今日の臨床サポート

内ヘルニア・横隔膜ヘルニア

著者: 佐々木健 鹿児島大学大学院 消化器・乳腺甲状腺外科学

監修: 杉原健一 東京医科歯科大学大学院

著者校正/監修レビュー済:2021/03/03
参考ガイドライン:
  1. 日本消化器病学会:胃食道逆流症(GERD)診療ガイドライン2015 第2版
  1. 米国消化器内視鏡外科学会(SAGES):Guidlines for Surgical treatment of Gastroesophageal Reflux Disease (GERD), 2010
患者向け説明資料

概要・推奨   

  1. 嘔吐、腹痛、腹部膨満、便秘などを主訴に受診した場合には、腸閉塞の診断を行い、その原因として、内ヘルニアを念頭に置いておく必要がある。内ヘルニアによる絞扼性腸閉塞は重篤化するため、早期診断が重要である。早期診断には造影CTが有用であるため、行うことが勧められる(推奨度1 O
  1. 内ヘルニア・横隔膜ヘルニアと診断がつき次第、手術適応である。緊急的に行うか、待機的に行うかについては、造影CTで腸閉塞の状態を把握する必要がある。陥入した腸管を整復し、ヘルニア門を閉鎖もしくは開放する手術を行う(推奨度2 C
  1. 食道裂孔ヘルニアのある場合には胃食道逆流症(GERD)の合併率が高い。胃液の逆流による逆流症状を認め、治療はまず胃酸分泌抑制としてPPIによる治療を行う。内服治療だけでなく、食事指導、生活指導も重要である(推奨度1 M
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必 要となりま
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
佐々木健 : 未申告[2021年]
監修:杉原健一 : 講演料(大鵬薬品)[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 内ヘルニアとは、腹腔内の異常に大きな陥没部、嚢状部、裂孔に腸管など腹腔内臓器が陥入した状態である[1]
  1. 腸間膜や大網にできた異常裂孔へ陥入する異常裂孔ヘルニアと腹膜窩を通じて後腹膜へ入り込んだり、窩や嚢状部へ陥入する腹膜窩ヘルニアに大きく分類される。
  1. 内ヘルニアの分類として傍十二指腸窩(53%)、盲腸窩(13%)、Winslow孔(8%)、腸間膜裂孔(8%)、S状結腸間膜窩(6%)、後吻合部(5%)などがある[2][3]
 
内ヘルニアの発生部位

A:傍十二指腸 B:Winslow孔 C:S状結腸間 D:盲腸周囲 E:小腸腸間膜 F:後方吻合部

出典

 
  1. 腸閉塞症状を契機に指摘される比較的まれな疾患であり、機械性腸閉塞全体の0.5~5.8%である[2]
  1. 腸閉塞の術前に内ヘルニアと診断される頻度は4.1~9.3%である。
  1. 診断には、理学的所見のほかに腹部単純X線写真、超音波、CTを用いるが、内ヘルニアの明確な診断基準はなく、発見動機となる腸閉塞の診断がもとになる。
  1. 診断がつき次第、手術を行う必要があるが、絞扼性腸閉塞では、緊急手術を行う必要がある。腸管壊死となり、敗血症など重篤な状態となれば、死に至ることもあり、早期診断により手術適応を見誤らないことが重要である[2][4]
  1. 横隔膜ヘルニアは、横隔膜の欠損部位から腹腔内臓器が胸腔内へ脱出する内ヘルニアである[5]
  1. 脱出する部位により胸腹裂孔(Bochdalek)ヘルニア・傍胸骨裂孔(Morgagni)ヘルニア・食道裂孔ヘルニアに大きく分類される。
 
横隔膜ヘルニアの部位

先天性横隔膜ヘルニア:横隔膜でヘルニアの様相を呈している部分を下部からみたところ。
1. 前側よりみた傍胸骨のMorgagni孔
2. 食道裂孔
3. 後側よりみた胸腹のBochdalek 孔
矢印はヘルニアの方向を示す。

