今日の臨床サポート

腸閉塞とイレウス

著者: 古畑智久 聖マリアンナ医科大学東横病院 消化器病センター 消化器・一般外科

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:2021/10/27
参考ガイドライン:
  1. 日本腹部救急医学会日本プライマリ・ケア連合学会日本医学放射線学会日本産科婦人科学会、[日本血管外科学会 日本血管外科学会]:急性腹症診療ガイドライン2015 第1版
  1. 大腸癌研究会大腸癌治療ガイドライン2019年版
  1. 欧州消化器内視鏡学会ガイドライン 2020年版(Endoscopy 2020 May;52(5):389-407. doi: 10.1055/a-1140-3017. Epub 2020 Apr 7.
患者向け説明資料

概要・推奨   

  1. 単純性癒着性腸閉塞には、まずは胃管による減圧を行う。胃管により腸管の減圧を行い、1~2日間経過観察する。改善傾向を認めない場合は、イレウス管挿入を考慮する(推奨度1)。
  1. 減圧チューブからのガストログラフィン注入は腸閉塞やイレウスの診断だけでなく、治療にも有用である(推奨度1)。
  1. 高圧酸素療法は、単純性癒着性腸閉塞の治療に有用である(推奨度2)。
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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:
古畑智久 : 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. 根治的外科的切除を前提とした術前の閉塞解除処置(bridge to surgery:BTS)としてのステント治療に関して、欧州消化器内視鏡学会ガイドライン 2020年版に基づき改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 欧米では、イレウスは機械的な閉塞のない腸管運動が麻痺している状態を意味し、いわゆる腸閉塞とは区別して使われる。わが国では、これまで腸閉塞とイレウスを同義語として扱ってきたが、急性腹症診療ガイドライン2015(日本腹部救急医学会、日本プライマリ・ケア連合学会、日本医学放射線学会、日本産婦人科学会、日本血管外科学会)において、「従来の機能性イレウス(腸管麻痺)のみをイレウスとし、従来の機械性イレウスはイレウスとは呼ばず、腸閉塞と定義する」と述べられており、本稿ではそれにしたがって記載することとする。
 
疫学:
  1. 急性腹症による入院の20%は、腸閉塞によるといわれている。それらの約80%は小腸の腸閉塞である[1]
  1. 大腸癌によって腸閉塞を呈することがあり、その頻度は16%とする報告がある[2]
  1. 29,970人の開腹手術患者の経過をレトロスペクティブに検討したところ、術後10年間で34.6%の患者が癒着性腸閉塞により入院を要した[3]

病態:
  1. 腸管通過障害の原因が機械的な場合を腸閉塞、機能的な場合をイレウスと定義される[4]
 
腸閉塞、イレウスの病態による分類

腸管通過障害を認めた場合、次にこの分類のどれに属するかを検討し、治療方針を決定していく。

出典

img1:  著者提供
 
 
 
  1. 腸閉塞には、血流障害を伴わない単純性腸閉塞と血流障害を伴う複雑性腸閉塞がある。
  1. イレウスは、麻痺性イレウスと痙攣性イレウスがある。
  1. 腸閉塞の原因は開腹術後の癒着、腫瘍、異物、イレウスの原因は腹膜炎、代謝性疾患など多岐にわたる。主たる病態が背景に存在することも多い。
  1. 数日の絶食で軽快する症例から、腸管内圧上昇によりbacterial translocationが発生し敗血症に至る症例、突然の発症から腸管壊死に至る症例まで重症度も様々である。

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文献 

著者: R K Phillips, R Hittinger, J S Fry, L P Fielding
雑誌名: Br J Surg. 1985 Apr;72(4):296-302.
Abstract/Text Of 4583 patients in the Large Bowel Cancer Project, 713 (16 per cent) were obstructed. The site of greatest risk was the splenic flexure (49 per cent). Advanced stage was neither the full reason why some patients obstructed nor for their subsequent poor prospects (age-adjusted 5-year survival: not obstructed, 45 per cent; obstructed, 25 per cent). Also, there was no greater risk of vascular invasion, no heavier lymph node burden and no worse tumour differentiation in patients with obstruction. In-hospital mortality was high (23 per cent), was not reduced by either a policy of primary or staged resection and was not influenced by the site of obstruction. There was no survival advantage for either policy, but hospital stay after primary resection was half that of staged. Immediate anastomosis in the obstructed left colon had a high clinical leak rate (18 per cent versus 6 per cent elective; P less than 0.001). Both registrars and consultants had similar mortality rates for elective primary resection and for the management of obstruction itself (as evidenced by results after the first stage of a staged resection). Selection probably accounts for the very much better results achieved by consultants for primary resection in the presence of obstruction (in-hospital mortality: consultants, 13 per cent; registrars, 24 per cent).

PMID 3986481  Br J Surg. 1985 Apr;72(4):296-302.
著者: H Ellis, B J Moran, J N Thompson, M C Parker, M S Wilson, D Menzies, A McGuire, A M Lower, R J Hawthorn, F O'Brien, S Buchan, A M Crowe
雑誌名: Lancet. 1999 May 1;353(9163):1476-80. doi: 10.1016/S0140-6736(98)09337-4.
Abstract/Text BACKGROUND: Adhesions after abdominal and pelvic surgery are important complications, although their basic epidemiology is unclear. We investigated the frequency of such complications in the general population to provide a basis for the targeting and assessment of new adhesion-prevention measures.
METHODS: We used validated data from the Scottish National Health Service medical record linkage database to identify patients undergoing open abdominal or pelvic surgery in 1986, who had no record of such surgery in the preceding 5 years. Patients were followed up for 10 years and subsequent readmissions were reviewed and outcomes classified by the degree of adhesion. We also assessed the rate of adhesion-related admissions in 1994 for the population of 5 million people.
FINDINGS: 1209 (5.7%) of all readmissions (21,347) were classified as being directly related to adhesions, with 1169 (3.8%) managed operatively. Overall, 34.6% of the 29,790 patients who underwent open abdominal or pelvic surgery in 1986 were readmitted a mean of 2.1 times over 10 years for a disorder directly or possibly related to adhesions, or for abdominal or pelvic surgery that could be potentially complicated by adhesions. 22.1% of all outcome readmissions occurred in the first year after initial surgery, but readmissions continued steadily throughout the 10-year period. In 1994, 4199 admissions were directly related to adhesions.
INTERPRETATION: Postoperative adhesions have important consequences to patients, surgeons, and the health system. Surgical procedures with a high risk of adhesion-related complications need to be identified and adhesion prevention carefully assessed.

