AOKI, YOZO

KATSUMI, MASAHARU

OHTA, MASATAKA

SAKAGUCHI, MASAHIRO

SAKAMOTO, YUKITOMO

SHIMADA, KOSUKE

TAKEI, NOBUO

Kyoto University Research Information Repository

TitleApplication of Solid Low Residue Diet Consisting Mainly ofElemental Diet in Colorectal DiseasesAuthor(s)AOKI, YOZO; OHTA, MASATAKA; SAKAMOTO,YUKITOMO; SHIMADA, KOSUKE; SAKAGUCHI,MASAHIRO; TAKEI, NOBUO; KATSUMI, MASAHARUCitation日本外科宝函 (1986), 55(2): 358-366Issue Date1986-03-01URL http://hdl.handle.net/2433/208608RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversityArch Jpn Chir 5(2), 358～36, Marz, 1986 臨床Application of Solid Low Residue Diet Consisting Mainly of Elemental Diet in Colorectal Diseases Yozo AoKI, MASATAKA OHTA, YuKITOMO SAKAMOTO, KosuKE SHIMADA, MASAHIRO SAKAGUCHI, NOBUO TAKEI and MASAHARU KATSUMI Department of Gastroenterologic乱lSurgery, Wakayama Medical College Received for Publication, Dec. 24, 1985. Summary An application of our modified elemental diet (ED) to Crohn’s disease, low output fistula raused by anastomotic leak after colonic surgery‘and pre-and postoperative use in colorectal surgeηr are presented. The modified ED. which had been devised to make the patients easier to take it orally, was prepared and cooked by adding ED with wheat flour in the ratio of 3 to1. The clinical usefullness of the modified ED became obvious in the treatment of the above patho-logical conditions. The limit in the use of this modified ED for preoperative colonic preparation are also discussed. Introduction Elemental diet (ED) is widely used for the treatment of inflammatory bowel diseases and colorectal surgery. In this paper, application of our modified ED to Crohn’s disease, low output fistula caused by anastomotic leak after colonic surgery, and pre-and postoperative use in colo-rectal surgery are presented. Materials and Methods 1. Preparation of modified ED: Some solid or liquid foods mainly consisting of ED were devised to make the patient easier to take it by mouth1>. In preparing solid foods, ED (ElentalR, Azinomoto Co. Ltd.ラJapan)was mixed with wheat flour (HeartR, Nippon Flour Production Co. Ltd・，Japan), in the ratio of 3to1, and some sw田tners,butter and hen yolk were added to it. Then the mixture was cooked. Key words: Elemental diet, Crohn’s disease, Low output fistula, Colorectal cancer. Preoperative colonic prepara・ t10n. 索引語：成分栄養，クローン病，消化管痩，結腸直腸癌，大腸術前準備Present address: Department of Gastroenterological Surgery, Wakayama Medical College, 7-1, Wakayama Ciザ，Wakayama 640. Japan APPLICATION OF ELEMENTAL DIET IN COLORECTAL DISEASES 359 Figure. 1. Some kinds of our modi五edEDs and liquid diets. 1: cookies; 2: steamed cakes; 3: doughn_uts; 4: hot cakes; 5: fruit juice; 6: blanc-mange; 7: potage; 8: pudding. Liquid diets were prepared by adding ED to fruit-flavoured juice or clear soup. Some of these diets are exhibited in Figure 1. 2. Liking test: Liking test for these foods was done in a total of 89 subjects (37 healthy volunteers; 52 hos pitalized patients for abdominal surgery; 46 male, 43 female) to estimate a possibility of its clinical use. 3. Patients studied: The subjects included in this study were 5 patients with Crohn’s disease and 76 patients undergoing colorectal surgery. 4. Patients with Crohn's disease: In patients with Crohn’s disease, after their admission、theywere checked their physical states, clinical, anthropometric and biochemical assessments, and received salicylasosulfapyridine (SalazopyrinR, Green Cross Pharmaceutical Co. Ltd., Japan) and metronidazole (FragylR, 360 日外宝第5巻第2号（昭和61年3月）Shionogi Pharmaceutical Co. Ltd., Japan). They took a total of 2000 kcal of the modified ED with liquid diets. Water, tea and candy were allowed at will. Ingestion period of the diet in 5 cases ranged from 16 to 160 days. As one of the parameters of disease improvement, Crohn’s Disease Activity Index (CDAI). which had been proposed by BEST et al. 4> in 1976. was adopted. 