 
  1. 横隔膜ヘルニアのなかでも、食道裂孔ヘルニアが頻度として圧倒的に多く、Bochdalekヘルニア、Morgagniヘルニアは先天性疾患として知られ、Bochdalekヘルニアが多い。
  1. 食道裂孔ヘルニアは、滑脱型、傍食道型、混合型に分けられ、滑脱型の頻度がほとんどで、胃食道逆流症(GERD)と密接に関連しており、逆流による症状などから食道胃造影検査や上部消化管内視鏡検査で判明する。<図表>
  1. 食道裂孔ヘルニアの治療は、合併するGERDの治療が目的であり、GERDの治療ガイドラインに沿って、まず内服治療からはじめ、薬物治療に抵抗性の場合や、患者が希望する場合には手術を行う[6]
  1. Bochdalekヘルニアは、約10%が成人になるまで無症状・軽症で経過することがあり、内ヘルニアと同様に腸閉塞症状で指摘され、診断には腹部単純X線写真、超音波、CTを行う。
  1. Bochdalekヘルニア、Morgagniヘルニアの治療は、脱出臓器の還納とヘルニア門の閉鎖が基本である。
問診・診察のポイント  
  1. 臨床症状を確認する。特に腸閉塞症状の有無、消化器症状の有無を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Lucie C Martin, Elmar M Merkle, William M Thompson
雑誌名: AJR Am J Roentgenol. 2006 Mar;186(3):703-17. doi: 10.2214/AJR.05.0644.
Abstract/Text OBJECTIVE: Internal hernias, including paraduodenal (traditionally the most common), pericecal, foramen of Winslow, and intersigmoid hernias, account for approximately 0.5-5.8% of all cases of intestinal obstruction and are associated with a high mortality rate, exceeding 50% in some series. To complicate matters, the incidence of internal hernias is increasing because of a number of relatively new surgical procedures now being performed, including liver transplantation and gastric bypass surgery. A significant increase in hernias is occurring in patients undergoing transmesenteric, transmesocolic, and retroanastomotic surgical procedures. It is important for radiologists to be familiar with and to understand the various types of internal hernias and their imaging features so that prompt and accurate diagnosis of these conditions can be made.
CONCLUSION: This article illustrates the imaging findings of internal hernias, with emphasis placed on the CT findings, especially in transmesenteric, transmesocolic, and retroanastomotic types of internal hernias.

PMID 16498098  AJR Am J Roentgenol. 2006 Mar;186(3):703-17. doi: 10.22・・・
著者: Saber Ghiassi, Scott Q Nguyen, Celia M Divino, John C Byrn, Avraham Schlager
雑誌名: J Gastrointest Surg. 2007 Mar;11(3):291-5. doi: 10.1007/s11605-007-0086-2.
Abstract/Text Internal hernia, the protrusion of a viscus through a peritoneal or mesenteric aperture, is a rare cause of small bowel obstruction. We report the clinical presentation, surgical management, and outcomes of one of the largest series of nonbariatric internal hernias. Ten-year retrospective review of patients at our institution yielded 49 cases of internal hernias. Majority of patients presented with symptoms of acute (75%) or intermittent (22%) small bowel obstruction. While 16% of CT scans were suspicious for internal hernia, in no cases the preoperative diagnosis of internal hernia was made. The most frequent internal hernias were transmesenteric (57.0%) and 34 hernias (69%) were caused by previous surgery. All internal hernias were reduced and the defects were repaired. Compromised bowel was present in 22 cases and 11 patients underwent small bowel resection. The mean postoperative hospitalization was 10.9 days. The overall mortality rate from our series is 2%, and the morbidity rate is 12%. Transmesenteric hernias, as complications of previous surgeries, are the most prevalent internal hernias. Preoperative diagnosis of internal hernia is extremely difficult because of the nonspecific clinical presentation. However, if discovered promptly, internal hernias can be repaired with acceptable morbidity and mortality.

