腮腺手术分类 by European Salivary Gland Society

腮腺肿瘤的治疗从最初的剜除术发展到以面神经为标志的腺叶切除术，而在近些年更趋向于尽量保存腺体及面神经功能，所以又出现了各种"部分切除术"，导致常用的腮腺浅叶切除术、腮腺全叶切除术等等已难以满足需要。而腮腺肿瘤根据其所在位置、大小、以及良恶性，又可能需要解剖不同的面神经分支、切除不同的非腮腺解剖结构，为了方便学术交流以及对比治疗效果，European Salivary Gland Society (ESGS)提出了一个腮腺手术分类方法[1]。

在这个分类方法中，通过一条假想的连线——从面神经主干发出颞面干和颈面干的分叉处到腮腺导管的连线——将腮腺分为上部和下部，同时采用传统的浅叶和深叶概念，将腮腺主体分为四部分——I(lateral superior), II (lateral inferior), III (deep inferior), IV (deep superior)，加上副腮腺(V)，形成腮腺手术的5个分区。

腮腺手术5个分区[1]

腮腺手术5个分区[1]

ESGS将腮腺手术分为两类：包膜外切除术(extracapsular dissection (ECD))和腮腺切除术(parotidectomy)。定义如下：

• 包膜外切除术(extracapsular dissection (ECD))，满足下述两个条件之一：
  1. No facial nerve dissection performed;
  2. Less than one level removed.
• 腮腺切除术(parotidectomy)，需同时满足下述两个条件：
  1. Dissection of the facial nerve (at least the main trunk and one of the two major divisions—temporofacialis, cervicofacialis);
  2. At least one level is removed.

命名规则：

1. 腮腺切除术

• The term parotidectomy is the first component of the description. A prefix should be included to denote the side using the abbreviation L for left, and R for right. If bilateral, both sides must be classified independently.
• The second component of the description should be the level or levels removed, each designated by the Roman numerals I through V, in ascending order.
• The third component of the description should be the non glandular structures removed, each identified through the use of specified acronyms (symbols) (本文作者注：公认缩写), all of which have been universally accepted.

2. 包膜外切除术

• The symbol ‘‘ECD’’ should be used to represent the term extracapsular dissection and applied as the first component of the description. A prefix should be included to denote the side using the abbreviation L for left, and R for right. If bilateral, both sides must be classified independently.
• The second component of the description should be the level where the tumor was located (level I or level II; it does not mean that both levels have been completely removed, it just means the tumor was located in this level).

ESGS提供的一些常用的非腮腺解剖缩写：

Symbol	Definition
CN VII	acial nerve trunk and/or all the main branches (*)
CN VII t-z-b-m-c	Facial nerve branches (*)
ECA	External carotid artery
GAN	Greater auricular nerve
LTB	Lateral temporal resection
MB	Mastoid bone
MM	Masseter muscle
S	Skin
Others to be defined

* In the case of facial nerve, when all the nerve has been sacrificed just use CN VII, but when the surgeon has sacrificed just some branches then CN VII z for example means the surgeon has removed only the zygomatic branches. 即加入面神经所有分支都切除了，那么直接使用CN VII，如果只切除了部分分支，那么需要通过分支首字母缩写注明所切除的分支。（另外这个里面没有包括TMJ，所以有人comment建议加上去，作者表示会在未来的版本中加上）。

经典命名比较：

ESGS proposal	Classical classifications
Parotidectomy I–IV (VII)	Total parotidectomy with facial nerve resection
Parotidectomy I–IV	Total parotidectomy with facial nerve preservation
Parotidectomy I–IV (VII, S, MM)	Extended total parotidectomy with facial nerve resection plus skin and masseter muscle resection
Parotidectomy I–II	Superficial parotidectomy
Parotidectomy III–IV	Deep lobe parotidectomy
Parotidectomy I	Partial superficial parotidectomy
Parotidectomy II	Partial superficial parotidectomy
Parotidectomy I–II–III	Superficial parotidectomy extended to the inferior deep lobe
Parotidectomy V	Accessory lobe removal
ECD I	Extracapsular dissection with tumor in level I
ECD II	Extracapsular dissection with tumor in level II
ECD V	Extracapsular dissection with tumor in level V

在ECD的定义中，有可能存在两种和定义不严格一致的情况：

1. 肿瘤较大，占据一个区或不止一个区，但是可以通过不解剖面神经的方式将其切除；
2. 肿瘤较小，手术当中解剖了面神经主干或分支的一部分，发现可以通过包括部分正常腮腺组织的方式将肿瘤完整切除，但是切除的这部分明显局限于一个分区内。

不过ESGS在讨论中也申明，虽然给出了包膜外切除这么一个分类，但是不表明ESGS支持这种手术方式，尤其对于多形性腺瘤而言 (It should not be seen as a endorsement by ESGS of this type of approach for parotid tumors and especially for pleomorphic adenoma where it could lead to an increased incidence of difficult to treat recurrences because of pseudopodia and an absent capsule)。

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参考资料：

1. Quer M, Guntinas-Lichius O, Marchal F, et al. Classification of parotidectomies: a proposal of the European Salivary Gland Society. Eur Arch Otorhinolaryngol 2016;273(10):3307-12. doi: 10.1007/s00405-016-3916-6 [published Online First: 2016/02/11]