5. Patients with colorectal surgery: For pre-and postoperative patients with colorectal disease, the modified ED with or without liquid diets was aまministeredand the usefulness of this food was evaluated from the standpoint of colonic preparation and bowel rest. No antibiotics were administered preoperatively. 6. Calculation of index of stenosis: The index of stenosis was measured according to the method of McADAMS et al.13> from the findings of preoperative barium enema to estimate the degree of preoperative colorectal stricture due to the lesion. 7. Linear discriminant function for colonic preparation: A linear discriminant function was devised to seek the requisite pericd of preoperative inges-tion of the modified ED with or without liquid diet to get an ideal colonic preparation. Results 1. Liking test : Sixty-three of 89 subjects (70.l %) well tolerated the modified ED. Figure. 2. Pre-(left) and posttherapeutic (right) pictures of the colon in patient with Crohn’s disease. 361 The efect of the modified ED on patients with Crohn’s disease: Five patients with this disease were administered the modified ED as a part of the conservat司ive treatments. One of our cases who responded well to it is as follows. The patient was a 14ぅrear-oldfemale and admitted to our department with a chief complaint of perianal pain. Three years before her admission, she had been operated on for anal fistula. After the operation, she had received some remedies for Crohn’s disease because of a fever and lower abdominal pain. On her admission, she had a recurred anal fistula and her CDAI value amounted to 228 (normal range豆150). The patient stopped normal diet and received the modified ED with liquid diets in addition to some medical treatments. Figure 2 shows the pre司and posttherapeutic pictures of the colon. On rentgenogram, her remission was not so remark-able. Her clinical course is shown in Figure 3, and her CDAI value gradually diminished, and amounted to 121 after 3 months, 88 after 5 months, respectively. During this period, her weight gain was as much as 13 kg. Similar results were obtained in the remainders. The efect of the modified ED on patients with low output fistula: The modified ED was applied to 4 patients with low output fistula. one of these cases is as follows. The patient was a 47-year-old man and underwent anterior resection for his rectal cancer. His postoperative course was uneventful and on the 8th postoperative day, he was given normal postoperative diet. On the next day, fecal discharge was recognized through the drain which had been put near the anastomosis. Slight leucocytosis was observed, and a minor leak was suspected. He was given the modified ED with liquid diets alone. The discharge gradually diminished, and became minimum one week later. After al, this untoward complication spontaneously subsided. His clinical course is summarized in Figure 4. We experienced the other 3 cases with low putput fistula and could obtain good results by the The clinical course in APPLICATION OF ELEMENTAL DIET IN COLORECTAL DISEASES 2. 3. 400 ｛?｝???????? ?100 ??????｛ ，???????、。〔???｝??。 。 ? ? ?? ?Salicylaz。sulfapyridine(3g/day) 陰蕊:ssss:蕊S蕊ミ芯蕊S蕊~部SS>:S:蕊芯良部芯Sぼ芯S蕊$蕊~蕊$蕊S蕊$ミSお求蕊ミヨLiquid diet & modified ED (2000 Cal/day) i:;；：；：；：；；；；；：；在日2・：i：宇：よミ：；：；：；：誌：：；：；・i：日中；：；：；：；：；：；：・中討中：：：：：：；；：：宇ぺ：；：；：；：：；：；市：：；：：；：；：；：；：；：主，：；：；：；：・23 4 Time Cm。nths)Clinical course in patient with Crohn’s disease. 6 5 Fi~ure. 3. 2 0 1 362 日外宝第55巻第2号（昭和61年3月）• 9200 ＼、5300．