PMID 17458600  J Gastrointest Surg. 2007 Mar;11(3):291-5. doi: 10.1007・・・
著者: J D Iannuccilli, D Grand, B L Murphy, P Evangelista, G D Roye, W Mayo-Smith
雑誌名: Clin Radiol. 2009 Apr;64(4):373-80. doi: 10.1016/j.crad.2008.10.008. Epub 2008 Dec 16.
Abstract/Text AIM: To evaluate the sensitivity and specificity of eight previously reported computed tomography (CT) signs in diagnosing internal mesenteric hernia following Roux-en-Y gastric bypass surgery.
MATERIALS AND METHODS: Preoperative CT images of nine patients with surgically proven internal mesenteric hernia as a complication of gastric bypass surgery and 10 matched control patients were reviewed in a blinded fashion by three radiologists. The presence of eight previously reported signs of internal mesenteric hernia was assessed: mesenteric swirl sign, hurricane eye sign, mushroom sign, small bowel obstruction, clustered small bowel loops, small bowel other than duodenum located behind the superior mesenteric artery (SMA), presence of the jejunal anastomosis to the right of the midline, and engorged mesenteric lymph nodes. The sensitivity and specificity were calculated for each sign, as well as inter-observer reliability in recognizing these signs.
RESULTS: Mesenteric swirl was the most predictive sign of internal hernia (sensitivity 78-100%, specificity 80-90%). Other CT signs showed good specificity (70-100%), but sensitivities were low (0-44%). The presence of a small-bowel obstruction and engorged mesenteric nodes was found to be 100% specific in predicting the presence of an underlying hernia. There was substantial inter-observer agreement in detecting mesenteric swirl sign (kappa=0.48-0.79), but agreement was relatively poor for all other signs.
CONCLUSION: Mesenteric swirl is an easily recognized CT sign, and is the best indicator of internal hernia following Roux-en-Y gastric bypass surgery. Other reported CT signs are diagnostically insensitive. The presence of small-bowel obstruction with engorged mesenteric nodes is highly specific in diagnosing internal mesenteric hernia.

PMID 19264181  Clin Radiol. 2009 Apr;64(4):373-80. doi: 10.1016/j.crad・・・
著者: A Blachar, M P Federle, G Brancatelli, M S Peterson, J H Oliver, W Li
雑誌名: Radiology. 2001 Nov;221(2):422-8. doi: 10.1148/radiol.2212010126.
Abstract/Text PURPOSE: To evaluate the performance of radiologists in the diagnosis of internal hernia with specific computed tomographic (CT) findings.
MATERIALS AND METHODS: Abdominal CT scans obtained in 42 patients were retrospectively reviewed by three radiologists. The case group consisted of 18 patients with internal hernias (two paraduodenal, 16 transmesenteric); the comparison group was 24 patients with no internal hernia. Images were reviewed in a random and blinded fashion. Individual and group performance was evaluated with receiver operating characteristic (ROC) analysis, and interobserver agreement was measured with Cronbach coefficient alpha. Individual CT signs relevant as predictors of transmesenteric hernia were identified with logistic regression analysis and ranked by their odds ratio and P values.
RESULTS: Both paraduodenal hernias were diagnosed by all readers on the basis of CT signs, including a retrogastric saclike mass of small-bowel loops. Diagnosis of transmesenteric hernia was more difficult and variable, with an average accuracy of area under the ROC curve (A(z)) of 77%, sensitivity of 63%, and specificity of 76%. CT signs of transmesenteric hernia were recognized consistently (Cronbach coefficient alpha >or= 0.80) and included a cluster of dilated small-bowel segments and stretching and displacement of mesenteric vessels. Coexisting volvulus and ischemia were diagnosed with low sensitivity (46% and 43%, respectively) but high specificity (96% and 98%, respectively).
CONCLUSION: Diagnosis of internal hernia with CT remains difficult. Special attention should be given to the clustering of bowel loops, the mesenteric vessels, and signs of small-bowel obstruction.

