肥満症，2型糖尿病に対する腹腔鏡下スリーブバイパス術を安全に実施するために施設内に集中治療室は必須か

Laparoscopic sleeve gastrectomy with duodenojejunal bypass can be performed safely in a secondary health care center that has no intensive care unit but has a dedicated service

◆要旨：［背景］腹腔鏡下スリーブバイパス術（LSG-DJB）は高度肥満症に対して高い減量，血糖改善効果を有する．［目的］LSG-DJBの安全な実施に施設内に集中治療室（ICU）が必須かを検証する．［方法］麻酔リカバリー室（PACU）を有し，ICUを有さない単一施設において，LSG-DJBが行われた251例を対象に術後早期，晩期合併症を抽出した．［結果］全例手術室で抜管し，PACUに短期滞在後，一般病棟に帰室した．再挿管例はなかった．早期合併症は13名（5.2％），晩期合併症は8名（3.2％）に発生した．提携病院ICUへの患者搬送例，死亡例はなかった．［結論］経験豊富なチームのもとで，ICUに準じた管理ができる体制を整えていれば，LSG-DJBの安全な実施にICUは必須ではない．

　［Background］ Laparoscopic sleeve gastrectomy with duodenojejunal bypass （LSG-DJB） is a bariatric procedure which is shown to be effective for weight loss and glycemic control in morbidly obese patients. The procedure is the combination of sleeve gastrectomy and proximal intestinal bypass, thus technically challenging since two totally laparoscopic intracorporeal anastomoses are required. ［Aims］ To validate whether LSG-DJB can be performed safely in a secondary health care center （SHCC） without an on-site ICU. ［Methods］ Consecutive 251 patients undergoing LSG-DJB at a single SHCC without an on-site ICU from April 2007 to December 2017 were included in the study. An independent evaluator retrospectively reviewed the medical records and extracted the early （within 30 days） and the late （more than 30 days up to 2 years） severe complications. ［Results］ After LSG-DJB, all patients were extubated in the operating theater, stayed at the post-anesthesia care unit （PACU） for a short period and were transferred to the general ward. No patient required re-intubation. Early complications occurred in 13 patients （5.2％） including 9 postoperative hemorrhages, 3 leakages and 1 wound infection. Late complications occurred in 8 patients （3.2％） including 4 sleeve strictures associated with intractable GERD, 2 bowel obstructions, 1 internal hernia and 1 hemorrhagic marginal ulcer. No patient required inter-hospital transfer to a tertiary health care center （THCC） for unplanned ICU care and there was no mortality. ［Conclusion］ With proper patient selection, experienced health care team and an appropriate system with smooth connection to affiliated THCC, LSG-DJB can be performed safely in a SHCC without an on-site ICU.