旬、 .4300Leucocyte count C/mm3) .4300 Fecal discharge Liquid diet & modified ED Normal diet 49 Weight (kg) 2 Time (weeks) Fi~ure. 4. Clinical course in patient with low output fistula. administration of the modified ED2> 4. The use of modified ED for preoperative colonic preparation: Seventy-six patients were included in this study. Our standard plan of preoperative colonic preparation is as follows. Patients. who were scheduled to be operated on for their colorectal disease, received laxative, i.e., 250 ml of 34% magnesium citrate solution (MagcorolR, Horii Pharmaceutical Co. Ltd., Japan), 4 days before operation and were followed by ingestion of 2000 kcal of the modified ED and liquid diet. On the previous night of operation, they received the second administration of the same laxative. The outline of the standard procedure is shown in Figure 5. 5. Postoperative use of the modified ED in colorectal surgery: Postoperatively, the patients were maintained with total parenteral nutrition (TPN) for the 五rst1 to 2 weeks, and thereafter, followed by the administration of the modified ED for the purpose of decreasing the intraluminal pressure of the anastomosed intestine, nutritional support, ????????? ? ? ? ? ???????』?Liquid diet & modified ED ????????????????????』?－麗臨輯臨悪霊 Operation 4 3 2 。， ， Preoperative days Figure. 5. Outline of our standard procedure for preoperative colonic preparation. 363 APPLICATION OF ELEMENTAL DIET IN COLORECTAL DISEASES Liquid diet & modified ED ?－：・：：：：：：：手：：：ヌ？：:3－ ・；：；：；吟Operation Postoperative weeks Outline of our standard course for postoperative nutritional support. 1～2 Jt 1～2 Figure. 6. and provision for the initiation of normal postoperative diet. in Figure 6. Retrospective study of preoperative colonic preparation: Preoperative colonic preparation with the modified ED was sometimes unsatisfactory be-cause stenosis of the colon or rectum casued by the lesion was too intense. Hence, the result of colonic preparation in 76 patients was plotted retrospectively in the relation between each index of stenosis (y) and ingestion period of the modified ED (x). In the Figure 7, an open circle shows the case in whom a good preparation has been obtained司anda closed one a poor. On the basis of these data, a "linear discriminant functionぺy=4.2x+52.0, was obtained to seek the requisite period of the ingestion of the modified ED to get an ideal colonic preparation by calculat ing the index of stenosis. The outline of this course is shown 6. ??? ? ? 。 ??。。． ． ． ． y 100 80 60 （??）?????? ? ? ?。。。。Colonic preparation 。：good・；poor。。。~ 。00 。。。。40 20 。。。。x Ingestion of elemental diet (days) Fi邑UI・e.7. Correlation between index of stenosis and ingestion period of the modified ED in colonic preparation. 10 8 6 4 2 。364 日外宝第55巻第2号（昭和61年3月）Discussion ED stems from space diet26> and is applied for a wide variety of clinical situations in which it has sometimes proven therapeutics. However, poor palatability of the diet makes the patients di伍cultto sustain daily oral intake16>. This unpalatability results from the organic taste and smell of the amino acid mixtures and some of the vitamins contained in it, and flavoring agents are often added to ED when patients try oral intake. Such an unpalatability sometimes leads to use TPN in preoperative bowel preparation, inflammatory bowel disease, enteral fistula, postoperative state and other pathological conditions. However, complication of catheter insertion, great vein thrombosis, septic and metabolic complications are encountered in a few patients with TPN19>. This is the reason why we devised low residue diet by mixing ED with small amount (25%) of wheat flour to make patients easier to take by mouth. Our liking test tried in 89 subjects shows