PMID 11687686  Radiology. 2001 Nov;221(2):422-8. doi: 10.1148/radiol.2・・・
著者: N Furukawa, R Iwakiri, T Koyama, K Okamoto, T Yoshida, Y Kashiwagi, T Ohyama, T Noda, H Sakata, K Fujimoto
雑誌名: J Gastroenterol. 1999 Aug;34(4):441-4.
Abstract/Text Compared with findings in Western countries, the prevalence of reflux esophagitis in Oriental countries is estimated to be low. In this prospective study, we aimed to examine the proportion of reflux esophagitis in Japanese adults, as evaluated by endoscopy. Endoscopists were prospectively directed to grade esophageal mucosal breaks with esophagitis according to the Los Angeles Classification of Esophagitis in all subjects that underwent endoscopic examination. In total, 6010 subjects underwent endoscopic examination for evaluation of esophagitis grading from December 1996 to February 1998. The subjects included 4394 outpatients who were not receiving medication for gastrointestinal disease and 1616 subjects who visited the hospital for routine physical examinations. The overall proportion of esophagitis was 16.3%. Most of the subjects with esophagitis were classified as having grade A or B (proportion of grades A and B, 9.6% and 4.6%, respectively). The age-related proportion of esophagitis and of severe esophagitis (i.e., grades C and D) increased in females aged over 70 and in males aged over 80. Increased body mass index (partly due to decreased height caused by osteoporosis), and/or hiatal herniation, were related to the proportion of esophagitis in females aged over 70. These data indicated that reflux esophagitis is a common disease in Japan. However, severe esophagitis (grades C and D) is not common.

PMID 10452674  J Gastroenterol. 1999 Aug;34(4):441-4.
著者: Hanneke Beaumont, Roelof J Bennink, Jan de Jong, Guy E Boeckxstaens
雑誌名: Gut. 2010 Apr;59(4):441-51. doi: 10.1136/gut.2009.178061. Epub 2009 Aug 2.
Abstract/Text INTRODUCTION: Gastro-oesophageal reflux occurs twice as much during transient lower oesophageal sphincter relaxations (TLOSRs) in patients with gastro-oesophageal reflux disease (GORD) compared to healthy volunteers (HVs). Our aim was to assess whether the localisation of the postprandial acid pocket and its interaction with a hiatal hernia (HH) play a role in the occurrence of acidic reflux during TLOSRs.
METHODS: Ten HVs and 22 patients with GORD (12 with HH<3 cm (s-HH), 10 with HH > or =3 cm (l-HH)) were studied. The squamocolumnar junction and diaphragmatic impression were marked with a radioactively labelled clip. To visualise the acid pocket, (99m)Tc-pertechnetate was injected intravenously and images were acquired up to 2 h postprandial. Concurrently, combined manometry/impedance and four-channel pH-metry were performed, with pH pull-through at multiple time-points.
RESULTS: The rate of TLOSRs and the per cent associated with reflux was comparable between all groups. However, acidic reflux was significantly increased in patients, especially in patients with l-HH. Acid pocket length was significantly enlarged in patients. Moreover, immediately before a TLOSR, the acid pocket was more frequently located within the hiatus or above the diaphragm in patients with GORD (s-HH, 54%; l-HH, 77%) compared to HVs (22% of TLOSRs). Acidic reflux was significantly increased when the acid pocket was located above the diaphragm in all groups compared to a sub-diaphragmatic localisation.
CONCLUSION: The position of the acid pocket is largely determined by the presence of a HH. Entrapment of the pocket above the diaphragm, especially in patients with l-HH, is a major risk factor underlying the increased occurrence of acidic reflux during a TLOSR in patients with GORD.