PMID 10232313  Lancet. 1999 May 1;353(9163):1476-80. doi: 10.1016/S014・・・
著者: Kyung Mi Jang, Kwangseon Min, Min Jeong Kim, Sung Hye Koh, Eui Yong Jeon, In-Gyu Kim, Dongil Choi
雑誌名: AJR Am J Roentgenol. 2010 Apr;194(4):957-63. doi: 10.2214/AJR.09.2702.
Abstract/Text OBJECTIVE: The purpose of this study was to assess the diagnostic performance of CT in the detection of intestinal ischemia associated with small-bowel obstruction using the maximal attenuation of a region of interest (ROI).
MATERIALS AND METHODS: Abdominal CT scans of 60 patients with small-bowel obstruction were retrospectively reviewed. The reference standard of the clinicopathologic groups was classified into four categories: no bowel necrosis, mucosal-submucosal necrosis, superficial muscle necrosis, and transmural necrosis. The viability of the small bowel on CT was evaluated by visual assessment using five categories (i.e., definitely intestinal ischemia, probably intestinal ischemia, possibly intestinal ischemia, equivocal CT results, and no intestinal ischemia) and by measurement of the maximal attenuation of an ROI at selected obstructed small-bowel loops on contrast-enhanced and unenhanced CT scans. Diagnostic performances were evaluated by one-way analysis of variance and receiver operating characteristic (ROC) curve analysis.
RESULTS: The sensitivity, specificity, positive and negative predictive values, and accuracy of visual assessment for intestinal ischemia were 91.7% (33/36), 66.7% (16/24), 80.5% (33/41), 84.2% (16/19), and 81.7% (49/60), respectively. The maximal attenuation of the ROIs on contrast-enhanced CT and the subtraction value between the maximal attenuation on contrast-enhanced CT and that on unenhanced CT scans at selected bowel were significantly different according to clinicopathologic group (p < 0.001). The area under the ROC curve of the maximal attenuation subtraction values between contrast-enhanced and unenhanced CT scans (0.995) was higher than that of visual assessment (0.908) for the detection of intestinal ischemia.
CONCLUSION: The quantification of bowel wall enhancement using the maximal attenuation of an ROI was a reliable and useful method for the diagnosis of intestinal ischemia and showed good correlation with pathology results.

PMID 20308497  AJR Am J Roentgenol. 2010 Apr;194(4):957-63. doi: 10.22・・・
著者: P R Fleshner, M G Siegman, G I Slater, R E Brolin, J C Chandler, A H Aufses
雑誌名: Am J Surg. 1995 Oct;170(4):366-70.
Abstract/Text BACKGROUND: Many cases of acute adhesive small-bowel obstruction (SBO) can be successfully treated with intestinal tube decompression. There is considerable controversy, however, regarding whether a short nasogastric tube (NGT) or a long nasointestinal tube (LT) is the best method of intestinal tube decompression.
PATIENTS AND METHODS: A prospective, randomized trial was conducted to compare NGT and LT decompression with respect to the success of nonoperative treatment and morbidity of surgical intervention in 55 patients with acute adhesive SBO.
RESULTS: Twenty-eight patients were managed with NGT and 27 with LT. There were 44 cases of partial SBO (23 NGT, 21 LT) and 11 cases of complete SBO (5 NGT, 6 LT). Twenty-one patients ultimately required operation, including 13 managed with NGT (46%) and 8 with LT (30%) (P = 0.16). The mean period between admission and operation was 60 hours in the NGT group versus 65 hours in the LT group. At operation, 3 patients in the NGT group had ischemic bowel that required resection. Postoperative complications occurred in 23% of patients treated with NGT versus 38% of patients treated with LT (P = 0.89). Postoperative ileus averaged 6.1 days for NGT patients versus 4.6 days for LT patients (P = 0.44). There were no deaths.
CONCLUSIONS: Patients with adhesive SBO can safely be given a trial of tube decompression upon hospital admission. There was no advantage of one type of tube over the other in patients with adhesive SBO.

PMID 7573730  Am J Surg. 1995 Oct;170(4):366-70.
著者: R E Brolin, M J Krasna, B A Mast
雑誌名: Ann Surg. 1987 Aug;206(2):126-33.
Abstract/Text During the past 10 years 311 consecutive patients were admitted with 342 episodes of small bowel obstruction (SBO). There were 193 cases of partial small bowel obstruction (PSBO) and 149 cases of complete small bowel obstruction (CSBO) as determined by interpretation of the abdominal radiographs done on admission. The purpose of this review was to determine the reliability of the admission plain abdominal radiographs and subsequent upper gastrointestinal (UGI) contrast studies in predicting the need for operative intervention. The use of nasogastric tubes (NGT) versus nasointestinal (long) tubes (NIT) was correlated with the following outcome variables; length of hospital stay (LOS), timing of operative intervention, incidence of postoperative complications, and duration of postoperative ileus. Long tubes (NIT) were used in 64 episodes of PSBO and 81 episodes of CSBO, whereas nasogastric tubes (NGT) were used in 116 cases of PSBO and 68 cases of CSBO. Thirty-eight of 193 (19%) patients with PSBO required operation (20 of 116 with NGT and 18 of 64 with NIT), whereas 125 of 149 (84%) patients with CSBO required operation (60 of 68 with NGT and 65 of 81 with NIT). Need for operation was not correlated with whether or not long tubes passed beyond the pylorus; 50 passed versus 33 not passed in operative groups (p = 0.15). Twelve of 83 patients with NIT had operation within 24 hours versus 52 of 80 patients with NGT (p less than 0.001). In six of 64 patients who had surgery within 24 hours, complications developed versus in 39 of 99 patients operated on more than 24 hours after admission (p less than or equal to 0.001). In 29 of 83 patients treated with NIT, postoperative complications developed versus in 16 of 80 patients with NGT (p less than or equal to 0.04). The mean duration of postoperative ileus in patients with NIT was 7 days versus 4.1 days for NGT patients (p less than 0.001). The mean LOS was 12.2 days for NGT patients versus 21 days for patients with NIT (p less than 0.001). Barium UGI contrast studies were performed in 57 patients to establish the presence of obstruction. In 34 of 57 patients the UGI disclosed mechanical obstruction that required operative intervention. In the remaining 23 patients no obstruction was demonstrated, and all 23 patients recovered without operation. In conclusion, there is no inherent superiority of NIT versus NGT in the treatment of SBO.(ABSTRACT TRUNCATED AT 400 WORDS)