possibility for clinical use of this modified ED, solid low residue diet. Medical treatments for Crohn’s disease are very di伍cult. Though sulfasalazine and pre-donisone have generally been accepted as the standard medical treatment for this pathological condition, some cases are resistant to these remedies. On the other hand, sugery often results in a good outcome‘but recurrence of active disease is not so uncommon 8>. Nutritional treatment by TPN11,12,14,1s,21,2a> or EDa,10,11i, or a combination of both is reported to be effective in the disease. ED iswell absorbed by the small bowel of patients with Crohn’s disease, and may bring about a remission. Our diet is supposed to play one of the important roles in the remission of the disease activity, and later in the nutritional supplement. ED has been most successful in the management of low output fistula2,20,22>. BuRv6> re-ported that an overall spontaneous closure was achieved in 70% of such patients. Being predigested, ED does not bring forth copious amount of digestive juices, and containing no wastes while being completely absorbable, there is minimal fecal matter to pass over the fistula25>. By allowing the intestine and fistula to rest, ED provides needed nutrition and produces the favorable outcome0>. In this sense, oral modified ED as well as TPN makes a contribution to the healing of low output fistula. Although many authors agree that much fecal mass in the colon and peritoneal soilage with colonic contents during operation are sometimes followed by increase of postoperative com・plication。，a,IB>,the best method of preparing the colon for surgery stil remains unsolved. There has been controversy concerning ED administration in the preoperative bowel preparation, because oral ED failed to comfirm the remarkable reductions in bacterial concentrations7>. Since experimental and clinical evidence indicates that suture line recurrence of tumor is more common when antibiotics are used to prepare the bowel for surgeη，24>, oral modified ED plus liquid diet without any antibiotics was carried out in this study. However, in patients with in・tense stenosis of the colon or rectum due to the lesion, colonic preparation with the modified ED was sometimes unsatisfactory. To solve this problem司 wedevised a “linear discriminant func・ tion" to perceive the requisite period to take this food in order to get an ideal colonic preparation only by calculating the preoperative index of stenosis. The function also shows that we must APPLICATION OF ELEMENTAL DIET IN COLORECTAL DISEASES 365 abandon this diet and adopt the other colonic preparation when the index is too large. This paper was presented at the XXIVth Biennial Congress of International College of Surgeons, Manila, Philippines, December 3 to 7, 1984. References 1) Aoki Y, Takei N, et al: Elemental diet for pre-and postoperative managements in colonic surgery. I. Its menu and method of administration. Jpn J Gastroenterol Surg 12: 553-557, 1979. (in Japanese) 2) Aoki Y, Miki Y, et al: Application of elemental diet to management for “low output fistula’＇ J Jpn Soc Clin Surg 41: 691-695, 1980. (in Japanese) 3) Axelsson C, Jarnum S, et al: Assessment of the therapeutic value of an elemental diet in chronic inflam-matory bowel disease. Scand J Gastroenterol 12: 89 95, 1977. 4) Best WR, Beckel JM, et al: Development of a Crohn’s disease activity index. National cooperative Crohn’s disease study. Gastroenterology 70: 439-444, 1976. 5) Bury KD: Elemental diets. In Total parenteral nutrition edited by Fischer JE, Boston, Little, Brown and Company. 1976, p. 395-411. 6) Bury KD, Stephens RV, et al: Use of a chemically defined, liquid, elemental diet for nutritional manage-ment of五stulasof the alimentary tract. Am J Surg 121: 174 183, 1971. 