效［31］，所以腮腺手術(shù)時(shí)，只要分離出面神經(jīng)后，均可使用超聲刀進(jìn)行手術(shù)，術(shù)后通過(guò)組織病理學(xué)檢查，腮腺的切緣細(xì)胞未見(jiàn)明顯熱灼傷。更有研究［32-35］表明，超聲刀的使用可以明顯縮短手術(shù)時(shí)間，減少患者術(shù)后引流量，減少術(shù)后涎瘺的發(fā)生率，減少患者住院時(shí)間，操作簡(jiǎn)單，目前已經(jīng)廣泛應(yīng)用于臨床。

3.2 力確刀在腮腺手術(shù)中的運(yùn)用

力確刀是對(duì)雙極電刀改進(jìn)的成果。其優(yōu)點(diǎn)在于可以閉合7 mm內(nèi)的血管，閉合時(shí)局部溫度不高，熱擴(kuò)散少，熱傳導(dǎo)距離僅1.5～2 mm，對(duì)周圍組織損傷小，是腮腺手術(shù)可靠和安全的設(shè)備，相比傳統(tǒng)的手術(shù)止血效果好，節(jié)約手術(shù)時(shí)間，術(shù)后并發(fā)癥明顯減少、減輕［36-37］。

3.3 螺旋水刀在腮腺手術(shù)中的應(yīng)用

水刀，顧名思義，以水為刀，利用水的高速切割力切斷周圍組織，不產(chǎn)生熱量是其最大的優(yōu)點(diǎn)。但巨大的壓力是否會(huì)對(duì)面神經(jīng)造成影響有待進(jìn)一步研究，目前國(guó)外只有對(duì)動(dòng)物體的實(shí)驗(yàn)研究［38］，我國(guó)對(duì)這項(xiàng)技術(shù)的臨床研究［39］指出與傳統(tǒng)手術(shù)相比具有一定的優(yōu)勢(shì)，但這種優(yōu)勢(shì)并不明顯。

3.4 內(nèi)鏡和顯微鏡輔助下腮腺手術(shù)

微創(chuàng)手術(shù)是近年來(lái)比較提倡的手術(shù)方術(shù)，以減少周圍組織損傷，減少并發(fā)癥為特點(diǎn)。內(nèi)鏡手術(shù)的應(yīng)用主要是美容需要，使用內(nèi)鏡輔助進(jìn)行腮腺淺葉腫瘤手術(shù)，美容效果極好，術(shù)后無(wú)永久性面癱的發(fā)生。對(duì)于開(kāi)放性手術(shù)，術(shù)中放大視野是否可以減少面神經(jīng)損傷，臨床報(bào)道較少［40］。

4 小結(jié)

腮腺淺葉部分切除術(shù)目前是眾多學(xué)者所推崇的、可靠的手術(shù)方式，歷史的演變論證了這一結(jié)果。部分切除術(shù)切除了比較少的正常組織，術(shù)后并發(fā)癥如面神經(jīng)功能障礙和Frey綜合征的發(fā)生率也明顯的降低，患者生存質(zhì)量提高。腮腺術(shù)后并發(fā)癥和術(shù)后美學(xué)看似一個(gè)不可調(diào)和的問(wèn)題，學(xué)者們努力的在尋找一個(gè)平衡點(diǎn)，多個(gè)機(jī)構(gòu)聯(lián)合進(jìn)行一個(gè)前瞻性隨機(jī)性研究實(shí)驗(yàn)可能對(duì)決定腮腺腫瘤治療術(shù)式的選擇有幫助，但是進(jìn)行這樣的研究具有太多的阻礙和不可預(yù)測(cè)因素難以實(shí)施。新技術(shù)的應(yīng)用可以明顯的減少腮腺并發(fā)癥。腮腺淺葉部分切除術(shù)作為新型術(shù)式，遠(yuǎn)期療效還需要更多的研究進(jìn)行證實(shí)。

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（2014-01-21收稿）

（2014-04-08修回）

Development and history in parotid pleomorphic adenoma surgery

Hong LIU1,Chao LI2,Shaoxin WANG2,Wei WANG2,Jinchuan FAN2

Chao LI;E-mail:sclichao@qq.com
1Guangxi Medical University,Nanning 530021;2Department of Head and Neck Surgery,Sichuan Cancer Hospital&Cancer Institute,Chengdu 610041,China.

Pleomorphic adenoma ranks first among parotid gland tumors.Surgical procedure,which includes enucleation,extra-capsular resection,partial superficial parotidectomy(PSP),superficial parotidectomy(SP),and total parotidectomy(TP),remains to be the treatment of choice for pleomorphic adenoma.In the last century,physicians lacked understanding on the pathological characteristics of pleomorphic adenoma and facial neurotomia.Thus,simple enucleation of tumors has always been the major therapy for patients to reduce the rate of facial nerve injury.However,postoperative recurrence was frequently observed in patients that have undergone simple enucleation.In this study,the surgeons attempted to control the relapse rate by enlarging the scope of excision when removing a pleomorphic adenoma,and by performing an extra-capsular resection procedure that was developed in the clinic.Although the tumor peplos was excised,the surgeons failed to control the relapse rate.SP and TP apparently decreased the relapse rate of the pleomorphic adenomas.However,these therapies seem to be overcorrected by the aggravation of facial nerve injuries.PSP is a relatively advanced technique that is currently used in parotid surgery.PSP reduces the rate of relapse and facial nerve injury,as verified by basic pathology research.Nevertheless,the controversy between advanced PSP and classic SP still exists.Plastic surgery,pathology research,and gene testing were used to evaluate the advantages of advanced PSP and classic SP.However,the research failed to derive a confirmed result that can determine which treatment method is fit and unfit to treat pleomorphic adenoma.Our study reviews the trend of parotid surgery from a historic point of view.

pleomorphic adenoma,surgical procedure,parotid neoplasm,surgery

10.3969/j.issn.1000-8179.20140123

①?gòu)V西醫(yī)科大學(xué)研究生學(xué)院（南寧市530021）；②四川省腫瘤醫(yī)院頭頸外科

*本文課題受國(guó)家自然科學(xué)基金項(xiàng)目（編號(hào)：81302375）、四川省科技廳計(jì)劃項(xiàng)目(編號(hào)：2012JY0125)和四川省衛(wèi)生廳科研項(xiàng)目(編號(hào)：130230，110259)資助

李超 sclichao@qq.com

The study was supported by grants from the National Natural Science Foundation of China(No.81302375:Mechanism research on microenvironment change,EXOSOME with mir-155 in deoxygen MDS/Treg,prior to oral cancer metastasis),theApplied Projects of Sichuan Provincial Bureau of Science and Technology(No.2012JY0125:Research on the safe margin of parotid pleomorphic adenoma,fundament and clinic for modifying function preserving surgery,adds Meta Analysis),and the Projects of Sichuan Provincial Bureau of Science and Technology(No.130230 and 110259:Comparative research on Frey's syndrome and facial mobility with surgery after parotidectomy).

（本文編輯：邢穎）

劉洪 碩士研究生。研究方向?yàn)轭^頸部腫瘤的綜合治療。

E-mail：233082449@qq.com