PMID 3606237  Ann Surg. 1987 Aug;206(2):126-33.
著者: Jeanin E van Hooft, Emo E van Halsema, Geoffroy Vanbiervliet, Regina G H Beets-Tan, John M DeWitt, Fergal Donnellan, Jean-Marc Dumonceau, Robert G T Glynne-Jones, Cesare Hassan, Javier Jiménez-Perez, Søren Meisner, V Raman Muthusamy, Michael C Parker, Jean-Marc Regimbeau, Charles Sabbagh, Jayesh Sagar, Pieter J Tanis, Jo Vandervoort, George J Webster, Gianpiero Manes, Marc A Barthet, Alessandro Repici, European Society of Gastrointestinal Endoscopy (ESGE)
雑誌名: Gastrointest Endosc. 2014 Nov;80(5):747-61.e1-75. doi: 10.1016/j.gie.2014.09.018. Epub 2014 Oct 15.
Abstract/Text
PMID 25436393  Gastrointest Endosc. 2014 Nov;80(5):747-61.e1-75. doi: ・・・
著者: Gianpiero Manes, Mario de Bellis, Lorenzo Fuccio, Alessandro Repici, Enzo Masci, Sandro Ardizzone, Benedetto Mangiavillano, Alessandra Carlino, Giovanni Battista Rossi, Pietro Occhipinti, Vincenzo Cennamo
雑誌名: Arch Surg. 2011 Oct;146(10):1157-62. doi: 10.1001/archsurg.2011.233.
Abstract/Text OBJECTIVES: To evaluate the short- and long-term efficacy of self-expanding metal stents (SEMSs) in patients with colorectal obstruction and incurable cancer and the related factors that affect outcomes.
DESIGN: Retrospective analysis of SEMS placement for incurable colorectal obstruction in a 3-year period.
SETTING: Five tertiary care endoscopic centers.
PATIENTS AND INTERVENTION: Consecutive patients (N = 201) undergoing stenting for incurable malignant obstruction.
MAIN OUTCOME MEASUREMENTS: Clinical and technical success of stenting, complications rate, and factors affecting outcomes.
RESULTS: Technical success was achieved in 184 of 201 patients (91.5%) and clinical success occurred in 165 of 184 patients (89.7%; 82.1% of 201 patients). Technical and clinical failures were more frequent in extrinsic and long colorectal stenoses. Overall, 165 patients had normal bowel movements during follow-up (mean [SD], 115.5 [100.3] days; range, 1-500 days), 15 developed complications, 127 had a functioning SEMS at the time of death, and 23 were alive at completion of the study. Twenty-four (11.9%) major complications occurred: 11 migrations, 12 perforations, and 1 reobstruction. Migration of SEMSs was associated with stent diameter less than 25 mm. Bevacizumab therapy increased the risk of perforation by 19.6-fold. Karnofsky performance status of 50 or less was associated with shorter survival and a 3.7-fold higher risk of death within 6 months after the stent was placed.
CONCLUSIONS: The use of SEMSs is safe and effective for palliation of incurable malignant colonic obstruction; approximately 75% of patients with SEMSs are able to avoid colostomy.

PMID 22006874  Arch Surg. 2011 Oct;146(10):1157-62. doi: 10.1001/archs・・・
著者: Vincenzo Cennamo, Carmelo Luigiano, Federico Coccolini, Carlo Fabbri, Marco Bassi, Giuseppe De Caro, Liza Ceroni, Antonella Maimone, Paolo Ravelli, Luca Ansaloni
雑誌名: Int J Colorectal Dis. 2013 Jun;28(6):855-63. doi: 10.1007/s00384-012-1599-z. Epub 2012 Nov 15.
Abstract/Text PURPOSE: Surgical decompression is the traditional treatment for acute colorectal cancer obstruction. In recent years, colorectal stenting has been used to relieve the obstruction. This study used meta-analytic techniques to compare colonic stenting versus surgical decompression for colorectal cancer obstruction.
METHODS: A comprehensive search of several databases was conducted. The search identified 321 potential abstracts and titles of which eight randomized trials involving 353 patients were retrieved in full text. A meta-analysis of the studies included was carried out to identify the differences in outcomes between the two procedures.
RESULTS: The pooled analysis showed no significant differences for mortality (odds ratio (OR) 0.91) and morbidity (OR 2.05) rates between the two strategies while the permanent stoma creation rate was significantly higher in the surgical group as compared to the stent group (OR 3.12). By comparing surgery and colonic stenting in studies which analyzed the use of stenting as a "bridge to surgery," the pooled analysis showed that primary anastomosis was more frequent in the stent group as compared to the surgical group (OR 0.42), and the stoma creation was more frequent in the surgical group as compared to the stent group (OR 2.36).
CONCLUSION: Our study suggested that, in patients with acute colorectal cancer obstruction, stent placement improved several outcomes, such as primary anastomosis, stoma formation, and permanent stoma, while it failed to show an improvement in mortality and morbidity risk.

PMID 23151813  Int J Colorectal Dis. 2013 Jun;28(6):855-63. doi: 10.10・・・
著者: Roberto Cirocchi, Eriberto Farinella, Stefano Trastulli, Jacopo Desiderio, Chiara Listorti, Carlo Boselli, Amilcare Parisi, Giuseppe Noya, Jayesh Sagar
雑誌名: Surg Oncol. 2013 Mar;22(1):14-21. doi: 10.1016/j.suronc.2012.10.003. Epub 2012 Nov 24.
Abstract/Text INTRODUCTION: Colorectal carcinoma can present with acute intestinal obstruction in 7%-30% of cases, especially if tumor is located at or distal to the splenic flexure. In these cases, emergency surgical decompression becomes mandatory as the traditional treatment option. It involves defunctioning stoma with or without primary resection of obstructing tumor. An alternative to surgery is endoluminal decompression. The aim of this review is to assess the effectiveness of colonic stents, used as a bridge to surgery, in the management of malignant left colonic and rectal obstruction.
METHODS: We considered only randomized trials which compared stent vs surgery for intestinal obstruction from left sided colorectal cancer (as a bridge to surgery) irrespective of their size. No language or publication status restrictions were imposed. A systematic search was conducted in Medline, Cochrane Central Register of Controlled Trials and the Science Citation Index (from inception to December 2011)
RESULTS: We identified 3109 citations through our electronic search and 3 through other sources. Initial screening of the titles and abstracts resulted in the exclusion of 3104 citations. A further 5 citations were excluded after detailed screening of full articles. Three published studies were included in this systematic review. A total of 197 patients were included in our analysis, 97 of them had colorectal stent vs 100 who had emergency surgery. Clinical success has been defined in different manners. In included trials the clinical success rate was significantly higher in the emergency surgery group (99%) compared with the stent group (52.5%) (p < 0.00001). There was no difference in the overall complication rate in the stent group (48.5%) vs emergency surgery group (51%) (p = 0.86). There was no difference in 30-days postoperative mortality (p = 0.97). The overall survival was analyzed in none trial. When used as a bridge to surgery, colorectal stents provide some advantages: the primary anastomosis rate was significantly higher in the stent group (64.9%) vs emergency surgery group (55%) (p = 0.003); the overall stoma rate was significantly lower in the stent group (45.3%) compared with the emergency surgery group (62%) (p = 0.02). There were no significant differences between the two groups as to permanent stoma rate (46.7% in stent group vs 51.8% in surgical group, p = 0.56), anastomotic leakage rate (9% in stent group vs 3.7% in surgical group, p = 0.35) and intra-abdominal abscess rate (5.1% in stent group vs 4.9% in surgical group, p = 0.97).
CONCLUSION: Although colonic stenting appears to be an effective treatment of malignant large bowel obstruction, the clinical success resulted significantly higher in the emergency surgery group without any advantages in terms of overall complication rate and 30-days postoperative mortality. On the other hand, the colonic stenting as a bridge to surgery provides surgical advantages, as higher primary anastomosis rate and a lower overall stoma rate, without increasing the risk of anastomotic leak or intra-abdominal abscess. However, these results should be interpreted with caution because few studies reported data on these outcomes. Due to the small and variable sample size of the included trials, further RCTs are needed including a larger number of patients and evaluating long term results (overall survival and quality of life) and cost-effectiveness analysis.