PMID 19651625  Gut. 2010 Apr;59(4):441-51. doi: 10.1136/gut.2009.17806・・・
著者: N Chiba, C J De Gara, J M Wilkinson, R H Hunt
雑誌名: Gastroenterology. 1997 Jun;112(6):1798-810.
Abstract/Text BACKGROUND & AIMS: Esophagitis healing proportions are often incorrectly called the healing rate. The aim of this study was to compare different drug classes by expressing the speed of healing and symptom relief through a new approach.
METHODS: A fully recursive literature search to July 1996 identified 43 articles on gastroesophageal reflux disease (GERD) (7635 patients) meeting strict inclusion criteria: single- or double-blind randomized studies in adults with endoscopically proven erosive or ulcerative esophagitis. For each drug class, linear regression analysis estimated the average percentage of patients who were healed and heartburn free per week.
RESULTS: Mean overall healing proportion irrespective of drug dose or treatment duration (< or =12 weeks) was highest with proton pump inhibitors (PPIs; 83.6% +/- 11.4%) vs. H2-receptor antagonists (H2RAs; 51.9% +/- 17.1%), sucralfate (39.2% +/- 22.4%), or placebo (28.2% +/- 15.6%). Correcting for patients without baseline heartburn, the mean heartburn-free proportion was highest with PPIs (77.4% +/- 10.4%) vs. H2RAs (47.6% +/- 15.5%). PPIs showed a significantly faster healing rate (11.7%/wk) vs. H2RAs (5.9%/wk) and placebo (2.9%/wk). PPIs provided faster, more complete heartburn relief (11.5%/wk) vs. H2RAs (6.4%/wk).
CONCLUSIONS: More complete esophagitis healing and heartburn relief is observed with PPIs vs. H2RAs and occurs nearly twice as fast. This semiquantitative expression of speed of healing and symptom relief permits comparisons for future economic evaluation and quality-of-life assessments.

PMID 9178669  Gastroenterology. 1997 Jun;112(6):1798-810.
著者: Yoshikazu Kinoshita, Kiyoshi Ashida, Hiroto Miwa, Michio Hongo
雑誌名: Am J Gastroenterol. 2009 May;104(5):1106-11. doi: 10.1038/ajg.2009.77. Epub 2009 Mar 31.
Abstract/Text OBJECTIVES: Although lifestyle modification involving diet, exercise, cessation of smoking, etc. is generally advised for patients with reflux esophagitis (RE), few data that show its clinical benefits are available. We analyzed whether lifestyle modification improves health-related quality of life (HRQOL) in Japanese patients with RE receiving the proton pump inhibitor (PPI) lansoprazole as a post hoc analysis of an observational study that investigated the effect of lansoprazole on HRQOL.
METHODS: Patients with RE received lansoprazole for 8 weeks. HRQOL was assessed using the 8-Item Short-Form Health Survey (SF-8) and RE-specific HRQOL questionnaires at baseline and after 4 and 8 weeks of treatment. Physical and mental component summaries (PCS, MCS) and RE-specific summary (RES) scores were calculated.
RESULTS: Of the 8,757 patients analyzed, 40.8% were advised regarding new lifestyle at the start of lansoprazole treatment (Group A), 33.3% were advised to continue the lifestyle as advised previously (Group B), and 25.9% did not receive any advice (Group C). The change in PCS from baseline at week 8 for Group A was 5.7 +/- 8.1, and this was significantly greater (P < 0.001) than the increases achieved in Groups B (4.3 +/- 7.5) and C (4.0 +/- 7.6). The changes in MCS and RES were also significantly greater in Group A than in the other groups. The changes in HRQOL scores from baseline were significantly greater in Group A than in the other groups, irrespective of baseline patient characteristics.
CONCLUSIONS: Lifestyle modification may be clinically beneficial in terms of improving HRQOL in Japanese patients with RE who are receiving treatment with a PPI.

