Conflict of Interest of Hideki Kawanishi I have/had an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Honoraria of presentations by Terumo Corporation KISSEI PHARMACEUTICAL CO.,LTD Bayer Yakuhin Japan CO.,LTD
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Conflict of Interest of Hideki Kawanishi
I have/had an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Honoraria of presentations by Terumo Corporation KISSEI PHARMACEUTICAL CO.,LTD Bayer Yakuhin Japan CO.,LTD
• We recommend that patients with EPS should be referred or discussed
early with units who have expertise in EPS surgery. Surgery should be
performed by teams experienced in EPS surgery (GRADE 1B).
ISPD-GL
• It must be stated, though, that for surgical results to be successful, the
surgical team must have a thorough understanding of the pathology of
EPS. Such surgery should therefore only be done in specialist regional
centers that can provide appropriate surgical training and patient support.
Indication of surgery for EPS
Severe bowel obstruction: risk of bowel perforation
Malnutrition
Repeated obstruction symptoms
Jejunostomy Death
Time on PD 234 months
Scheme of EPS surgery
• Total enterolysis +
• Confirmation by Miller-Abbott’s Ileus tube
• Noble’s plications
Conventional
• +Jejuno-colostomy Sever obstruction
• Decompression by Percutaneous endoscopic gastrostomy (PEG)/PEG-J + home-TPN
Conservative
EPS surgery, Intestine cocooned
EPS surgery Peritoneal adhesions by repeated lysis of fibrin membranes
with a sharp instrument
EPS surgery Cut the fibrin membrane
EPS surgery Adhesiolysis of the mesenteric side is performed first, and
finally, encapsulated intestinal loops are lysed.
EPS surgery To identify the site of stenosis and/or injury part of intestine,
we have been inserting an Miller-Abbott’s ileus tube
balloon
EPS recurrent after surgery Probability of remaining EPS recurrence free
0
.2
.4
.6
.8
1 E
PS
rec
urr
ence
fre
e
0 20 40 60 80 100 120 140 160 180
Follow up (months)
1yr 22%
Enterolysis only:106
Recurrence:30 (28.3%)
Prevention of re-obstructive symptoms (recurrent)
Fixation of small bowel after adhesiotmy
Noble’s plication methods: Suture of small bowel
Noble TB, Am J Surgery 1937: 35, 41
KH, PD duration 115 m; Noble’s plication method
Treitz’s ligament
Ileum end
The prevents of passage disturbance and
escape into and adhesion in the pelvic
cavity
In the cases of risk of re-adhesion and/or Incomplete
enterolysis ; Side to side Jejuno-colostomy
Side to side Jejuno-colostomy
Incomplete enterolysis
Calcification
HK, PD duration 132 m
Side to side Jejuno-colostomy
EPS surgical video, HI, 2016/1/19
PD duration : 116 months, EPS caused by peritoneal sclerosis
EPS : 113 months after catheter, Operation : 12.8 months after EPS
Acidic ⇒ Neutral PDF
EPS surgical video, HI, 2016/1/19
PD duration : 116 months, EPS caused by peritoneal sclerosis
EPS : 113 months after catheter, Operation : 12.8 months after EPS
Acidic ⇒ Neutral PDF
石原
Survival of the EPS surgery, Cases 243, Total surgeries 318 times
1 2 3 5 8 years
Actuarial survival 91 83 77 66 53 %
Mortality EPS related death 5 10 13 20 28 %
Survival rates after diagnosis
0.0
0.2
0.4
0.6
0.8
1.0
0 24 48 72 96 120 144 168 192 216 240 264 288
Cu
mu
lati
ve
surv
ival
Time after diagnosis (months)
All cause death
EPS related death
Assessment of severity of intestinal damage The peritoneal calcification grade on CT
Grade 1<50% Grade 2 50-80% Grade 3 ≥80%
Grade 1 Grade 2 Grade 3
Assessment of severity of intestinal damage Degeneration/deterioration grade of small intestinal wall Grade 1: mild abnormal and soft; Grade 2: whole circumference/partial degeneration in several part, especially in the ileum; Grade 3: highly degenerated in almost all aria, Upper figure; before enterolysis, lower figure; after enterolysis
Kaplan-Maier survival analysis for assessment of severity of intestinal damage
Mortality curve for EPS-related death,
a) evaluation of peritoneal calcification grade (log rank test, grade 1 and 2, p<0.0015, grade 1 and
3, p<0.0065), G1:169, G2:27, G3:47
b) evaluation of degeneration grade of small intestinal wall, (log rank test, grade 1 and 2,
p<0.0452, grade 1 and 3, p<0.0008, grade 2 and 3 p<0.0058). G1:34, G2:163, G3:46
0
0.2
0.4
0.6
0.8
1.0
0 48 96 144 192 240 288 Time after diagnosis (months)
Peritoneal calcification, grade
Cu
mu
lati
ve
surv
ival
Grade 1
2 3
0 48 96 144 192 240 288 0
0.2
0.4
0.6
0.8
1.0
Time after diagnosis (months)
Degeneration of intestinal wall, grade
Cu
mu
lati
ve
surv
ival
Grade 1
2
3
Conclusion
EPS surgical experience and outcomes during 24 years in a
single center were reported; patients who undergo the
surgery showed better outcomes.
The increase in surgical treatment rate in the world promoted
improvements in countermeasures against and better
understanding of EPS.
Currently, EPS is no longer recognized as a fatal
complication.
Acknowledgment
Prof, Yoshindo Kawaguchi Prof Dimitrios Oreopoulos, Pass away April 2012