Copyright © 2012 Elsevier Ltd. All rights reserved.
PMID 23183301  Surg Oncol. 2013 Mar;22(1):14-21. doi: 10.1016/j.suronc・・・
著者: Akihisa Matsuda, Masao Miyashita, Satoshi Matsumoto, Takeshi Matsutani, Nobuyuki Sakurazawa, Goro Takahashi, Taro Kishi, Eiji Uchida
雑誌名: Ann Surg Oncol. 2015 Feb;22(2):497-504. doi: 10.1245/s10434-014-3997-7. Epub 2014 Aug 14.
Abstract/Text BACKGROUND: The short-term safety and efficacy of insertion of a self-expandable metallic colonic stent followed by elective surgery, bridge to surgery (BTS), for malignant large-bowel obstruction (MLBO) have been well described. However, long-term oncological outcomes are still debated. Hence, this study is conducted to evaluate long-term outcomes of colonic stent insertion followed by surgery for MLBO.
METHODS: A comprehensive electronic literature search through May 2014 was performed to identify studies comparing long-term outcomes between BTS and emergency surgery for MLBO. The main outcome measures were overall survival (OS), disease-free survival (DFS), and recurrence. A meta-analysis was performed using random-effects models to calculate risk ratios (RRs) with 95 % confidence intervals (95 % CIs).
RESULTS: There were 11 studies that matched the criteria for inclusion, yielding a total of 1136 patients, of whom 432 (38.0 %) underwent BTS and 704 (62.0 %) underwent emergency surgery. In OS analyses of all patients and patients who underwent curative resection, BTS was similar to emergency surgery [(RR = 0.95; 95 % CI 0.75-1.21; P = 0.66) (RR = 0.96; 95 % CI 0.67-1.37; P = 0.82), respectively]. DFS (RR = 1.06; 95 % CI 0.91-1.24; P = 0.43) and recurrence (RR = 1.13; 95 % CI 0.82-1.54; P = 0.46) did not differ significantly between the BTS and emergency surgery groups.
CONCLUSIONS: Results of this meta-analysis on long-term as well as well-described short-term outcomes suggest that BTS could be a promising alternative strategy for MLBO patients.

PMID 25120255  Ann Surg Oncol. 2015 Feb;22(2):497-504. doi: 10.1245/s1・・・
著者: Joyce V Veld, Femke J Amelung, Wernard A A Borstlap, Emo E van Halsema, Esther C J Consten, Peter D Siersema, Frank Ter Borg, Edwin S van der Zaag, Johannes H W de Wilt, Paul Fockens, Wilhelmus A Bemelman, Jeanin E van Hooft, Pieter J Tanis, Dutch Snapshot Research Group
雑誌名: JAMA Surg. 2020 Jan 8;. doi: 10.1001/jamasurg.2019.5466. Epub 2020 Jan 8.
Abstract/Text Importance: Bridge to elective surgery using self-expandable metal stent (SEMS) placement is a debated alternative to emergency resection for patients with left-sided obstructive colon cancer because of oncologic concerns. A decompressing stoma (DS) might be a valid alternative, but relevant studies are scarce.
Objective: To compare DS with SEMS as a bridge to surgery for nonlocally advanced left-sided obstructive colon cancer using propensity score matching.
Design, Setting, and Participants: This national, population-based cohort study was performed at 75 of 77 hospitals in the Netherlands. A total of 4216 patients with left-sided obstructive colon cancer treated from January 1, 2009, to December 31, 2016, were identified from the Dutch Colorectal Audit and 3153 patients were studied. Additional procedural and intermediate-term outcome data were retrospectively collected from individual patient files, resulting in a median follow-up of 32 months (interquartile range, 15-57 months). Data were analyzed from April 7 to October 28, 2019.
Exposures: Decompressing stoma vs SEMS as a bridge to surgery.
Main Outcomes and Measures: Primary anastomosis rate, postresection presence of a stoma, complications, additional interventions, permanent stoma, locoregional recurrence, disease-free survival, and overall survival. Propensity score matching was performed according to age, sex, body mass index, American Society of Anesthesiologists score, prior abdominal surgery, tumor location, pN stage, cM stage, length of stenosis, and year of resection.
Results: A total of 3153 of the eligible 4216 patients were included in the study (mean [SD] age, 69.7 [11.8] years; 1741 [55.2%] male); after exclusions, 443 patients underwent bridge to surgery (240 undergoing DS and 203 undergoing SEMS). Propensity score matching led to 2 groups of 121 patients each. Patients undergoing SEMS had more primary anastomoses (104 of 121 [86.0%] vs 90 of 120 [75.0%], P = .02), more postresection stomas (81 of 121 [66.9%] vs 34 of 117 [29.1%], P < .001), fewer major complications (7 of 121 [5.8%] vs 18 of 118 [15.3%], P = .02), and more subsequent interventions, including stoma reversal (65 of 113 [57.5%] vs 33 of 117 [28.2%], P < .001). After DS and SEMS, the 3-year locoregional recurrence rates were 11.7% for DS and 18.8% for SEMS (hazard ratio [HR], 0.62; 95% CI, 0.30-1.28; P = .20), the 3-year disease-free survival rates were 64.0% for DS and 56.9% for SEMS (HR, 0.90; 95% CI, 0.61-1.33; P = .60), and the 3-year overall survival rates were 78.0% for DS and 71.8% for SEMS (HR, 0.77; 95% CI, 0.48-1.22; P = .26).
Conclusions and Relevance: The findings suggest that DS as bridge to resection of left-sided obstructive colon cancer is associated with advantages and disadvantages compared with SEMS, with similar intermediate-term oncologic outcomes. The existing equipoise indicates the need for a randomized clinical trial that compares the 2 bridging techniques.

PMID 31913422  JAMA Surg. 2020 Jan 8;. doi: 10.1001/jamasurg.2019.5466・・・
著者: Ping Yang, Xiu-Feng Lin, Kai Lin, Wei Li
雑誌名: Rev Invest Clin. 2018;70(6):269-278. doi: 10.24875/RIC.18002516.
Abstract/Text Background: The role of self-expanding metallic stents (SEMS) as a bridge to surgery for acute left-sided obstructive colorectal cancer has remained controversial.
Objective: To study the efficacy of this approach, we performed a meta-analysis at the gastrointestinal surgery center of Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital (Eastern Hospital).
Methods: Two PubMed and science-direct electronic databases were searched up to December 30, 2017. Eligible studies were randomized controlled trials (RCTs).
Results: We selected 8 RCTs articles, which included 497 cases. The directly stoma rates were significantly lower in the stent group (odds ratio [OR] = 0.46, 95% confidence intervals [CIs] = 0.30-0.70, p = 0.0003). The successful primary anastomosis rates were significantly higher in the stent group (OR = 2.29, 95% CIs = 1.52-3.45, p < 0.0001). The post-procedural complication rates were significantly lower in the stent group (OR = 0.39, 95% CI = 0.18-0.82, p = 0.01). However, tumor recurrence rates were significantly higher in the stent group (OR = 1.79, 95% CI = 1.09-2.93, p = 0.02). Conclusions This meta-analysis confirms that SEMS placement could reduce direct stoma rate and increases the successful primary anastomosis rate; however, it was associated with a seemingly higher incidence of tumor recurrence.

