28. 低栄養・栄養障害合併例における食道癌手術と周術期管理

Surgery and Perioperative Management of Esophageal Cancer Patients with Malnutrition

術前に低栄養に陥った状態で手術を行うと術後の合併症が増加することは知られており，食道癌手術においても多くの報告がある1，2）．食道は細長い管腔臓器のため，進行食道癌の場合は容易に狭窄して閉塞をきたし，経口摂取が障害され，低栄養や体重減少をきたすことが多い．術前治療を施行する症例の場合，化学療法や化学放射線療法の副作用によりさらなる経口摂取不良となる．食事摂取量が低下しやすい状況においては異化が亢進し，筋肉量は減少する．筋肉量や筋力が低下した状態はサルコペニアと呼ばれており，術前のサルコペニアは術後合併症の発症や予後に関連するとの報告もあり注目されている3）．近年は術後回復強化（ERAS）の概念を反映したクリニカルパスが多くの施設で取り入れられており，低栄養の患者に対して術前から多職種介入による周術期管理が重要となってきている．本稿では食道癌患者の栄養アセスメントの方法および栄養障害患者に対する栄養学的介入と周術期管理について述べる．

The incidence of postoperative morbidity and mortality are higher in patients with preoperative malnutrition in esophageal cancer patients. Oral intake tends to decrease during preoperative chemotherapy, and nutritional status is likely to worsen. When nutrition intake decreases, catabolism increases and muscle mass can decrease. It has been reported that related to preoperative sarcopenia and the onset and prognosis of postoperative complications. It has been reported to be associated with preoperative sarcopenia and the incident of postoperative complications and prognosis. Early nutritional assessment and interventions should improve nutritional status before surgery. Amino acid intake and exercise therapy improve exercise capacity such as walking. It is expected that a synergistic effect on the improvement of long-term prognosis by nutrition therapy and exercise therapy. Our hospital has introduced a enhanced preoperative nutrition rehabilitation program for undernourished patients. Immuno-nutrition therapy, exercise therapy, and postexercise branched-chain amino acid preparations are administered. During surgery for such malnourished patient, it is necessary to minimize the surgical invasion and to avoid complications. It is important to have continuous nutritional evaluation, intervention and rehabilitation by various occupations from the initial diagnosis to the perioperative period as well as during outpatient follow-up after discharge.