PMID 19337239  Am J Gastroenterol. 2009 May;104(5):1106-11. doi: 10.10・・・
著者: Roberto Cirocchi, Iosief Abraha, Eriberto Farinella, Alessandro Montedori, Francesco Sciannameo
雑誌名: Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007511. doi: 10.1002/14651858.CD007511.pub2. Epub 2010 Feb 17.
Abstract/Text BACKGROUND: Acute intestinal obstruction is one of the most common surgical emergencies. The small bowel obstruction (SBO) is the site of obstruction in most patients (76%) and adhesions are the most common etiology (65%). Laparoscopy in SBO has no clear role yet as it may have a therapeutic and diagnostic function. In some settings laparoscopic or laparoscopy-assisted surgery is considered feasible and convenient more than conventional surgery for SBO; however little is known if laparoscopic or laparoscopy-assisted surgery is more suitable with respect to open surgery for patients with SBO.
OBJECTIVES: The aim of this systematic review is to assess whether laparoscopic or laparoscopy-assisted surgery is feasible and safe for acute SBO, and whether laparoscopic and laparoscopy-assisted surgery present advantages compared to open surgery in terms of short-term and long-term outcomes.
SEARCH STRATEGY: We searched for published randomised and prospective controlled clinical trials without language restrictions using the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 onwards) and EMBASE (1980 onwards).
SELECTION CRITERIA: Randomised controlled trials and non randomised controlled prospective trials evaluating laparoscopic and laparoscopy-assisted surgery versus traditional open surgery for acute SBO were considered.
DATA COLLECTION AND ANALYSIS: We conducted the review according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Group as well, using Review Manager 5 to conduct the review.
MAIN RESULTS: No published or unpublished randomised controlled trials or prospective controlled clinical trials comparing laparoscopy with open surgery for patients with SBO were identified.
AUTHORS' CONCLUSIONS: Although data from retrospective clinical controlled trials suggest that laparoscopy seems feasible and better in terms of hospital stay and mortality reduction, high quality randomised controlled trials assessing all clinically relevant outcomes including overall mortality, morbidity, hospital stay and conversion are needed.

PMID 20166096  Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007511. d・・・
著者: Stanley Ip, Athina Tatsioni, Alene Conant, Raffi Karagozian, Linda Fu, Priscilla Chew, Gowri Raman, Joseph Lau, Peter Bonis
雑誌名: Am J Gastroenterol. 2009 Mar;104(3):752-8; quiz 759. doi: 10.1038/ajg.2008.123. Epub 2009 Feb 3.
Abstract/Text OBJECTIVES: Surgical treatment is a therapeutic option for patients with gastroesophageal reflux disease (GERD). It is unclear which patient characteristics influence postoperative success. The purpose of this paper was to review the literature on prognostic factors for patients with GERD treated with fundoplication.
METHODS: We searched Medline and the Cochrane Library Central for studies from 1966 through July 2007. We identified additional studies by reviewing bibliographies of retrieved articles and by consulting experts. We included English language studies that evaluated factors potentially affecting the outcomes after surgical treatments in patients with GERD. We recorded baseline patient characteristics associated with treatment efficacy, details on the study design, comparators, and definitions of outcomes.
RESULTS: We assessed 6,318 abstracts; 53 cohorts and 10 case-control studies met our inclusion criteria. Age, body mass index, sex, esophagitis grade, and dysmotility were generally not associated with treatment outcomes. There were no consistent associations between preoperative response to acid suppression medications, baseline symptoms, baseline acid exposure, degree of lower esophageal sphincter competence, or position of reflux and surgical outcomes. Certain psychological factors might be associated with worse treatment outcomes.
CONCLUSIONS: Although several preoperative predictors of surgical outcomes have been described, the quality and consistency of the data were mixed and the strength of the associations remains unclear. Additional studies with improved methodological designs are needed to better define which patient characteristics are associated with surgical outcomes following fundoplication.