Copyright: © 2017 SecretarÍa de Salud.
PMID 30532112  Rev Invest Clin. 2018;70(6):269-278. doi: 10.24875/RIC.・・・
著者: Chi Chung Foo, Samuel Ho Ting Poon, Rosemaire Hon Yiu Chiu, Wai Yiu Lam, Lam Chi Cheung, Wai Lun Law
雑誌名: Surg Endosc. 2019 Jan;33(1):293-302. doi: 10.1007/s00464-018-6487-3. Epub 2018 Oct 19.
Abstract/Text BACKGROUND: Despite studies showing superior results in terms of reduced stoma rate and higher primary anastomosis rate, the safety of bridge to surgery stenting (BTS stent) for left-sided malignant colonic obstruction, especially in oncological terms, remains a concern.
AIM: The aim of this meta-analysis was to evaluate whether BTS stent is a safe alternative to emergency surgery (EmS).
METHODS: Randomized control trials (RCTs) comparing BTS stent and EmS for left-sided colonic obstruction caused by primary cancer of the colon, up to Sep 2018, were retrieved from the Pubmed, Embase database, clinical trials registry of U. S. National Library of Medicine and BMJ and Google Search.
RESULTS: There were seven eligible RCTs, involving a total of 448 patients. Compared to EmS, BTS stent had a significantly lower risk of overall complications (RR = 0.605; 95% CI 0.382-0.958; p = 0.032). However, the overall recurrence rate was higher in the BTS stent group (37.0% vs. 25.9%; RR = 1.425; 95% CI 1.002-2.028; p = 0.049). BTS stent significantly increased the risk of systemic recurrence (RR = 1.627; 95% CI 1.009-2.621; p = 0.046). This did not translate into a significant difference in terms of 3-year disease-free survival or 3-year overall survival.
CONCLUSION: BTS stent is associated with a lower rate of overall morbidities than EmS. However, BTS stent was associated with a greater chance of recurrence, especially systemic recurrence. Clinicians ought to be aware of the pros and cons of different interventions and tailor treatments for patients suffering from left-sided obstructing cancer of the colon.

PMID 30341649  Surg Endosc. 2019 Jan;33(1):293-302. doi: 10.1007/s0046・・・
著者: Sara K Story, Ronald S Chamberlain
雑誌名: Dig Surg. 2009;26(4):265-75. doi: 10.1159/000227765. Epub 2009 Jul 3.
Abstract/Text BACKGROUND: Postoperative ileus (POI) is a common complication of abdominal and several other surgeries leading to increased hospital stay and healthcare costs. POI also contributes towards numerous postsurgical comorbidities including deep vein thrombosis and pneumonia. POI is characterized by bowel distention and lack of bowel sounds, flatus and bowel movements. The causative mechanism is not fully understood and may be multifactorial including disorganized electrical activity, activation of inflammatory mediators and the use of opioid analgesics.
METHODS: A selective review of the literature pertaining to the prevention and treatment of adynamic ileus and POI was completed. More specifically we sought to evaluate RCTs, meta-analyses, consensus statements and articles providing graded evidence-based data on POI prevention and treatment.
RESULTS: Perioperative strategies employed to prevent or limit the duration of POI include avoidance of preoperative fasting and mechanical bowel preparation, use of epidural-local anesthetics, implementation of minimally-invasive surgical techniques, and modification of pain management strategies to limit opioid administration among others.
CONCLUSION: Though many of these strategies have proven beneficial, no single approach has demonstrated the ability to prevent or treat POI. However, when these strategies are used in combination as part of a fast-track multimodal treatment plan, there is a significant decrease in time to return of normal bowel function and a shortened hospital stay. Additional studies are needed to make specific recommendations regarding which components of fast-track protocols are most beneficial.

Copyright 2009 S. Karger AG, Basel.
PMID 19590205  Dig Surg. 2009;26(4):265-75. doi: 10.1159/000227765. Ep・・・
著者: Ned S Abraham, Christopher M Byrne, Jane M Young, Michael J Solomon
雑誌名: ANZ J Surg. 2007 Jul;77(7):508-16. doi: 10.1111/j.1445-2197.2007.04141.x.
Abstract/Text Laparoscopic resection remains to be established as the procedure of first choice for operable colorectal cancer. The aim of the study was to conduct a systematic review of non-randomized comparative studies of laparoscopic resection for colorectal cancer. Published work in English was searched for relevant articles published by the end of 2003. The MOOSE statement was used to conduct the meta-analysis. Study quality was assessed by two investigators using the MINORS tool and the analysis was conducted using Comprehensive Meta-analysis software (Biostat, Englewood, NJ, USA) and Microsoft Excel (Microsoft, Redmond, WA, USA). One thousand two hundred and twenty abstracts were reviewed and 398 articles examined in detail. Out of 108 articles reporting the results of relevant studies, 75 were reports of 64 non-randomized comparative studies. Fifteen studies were excluded. Analysis of the outcomes of 6438 resections showed that the conversion rate was 13.3% with a statistically significant difference between studies with more than 50 versus those with 50 or less attempted resections (11.7 vs 16.5%; P<0.001). Laparoscopic resection took 27.6% (41 min) longer to carry out than open resection. There was no significant difference between the two groups in early mortality rates (1.2 vs 1.1%; P=0.787) or likelihood of re-operation (2.3 vs 1.5%; P=0.319). Laparoscopic resection was associated with a lower morbidity rate (24.05 vs 30.80%, odds ratio (95% confidence interval)=0.77 (0.63-0.95); P=0.014, n=4111, random-effects model). Time until passage of first flatus, passage of a bowel motion, tolerating oral fluids and a solid diet was 1.2-1.6 days (26 to 37%) shorter, measurements of pain and narcotic analgesic requirements were 16-35% lower and hospital stay was 3.5 days (18.8%) shorter following laparoscopic resection compared with open resection. The two approaches were 99% similar in terms of adequacy of oncological clearance. Meta-analysis of non-randomized comparative studies favours laparoscopic over open resection for colorectal cancer. The results were remarkably similar to those of a contemporaneous meta-analysis of randomized controlled trials published by the end of 2002.