7) Crowther JS, Drasar BS, et al: The effect of a chemically de五neddiet on the faecal flora and faecal steroid concentration. Gut 14・790793, 1973. 8) Greenstein AJ, Sachar DB, et al: Reoperation and recurrence in Crohn’s colitis and ileocolitis. N Engl J Med 293: 685-690, 1975. 9) Herter FP: Preparation of the bowel for surgery. Surg Clin North Am 52: 859 870, 1972. 10) Hiwatashi N, Suzuki K, et al: Evaluation of enteral hyperalimentation in the management of Crohn’s disease. In Parenteral and enteral hyperalimentation edited by Ogoshi S. and Okada A, Amsterdam, New York, Oxford, Elsevier Science Publishers B.V. 1984, p. 188 204. 1) Kelts DG, Grand RJ, et al: Nutritional basis of growth failure in children and adolescents with Crohn's disease. Gastroenterology 76: 720-727, 1979. 12) Layden T, Rosenberg J, et al: Reversal of growth arrest in adolescents with Crohn's disease after parenteral alimentation. Gastroenterology 70: 1017 1021, 1976. 13) McAdams AJ, Meikle AG, et al: One layer or two layer colonic anastomoses? Am J Surg 120: 546 550, 1970. 14) Muller JM, Keller HW, et al: Total parenteral nutrition as the sole therapy in Crohn’s disease a prospective study. Br J Surg 70・40-43,1983. 15) Nichols RL, and Condon RE: Preoperative preparation of the colon. Surg Gynecol Obstet 132: 323-337‘ 1971. 16) 0’Morain C, Segal AW, et al: Elemental diet in treatment of acute Crohn’s disease. Br Med J 281: 1173 1175, 1980. 17) 0‘Morain C, Segal AM, et al: Elemental diet in acute Crohn’s disease. Arch Dis Ch臼d53: 44-47, 1983. 18) Rosenberg IL, Graham NG, et al: Preparation of the intestine in patients undergoing m句orlarge bowel surgery, mainly for neoplasms of the colon and rectum. Br J Surg 58: 266-169, 1971. 19) Ryan JA Jr: Complications of total parenteral nutrition. In Total parenteral nutrition edited by Fischer JE, Boston, Little, Brown and Company 1976, p. 55-100. 20) Sheldon GF, Gardiner BN, et al: Management of gastrointestinal五stulas. Surg Gynecol Obstet 133: 385-389, 1971. 21) Shiloni E and Freund HR: Total parenteral nutrition in Crohn’s disease. Is it a primary or supportive mode of therapy? Dis Colon Rectum 26: 275 278, 1983. 22) Stephens RV and Randall HT: Use of a concentrated, balanced, liquid elemental diet for nutritional manage-ment of catabolic states. Am Surg 170: 642-667, 1969. 23) Strobel CT, Byrne WJ, et al: Home parenteral nutrition in children with Crohn’s disease, an effective manage-ment alternative. Gastroenterology 77: 272-279, 1979. 24) Vink M : Local recurrence of cancer in the large bowel: the role of implantation metastases and bowel di sin-366 日外宝第55巻第2号（昭和61年3月）fection. Br J Surg 41: 431-433, 1954. 25) Voitk AJ, Echave ¥'. et al: Elemental diet in the treatment of五stulaof the alimentary tract. Surg Gynecol Obstet 137: 68ー72,1973. 26) Winit7. i¥l. Graff J, et al: Evaluation of chemical diets as nutrition for man-in-space. Nature 205: 741-743, 1965. 和文抄録Elemental dietを主体とした低残澄食の結腸・直腸疾患への応用和歌山県立医科大学消化器外科教室青木洋三，太田正孝，坂本幸具，嶋田浩介坂口雅宏，竹井信夫，勝見正治私達が工夫した elementaldiet (ED）を主体とした する症例に1日2000kcal経口的に投与し，それぞれ低残澄食をクローン病，結腸手術後の縫合不全に起因 所期の目的を達した．しかし病変による強度の狭窄をする lowoutput fistula，ならびに結腸・直腸疾患の術 示す結腸・直腸疾患症例では， colonicpreparationを前準備と術後栄養iζ応用した．乙の低残澄食はEDの 目的にとの低残澄食を術前lと投与しでも無効なことが有する特有の臭気，味からくる経口摂取の困難性を打 多かった．とのことから， 79症例の術前注腸造影像よ関するために工夫されたもので， ED3に対し，小麦 り算出した狭窄指数と preparationの結果との retro-粉1の割合で混合し，これに種々の甘味料，バター， spectiveな検討により，個々の症例の狭窄度に応じたフレーパーを添加し，クッキー，ドーナツ，プリンな 本低残澄食の術前投与期間を定められるよう線形判別どに加工した．これらの食品を上記の病態や疾患を有 関数を設定した．

Elemental dietを主体とした低残渣食の結腸・直腸疾患への応用

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Elemental dietを主体とした低残渣食の結腸・直腸疾患への応用

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