PMID 19262527  Am J Gastroenterol. 2009 Mar;104(3):752-8; quiz 759. do・・・
著者: Matthew James Peters, Athar Mukhtar, Rossita Mohamad Yunus, Shahjahan Khan, Juanita Pappalardo, Breda Memon, Muhammed Ashraf Memon
雑誌名: Am J Gastroenterol. 2009 Jun;104(6):1548-61; quiz 1547, 1562. doi: 10.1038/ajg.2009.176. Epub 2009 Apr 28.
Abstract/Text OBJECTIVES: The aim of this study was to conduct a meta-analysis of randomized evidence to determine the relative merits of laparoscopic anti-reflux surgery (LARS) and open anti-reflux surgery (OARS) for proven gastro-esophageal reflux disease (GERD).
METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents, and PubMed databases identified all randomized clinical trials that compared LARS and OARS and that were published in the English language between 1990 and 2007. A meta-analysis was carried out in accordance with the QUOROM (Quality of Reporting of Meta-Analyses) statement. The six outcome variables analyzed were operating time, hospital stay, return to normal activity, perioperative complications, treatment failure, and requirement for further surgery. Random-effects meta-analyses were carried out using odds ratios (ORs) and weighted mean differences (WMDs).
RESULTS: Twelve trials were considered suitable for the meta-analysis. A total of 503 patients underwent OARS and 533 had LARS. For three of the six outcomes, the summary point estimates favored LARS over OARS. There was a significant reduction of 2.68 days in the duration of hospital stay for the LARS group compared with that for the OARS group (WMD: -2.68, 95% confidence interval (CI): -3.54 to -1.81; P<0.0001), a significant reduction of 7.75 days in return to normal activity for the LARS group compared with that for the OARS group (WMD: -7.75, 95% CI: -14.37 to -1.14; P=0.0216), and finally, there was a statistically significant reduction of 65% in the relative odds of complication rates for the LARS group compared with that for the OARS group (OR: 0.35, 95% CI: 0.16-0.75; P=0.0072). The duration of operating time was significantly longer (39.02 min) in the LARS group (WMD: 39.02, 95% CI: 17.99-60.05; P=0.0003). Treatment failure rates were comparable between the two groups (OR: 1.39, 95% CI: 0.71-2.72; P=0.3423). Despite this, the requirement for further surgery was significantly higher in the LARS group (OR: 1.79, 95% CI: 1.00-3.22; P=0.05).
CONCLUSIONS: On the basis of this meta-analysis, the authors conclude that LARS is an effective and safe alternative to OARS for the treatment of proven GERD. LARS enables a faster convalescence and return to productive activity, with a reduced risk of complications and a similar treatment outcome, than an open approach. However, there is a significantly higher rate of re-operation (79%) in the LARS group.