PMID 17610681  ANZ J Surg. 2007 Jul;77(7):508-16. doi: 10.1111/j.1445-・・・
著者: Salomone Di Saverio, Fausto Catena, Luca Ansaloni, Margherita Gavioli, Massimo Valentino, Antonio Daniele Pinna
雑誌名: World J Surg. 2008 Oct;32(10):2293-304. doi: 10.1007/s00268-008-9694-6.
Abstract/Text BACKGROUND: Patients with adhesive small intestine obstruction (ASIO) are difficult to evaluate and to manage and their treatment is still controversial. The diagnostic and therapeutic role of water-soluble contrast medium (Gastrografin) in ASIO is still debated. This study was designed to determine the therapeutic role of Gastrografin in patients with ASIO.
METHODS: The study was a multicenter, prospective, randomized, controlled investigation. The primary end points were the evaluation of the operative rate reduction and shortening the hospital stay after the use of Gastrografin. A total of 76 patients were randomized into two groups: the control group received traditional treatment (TT), whereas the study group (GG) received in addition a Gastrografin meal and follow-through study immediately. Patients with Gastrografin in the colon within 36 hours were considered to be partially obstructed and submitted to nonoperative management. If after 36 hours, the Gastrografin had not entered the colon, the subjects were submitted to laparotomy.
RESULTS: No significant differences were found in age, sex, intravenous administration of prokinetics, incidence and characteristics of the previous procedures in surgical history of the patients, previous episodes of ASIO and surgery for adhesiolysis, or duration of symptoms before admission. In the GG group obstruction resolved subsequently in 31 of 38 cases (81.5%) after a mean time of 6.4 hours. The remaining seven patients were submitted to surgery, and one of them needed bowel resection for strangulation. In the control group, 21 patients were not submitted to surgery (55%), whereas 17 showed persistent untreatable obstruction and required laparotomy: 2 of them underwent bowel resection for strangulation. The difference in the operative rate between the two treatment groups reached statistical significance (p = 0.013). The time from the hospital admission for obstruction to resolution of symptoms was significantly lower in the GG group (6.4 vs. 43 hours; p < 0.01). The length of hospital stay revealed a significant reduction in the GG group (4.7 vs. 7.8 days; p < 0.05). This reduction was more evident in the subset of patients who did not require surgery (3 vs. 5.1 days; p < 0.01). No GG-related complications or significant differences in major complications and the relapse rate were found (relapse rate, 34.2% after a mean time to relapse of 6.3 months in the GG group vs. 42.1% after 7.6 months in the TT; p = not significant).
CONCLUSIONS: Data showed that the use of Gastrografin in ASIO is safe and reduces the operative rate and the time to resolution of obstruction, as well as the hospital stay.

PMID 18688562  World J Surg. 2008 Oct;32(10):2293-304. doi: 10.1007/s0・・・
著者: Mitsuru Ishizuka, Norisuke Shibuya, Kazutoshi Takagi, Yoshimi Iwasaki, Hiroyuki Hachiya, Taku Aoki, Keiichi Kubota
雑誌名: Ann Gastroenterol Surg. 2019 Mar;3(2):187-194. doi: 10.1002/ags3.12223. Epub 2018 Dec 17.
Abstract/Text Background: Small bowel obstruction (SBO) is a well-known major postoperative complication requiring immediate diagnosis and treatment to avoid additional invasive surgical procedures. Water-soluble contrast medium is often given not only for diagnosis but also for treatment. Although numerous studies have investigated the significance of this treatment, no consensus has yet been established regarding its indications and efficacy.
Objective: To explore whether Gastrografin can reduce the need for additional surgery in patients with postoperative SBO (PSBO).
Methods: We carried out a comprehensive electronic search of the literature (Cochrane Library, MEDLINE, PubMed and the Web of Science) up to February 2017 to identify studies that had shown efficacy of Gastrografin in reducing the need for surgery in patients with PSBO. To integrate the individual effects of Gastrografin, a meta-analysis was done using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI), and heterogeneity was analyzed using I2 statistics.
Results: Twelve studies involving a total of 1153 patients diagnosed as having PSBO were included in this meta-analysis. Not all patients received long-tube insertion. Among 580 patients who received Gastrografin, 100 (17.2%) underwent surgery, whereas among 573 patients who did not receive Gastrografin, 143 (25.0%) underwent surgery. Giving Gastrografin significantly reduced the need for surgery (RR, 0.66; 95% CI, 0.46-0.95; P = 0.02; I2 = 52%) in comparison with patients who did not receive Gastrografin.
Conclusion: Results of this meta-analysis show that giving Gastrografin reduces the need for surgery in PSBO patients without long-tube insertion.

PMID 30923788  Ann Gastroenterol Surg. 2019 Mar;3(2):187-194. doi: 10.・・・
著者: Donal B O'Connor, Desmond C Winter
雑誌名: Surg Endosc. 2012 Jan;26(1):12-7. doi: 10.1007/s00464-011-1885-9. Epub 2011 Sep 5.
Abstract/Text BACKGROUND: Adhesive small-bowel obstruction (SBO) contributes significantly to emergency surgical workload. Laparotomy remains the standard approach. Despite published reports with high success rates and low morbidity, acute SBO is still considered by many a relative contraindication to laparoscopy. Our aim was to review the available literature and define important outcomes such as feasibility, safety, iatrogenic bowel injury, and benefits to patients with acute SBO who are approached laparoscopically.
METHODS: A systematic literature search was carried out using the Medline database and the search terms "laparoscopy" or "laparoscopic approach" and "bowel obstruction." Only adult studies published in English between 1990 and 2010 were included. Studies were excluded if data specific to outcomes for laparoscopic management of acute SBO could not be extracted.
RESULTS: Twenty-nine studies were identified. A laparoscopic approach was attempted in 2,005 patients with acute SBO. Adhesions were the most common etiology (84.9%). Laparoscopy was completed in 1,284 cases (64%), 6.7% were lap-assisted, and 0.3% were converted to hernia repair. The overall conversion rate to midline laparotomy was 29% (580/2,005). Dense adhesions, bowel resection, unidentified pathology, and iatrogenic injury accounted for the majority of conversions. When the etiology of SBO was a single-band adhesion, the success rate was 73.4%. Morbidity was 14.8% (283/1,906) and mortality was 1.5% (29/1,951). The enterotomy rate was 6.6% (110/1,673). The majority were recognized and converted to laparotomy. Laparoscopy was associated with reduced morbidity and length of stay.
CONCLUSION: Laparoscopy is a feasible and effective treatment for acute SBO with acceptable morbidity. Further studies are required to determine its impact on recurrent SBO.

PMID 21898013  Surg Endosc. 2012 Jan;26(1):12-7. doi: 10.1007/s00464-0・・・
著者: Pepijn Krielen, Salomone Di Saverio, Richard Ten Broek, Claudio Renzi, Mauro Zago, Georgi Popivanov, Paolo Ruscelli, Rinaldo Marzaioli, Massimo Chiarugi, Roberto Cirocchi
雑誌名: J Trauma Acute Care Surg. 2020 Jun;88(6):866-874. doi: 10.1097/TA.0000000000002684.
Abstract/Text BACKGROUND: Adhesive small bowel obstruction (ASBO) is one of the most frequent causes of emergency hospital admissions and surgical treatment. Current surgical treatment of ASBO consists of open adhesiolysis. With laparoscopic procedures rising, the question arises if laparoscopy for ASBO is safe and results in better patient outcomes. Although adhesiolysis was among the first surgical procedures to be approached laparoscopically, uncertainty remains about its potential advantages over open surgery. Therefore, we performed a systematic review and meta-analysis on the benefits and harms of laparoscopic surgery for ASBO.
METHODS: A systematic literature review was conducted for articles published up to May 2019. Two reviewers screened all articles and did the quality assessment. Consecutively a meta-analysis was performed. To reduce selection bias, only matched studies were used in our primary analyses. All other studies were used in a sensitivity analyses. All the outcomes were measured within the 30th postoperative day. Core outcome parameters were postoperative mortality, iatrogenic bowel perforations, length of postoperative stay [days], severe postoperative complications, and early readmissions. Secondary outcomes were operative time [min], missed iatrogenic bowel perforations, time to flatus [days], and early unplanned reoperations.
RESULTS: In our meta-analysis, 14 studies (participants = 37.007) were included: 1 randomized controlled trial, 2 matched studies, and 11 unmatched studies. Results of our primary analyses show no significant differences in core outcome parameters (postoperative mortality, iatrogenic bowel perforations, length of postoperative stay, severe postoperative complications, early readmissions). In sensitivity analyses, laparoscopic surgery favored open adhesiolysis in postoperative mortality (relative risk [RR], 0.36; 95% CI, 0.29-0.45), length of postoperative hospital stay (mean difference [MD], -4.19; 95% CI, -4.43 to -3.95), operative time (MD, -18.19; 95% CI, -20.98 to -15.40), time to flatus (MD, -0.98; 95% CI, -1.28 to -0.68), severe postoperative complications (RR, 0.51; 95% CI, 0.46-0.56) and early unplanned reoperations (RR, 0.82; 95% CI, 0.70-0.96).
CONCLUSION: Results of this systematic review indicate that laparoscopic surgery for ASBO is safe and feasible. Laparoscopic surgery is not associated with better or worse postoperative outcomes compared with open adhesiolysis. Future research should focus on the correct selection of those patients who are suitable for laparoscopic approach and may benefit from this approach.
LEVEL OF EVIDENCE: Systematic Review/Meta-analysis, Level III.

PMID 32195994  J Trauma Acute Care Surg. 2020 Jun;88(6):866-874. doi: ・・・
著者: Ioannis Tierris, Constantinos Mavrantonis, Constantinos Stratoulias, George Panousis, Afrodite Mpetsou, Nicolaos Kalochristianakis
雑誌名: Surg Endosc. 2011 Feb;25(2):531-5. doi: 10.1007/s00464-010-1206-8. Epub 2010 Jul 7.
Abstract/Text BACKGROUND: Acute small bowel obstruction (SBO) is a relatively common cause of emergency hospital admission, most frequently due to postoperative adhesions. With increased experience and technical advances in laparoscopic surgery, the laparoscopic management of acute SBO has become feasible and potentially superior to the open approach. This retrospective study presents the authors' experience with laparoscopic treatment of SBO over a 6-year period to assess the feasibility, efficacy, and clinical outcome of this therapeutic method and to present the author's methodology.
METHODS: From April 2003 to January 2009, 32 patients hospitalized in the author's department for acute SBO underwent elective laparoscopic treatment after failure of conservative measures. Standard laparoscopic techniques and instruments were used.
RESULTS: Postoperative adhesions were identified in 62.5% of patients (n=20) as well as tumor (n=3), incarcerated ventral hernia (n=4), incarcerated femoral hernia (n=3), internal hernia (n=1), and Crohn's disease (n=1). The conversion rate was 18.7% (n=6), and the postoperative complication rate was 3.25% (n=1). The mean operative time was 78 min. Bowel function returned after a mean of 3.2 days, and the mean hospital stay was 4.6 days.
CONCLUSIONS: The laparoscopic treatment of acute SBO is an attractive alternative to the open approach. However, it must be kept in mind that surgery longer than 120 min is a significant predictor of postoperative morbidity, that bowel injury may be missed at the time of operation and can be avoided with improved surgical techniques and appropriate instrumentation, that lysis of all intraabdominal adhesions is unnecessary, and that a low threshold for conversion should be maintained, especially in cases of severe, dense, extensive adhesions.

PMID 20607558  Surg Endosc. 2011 Feb;25(2):531-5. doi: 10.1007/s00464-・・・
著者: Ville Sallinen, Salomone Di Saverio, Eija Haukijärvi, Risto Juusela, Heidi Wikström, Vesa Koivukangas, Fausto Catena, Berndt Enholm, Arianna Birindelli, Ari Leppäniemi, Panu Mentula
雑誌名: Lancet Gastroenterol Hepatol. 2019 Apr;4(4):278-286. doi: 10.1016/S2468-1253(19)30016-0. Epub 2019 Feb 12.
Abstract/Text BACKGROUND: Although laparoscopic adhesiolysis for adhesive small bowel obstruction is being done more frequently, it is not widely accepted due to the lack of supporting evidence of its superiority over an open approach and concerns regarding its benefits. We aimed to investigate whether laparoscopic adhesiolysis was a superior treatment for adhesive small bowel obstruction compared with an open approach in terms of length of postoperative hospital stay and morbidity.
METHODS: In this international, multicentre, parallel, open-label trial, we randomly assigned patients (1:1) aged 18-95 years who had adhesive small bowel obstruction that had not resolved with conservative management to have either open or laparoscopic adhesiolysis. The study was done in five academic university hospitals and three community (central) hospitals in two countries (Finland [n=3 academic university hospitals; n=3 community hospitals] and Italy [n=2 academic university hospitals]). We included only patients with high likelihood of a single adhesive band in the trial; additionally, patients who had an anaesthesiological contraindication, were pregnant, living in institutionalised care, or who had a hospital stay of more than 1 week before the surgical consultation were excluded from the trial. The randomisation sequence was generated using block randomisation, with randomly varied block sizes and stratified according to centre. The primary outcome was postoperative length of hospital stay assessed at time of discharge in the modified intention-to-treat population.
FINDINGS: Between July 18, 2013, and April 9, 2018, 566 patients were assessed for eligibility, of whom 104 patients were randomly assigned to the open surgery group (n=51) or to the laparoscopy group (n=53). Of these patients, 100 were included in the modified intention-to-treat analyses (49 in the open surgery group; 51 in the laparoscopy group). The postoperative length of hospital stay for open surgery group was on average 1·3 days longer than that in the laparoscopy group (geometric mean 5·5 days [range 2-19] vs 4·2 days [range 1 -20]; ratio of geometric means 1·31 [95% CI 1·06-1·61]; p=0·013). 21 (43%) patients in the open surgery group and 16 (31%) patients in the laparoscopy group had postoperative complications (Clavien-Dindo any grade) within 30 days (odds ratio 0·61 [95% CI 0·27-1·38]; p=0·23). One patient died in each group within 30 days.
INTERPRETATION: Laparoscopic adhesiolysis provides quicker recovery in selected patients with adhesive small bowel obstruction than open adhesiolysis.
FUNDING: Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, Martti I Turunen Foundation, and governmental (Finland) competitive research funds (EVO/VTR/TYH).