PMID 19491872  Am J Gastroenterol. 2009 Jun;104(6):1548-61; quiz 1547,・・・
著者: J A J L Broeders, F A Mauritz, U Ahmed Ali, W A Draaisma, J P Ruurda, H G Gooszen, A J P M Smout, I A M J Broeders, E J Hazebroek
雑誌名: Br J Surg. 2010 Sep;97(9):1318-30. doi: 10.1002/bjs.7174.
Abstract/Text BACKGROUND: Laparoscopic Nissen fundoplication (LNF) is currently considered the surgical approach of choice for gastro-oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) has been said to reduce troublesome dysphagia and gas-related symptoms. A systematic review and meta-analysis of randomized clinical trials (RCTs) was performed to compare LNF and LTF.
METHODS: Four electronic databases (MEDLINE, Embase, Cochrane Library and ISI Web of Knowledge CPCI-S) were searched and the methodological quality of included trials was evaluated. Outcomes included recurrent pathological acid exposure, oesophagitis, dysphagia, dilatation for dysphagia and reoperation rate. Results were pooled in meta-analyses as risk ratios (RRs) and weighted mean differences.
RESULTS: Seven eligible RCTs comparing LNF (n = 404) with LTF (n = 388) were identified. LNF was associated with a significantly higher prevalence of postoperative dysphagia (RR 1.61 (95 per cent confidence interval 1.06 to 2.44); P = 0.02) and dilatation for dysphagia (RR 2.45 (1.06 to 5.68); P = 0.04). There were more surgical reinterventions after LNF (RR 2.19 (1.09 to 4.40); P = 0.03), but no differences regarding recurrent pathological acid exposure (RR 1.26 (0.82 to 1.95); P = 0.29), oesophagitis (RR 1.20 (0.78 to 1.85); P = 0.40), subjective reflux recurrence, patient satisfaction, operating time or in-hospital complications. Inability to belch (RR 2.04 (1.19 to 3.49); P = 0.009) and gas bloating (RR 1.58 (1.21 to 2.05); P < 0.001) were more prevalent after LNF.
CONCLUSION: LTF reduces postoperative dysphagia and dilatation for dysphagia compared with LNF. Reoperation rate and prevalence of gas-related symptoms were lower after LTF, with similar reflux control. These results provide level 1a support for the use of LTF as the posterior fundoplication of choice for GORD.

Copyright 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
PMID 20641062  Br J Surg. 2010 Sep;97(9):1318-30. doi: 10.1002/bjs.717・・・
著者: Oliver O Koch, Adolf Kaindlstorfer, Stavros A Antoniou, Ruzica Rosalia Luketina, Klaus Emmanuel, Rudolph Pointner
雑誌名: Surg Endosc. 2013 Jul;27(7):2383-90. doi: 10.1007/s00464-013-2803-0. Epub 2013 Jan 30.
Abstract/Text BACKGROUND: The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce.
METHODS: This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294).
RESULTS: Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF.
CONCLUSIONS: Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

PMID 23361260  Surg Endosc. 2013 Jul;27(7):2383-90. doi: 10.1007/s0046・・・
著者: T Lind, T Havelund, L Lundell, H Glise, K Lauritsen, S A Pedersen, O Anker-Hansen, A Stubberöd, G Eriksson, R Carlsson, O Junghard
雑誌名: Aliment Pharmacol Ther. 1999 Jul;13(7):907-14.
Abstract/Text AIM: To observe the natural course of gastro-oesophageal reflux disease (GERD) in patients without oesophagitis following effective symptom relief, and to determine the place of acid pump inhibitor therapy in the long-term management of these patients.
METHODS: We investigated the efficacy of on-demand therapy with omeprazole 20 mg or 10 mg, or placebo in a double-blind, randomized multicentre trial. It involved 424 patients with troublesome heartburn without endoscopic evidence of oesophagitis in whom heartburn had been resolved with short-term treatment. Patients were told to take study medication on demand once daily on recurrence of symptoms until symptoms resolved over a 6-month period. They also had access to antacids. The primary efficacy variable was time to discontinuation of treatment, due to unwillingness to continue.
RESULTS: According to life-table analysis, after 6 months the remission rates were 83% (95% CI: 77-89%) with omeprazole 20 mg, 69% (61-77%) with omeprazole 10 mg, and 56% (46-64%) with placebo (P < 0.01 for all intergroup differences). The mean (s.d.) number of study medications used per day in these groups was 0.43 (0.27), 0.41 (0.27) and 0.47 (0.27), respectively. The use of antacids was highest in the placebo group and lowest in the omeprazole 20 mg group. Treatment failure was associated with more than a doubling of antacid use, and a deterioration in patient quality of life.
CONCLUSIONS: Approximately 50% of patients with heartburn who do not have oesophagitis need acid inhibitory therapy in addition to antacid medication to maintain a normal quality of life. On-demand therapy with omeprazole 20 mg, is an effective treatment strategy in these patients.

PMID 10383525  Aliment Pharmacol Ther. 1999 Jul;13(7):907-14.

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