Copyright © 2019 Elsevier Ltd. All rights reserved.
PMID 30765264  Lancet Gastroenterol Hepatol. 2019 Apr;4(4):278-286. do・・・
著者: Victor W Fazio, Zane Cohen, James W Fleshman, Harry van Goor, Joel J Bauer, Bruce G Wolff, Marvin Corman, Robert W Beart, Steven D Wexner, James M Becker, John R T Monson, Howard S Kaufman, David E Beck, H Randolph Bailey, Kirk A Ludwig, Michael J Stamos, Ara Darzi, Ronald Bleday, Richard Dorazio, Robert D Madoff, Lee E Smith, Susan Gearhart, Keith Lillemoe, Jonas Göhl
雑誌名: Dis Colon Rectum. 2006 Jan;49(1):1-11. doi: 10.1007/s10350-005-0268-5.
Abstract/Text INTRODUCTION: Although Seprafilm has been demonstrated to reduce adhesion formation, it is not known whether its usage would translate into a reduction in adhesive small-bowel obstruction.
METHODS: This was a prospective, randomized, multicenter, multinational, single-blind, controlled study. This report focuses on those patients who underwent intestinal resection (n = 1,701). Before closure of the abdomen, patients were randomized to receive Seprafilm or no treatment. Seprafilm was applied to adhesiogenic tissues throughout the abdomen. The incidence and type of bowel obstruction was compared between the two groups. Time to first adhesive small-bowel obstruction was compared during the course of the study by using survival analysis methods. The mean follow-up time for the occurrence of adhesive small-bowel obstruction was 3.5 years.
RESULTS: There was no difference between the treatment and control group in overall rate of bowel obstruction. The incidence of adhesive small-bowel obstruction requiring reoperation was significantly lower for Seprafilm patients compared with no-treatment patients: 1.8 vs. 3.4 percent (P < 0.05). This finding represents an absolute reduction in adhesive small-bowel obstruction requiring reoperation of 1.6 percent and a relative reduction of 47 percent. In addition, a stepwise multivariate analysis indicated that the use of Seprafilm was the only predictive factor for reducing adhesive small-bowel obstruction requiring reoperation. In both groups, 50 percent of first adhesive small-bowel obstruction episodes occurred within 6 months after the initial surgery with nearly 30 percent occurring within the first 30 days. Additionally no first adhesive small-bowel obstruction events were reported in Years 4 and 5 of follow-up.
CONCLUSIONS: The overall bowel obstruction rate was unchanged; however, adhesive small-bowel obstruction requiring reoperation was significantly reduced by the use of Seprafilm, which was the only factor that predicted this outcome.

PMID 16320005  Dis Colon Rectum. 2006 Jan;49(1):1-11. doi: 10.1007/s10・・・
著者: David E Beck, Zane Cohen, James W Fleshman, Howard S Kaufman, Harry van Goor, Bruce G Wolff, Adhesion Study Group Steering Committee
雑誌名: Dis Colon Rectum. 2003 Oct;46(10):1310-9. doi: 10.1097/01.DCR.0000089117.62296.E4.
Abstract/Text INTRODUCTION: Seprafilm adhesion barrier (Seprafilm) has been proven to prevent adhesion formation after abdominal and pelvic surgery. This article reports safety results, including the postoperative incidence of abdominal and pelvic abscess and pulmonary embolism, from a large, multicenter trial designed to evaluate the safety and effectiveness of Seprafilm for reduction of adhesion-related postoperative bowel obstruction after abdominopelvic surgery.
METHODS: A total of 1791 patients participated in this prospective, randomized, multicenter, multinational, single-blind, controlled study in patients undergoing abdominopelvic surgery, the majority of whom had inflammatory bowel disease. Just before closure of the abdomen, patients were randomized to a Seprafilm or no-treatment control group. Patients received an average of 4.4 and as many as 10 Seprafilm adhesion barriers applied to organs and tissue surfaces that sustained direct surgical trauma and to suspected adhesiogenic surfaces. Complications that occurred within the first month after surgery were evaluated.
RESULTS: During the safety evaluation period, the difference between the Seprafilm and control groups for the incidence of abscess (4 vs. 3 percent, respectively) or pulmonary embolism (<1 percent in both groups) was not statistically significant (P > 0.05). Foreign body reaction was not reported in either group. Fistula (2 vs. <1 percent) and peritonitis (2 vs. <1 percent) occurred more frequently (P CONCLUSIONS: This study confirmed the safety of Seprafilm adhesion barrier with respect to abdominal abscess, pelvic abscess, and pulmonary embolism when administered to patients undergoing abdominopelvic surgery. Foreign body reaction was not reported for any patient. However, wrapping the suture or staple line of a fresh bowel anastomosis with Seprafilm should be avoided, because the data suggest that this practice may increase the risk of sequelae associated with anastomotic leak.

PMID 14530667  Dis Colon Rectum. 2003 Oct;46(10):1310-9. doi: 10.1097/・・・
著者: Jun Watanabe, Fumio Ishida, Hideyuki Ishida, Yosuke Fukunaga, Kazuteru Watanabe, Masanori Naito, Masahiko Watanabe
雑誌名: Surg Today. 2019 Oct;49(10):877-884. doi: 10.1007/s00595-019-01816-7. Epub 2019 Apr 29.
Abstract/Text PURPOSE: The aim of this prospective multi-center registry was to evaluate the safety and clinical performance of INTERCEED® in laparoscopic colorectal surgery.
METHODS: This study was a prospective, multi-center, single-arm registry wherein patients who received INTERCEED® in laparoscopic colorectal surgery were registered consecutively (UMIN-CTR 00001872). The primary outcome was the incidence rate of postoperative adhesive small intestinal obstruction within 6 months. The secondary outcomes were reoperation related to postoperative bleeding and anastomotic leak, surgical site infection (SSI) and anastomotic leak.
RESULTS: Between March 2012 and March 2015, a total of 202 patients were enrolled from six institutions. INTERCEED® was not applied in two patients, so 200 patients were analyzed using the full analysis set population. The incidence rate of postoperative adhesive intestinal obstruction was 1.0% (2/200). The total SSI rate was 3.5% (7/200), the deep incisional SSI rate was 0.0% (0/200), and the organ SSI rate was 0.0% (0/200). The incidence of anastomotic leak was 1.0% (2/200). Reoperation was performed in two cases: one for anastomotic leak and the other as cardiac surgery due to heart disease.
CONCLUSIONS: Using INTERCEED® in laparoscopic colorectal surgery is safe and may be useful for preventing postoperative adhesive small intestinal obstruction.

PMID 31037393  Surg Today. 2019 Oct;49(10):877-884. doi: 10.1007/s0059・・・

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