耳鼻咽喉科・頭頸部外科84巻11号

2012年10月発行

特集 扁桃とアデノイドUpdate

―新しい治療法（1）―コブレーター扁桃摘出術

著者： 竹内啓¹

所属機関： ¹JR東京総合病院耳鼻咽喉科

ページ範囲：P.815 - P.821

Ⅰ　はじめに

　Coblator^®ⅡSurgery System（ArthroCare Co. Sunnyvale，CA，USA）（以下，Coblatorと略す）を用いて行うCoblation Tonsillectomyは，coldのメスと剝離子で行う従来の術式（以下，剝離法と略す）とは全く異なる。切離，吸引，止血が1本で行えるEvac 70 Xtra IC Wandを使用する。このWandの先端で発生したプラズマが生理食塩水中のNaイオン電子を惹起し，組織に直接触れずに組織の分子結合を切離していく全く新しい手術手技である。生じる熱は60～70度と低温で周囲組織への熱の影響が少ないのが特徴である。バイポーラや電気メスは口蓋扁桃摘出術に多用されているが，これらのdeviceが生じる高温の熱は術後出血や術後疼痛を増加させるとの報告^1）もあり注意が必要である。

　2001年にTempleら^2）が小児のCoblation Tonsillectomyは術後疼痛が軽いことを報告した以降，低い術後出血率^2～10），軽い術後疼痛^{2,4,7～14）}，早い術後回復^7,9,14），少ない鎮痛剤使用^7,13,14）などの有用性についても多数報告されている。

　このCoblation Tonsillectomyの手技，learning curve，術後出血，術後疼痛，熱浸達度について述べる。

参考文献

1）BAO-HNS/RCSENG 2005. British Association of Otorhinolaryngologists-Head and Neck Surgeons Comparative Audit Group & Clinical Effectiveness Unit, The Royal College of Surgeons of England. National Prospective Tonsillectomy Audit：FINAL Report of an Audit In England And Northern Ireland between July 2003 and September 2004. http://www.rcseng.ac.uk/publications/docs/national_prospective.html. May 2005

2）Temple RH, et al：Paediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 61：195-198, 2001

3）Roje Z, et al：Postoperative Morbidity and Histopathologic Characteristics of Tonsillar Tissue Following Coblation Tonsillectomy in Children：A Prospective Randomized Single-Blind Study. Coll Antropol 33：293-298, 2009

4）Timms MS, et al：Coblation tonsillectomy：a double blind randomized controlled study. J Laryngol Otol 116：450-452, 2002

5）Belloso A, et al：Coblation tonsillectomy versus dissection tonsillectomy：postoperative hemorrhage. Laryngoscope 113：2010-2013, 2003

6）Carney AS, et al：The coblation tonsillectomy learning curve. Otolaryngol Head Neck Surg 138：149-152, 2008

7）Mitic S, et al：A pilot randomized controlled trial of Coblation Tonsillectomy versus dissection tonsillectomy with bipolar diathermy heamostasis. Clin Otolaryngol 32：261-267, 2007

8）Parsons SP, et al：Comparison of Posttonsillectomy Pain Using the Ultrasonic Scalpel, Coblator, and Electrocautery. Otolaryngol Head Neck Surg 134：106-113, 2006

9）Businco LDR, et al：Paediatoric tonsillectomy：radiofrequency-based plasma dissection compared to cold dissection with sutures. Acta Otorhinolaryngologica Italica 28：67-72, 2008

10）Magdy EA, et al：Coblation tonsillectomy：a prospective, double-blind, randomized, clinical and histopathological comparison with dissection-ligation, monopolar electrocautery and laser tonsillectomies. J Laryngol Otol 122：282-290, 2008

11）Polites N, et al：Postoperative pain following coblation tonsillectomy：randomized clinical trial. ANZ J Surg 76：226-229, 2006

12）Noordzij JP, et al：Coblation versus Unipolar Electrocautery Tonsillectomy：A Prospective, Randomized, Single-Blind Study in Adults Patients. Laryngoscope 116：1303-1309, 2006

13）Stoker KE, et al：Pediatric total tonsillectomy using coblation compared to conventional electrosurgery：A prospective, controlled single-blind study. Otolaryngol Head Neck Surg 130：666-675, 2004

14）Heidemann CH, et al：Post-tonsillectomy hemorrhage：assessment of risk factors with special attention to introduction of coblation technique. Eur Arch Otorhinolaryngol 266：1011-1015, 2009

15）Glade RS, et al：Coblation adenotonsillectomy：An improvement over electrocautery technique? Otolaryngol Head Neck Surg 134：852-855, 2006

16）Lowe D, et al：Key Messages From the National Prospective Tonsillectomy Audit. Laryngoscope 117：717-724, 2007

17）Noon AP, et al：Increased post-operative haemorrhage seen in adult coblation tonsillectomy. J Laryngol Otol 117：704-706, 2003

18）Windfuhr JP, et al：Hemorrhage following coblation tonsillectomy. Ann Otol Rhinol Laryngol 114：749-756, 2005

19）Philpott CM, et al：A double-blinded randomized controlled trial of coblation versus conventional dissection tonsillectomy on postoperative symptoms. Clin Otolaryngol 30：143-148, 2005

20）Back L, et al：Traditional Tonsillectomy Compared With Bipolar Radiofrequency Thermal Ablation Tonsillectomy in Adults. Arch Otolaryngol Head Neck Surg 127：1106-1112, 2001

21）Mosges R, et al：Hemorrhage rate after coblation tonsillectomy：a meta-analysis of published trials. Eur Arch Otorhinolaryngol 268：807-816, 2011

22）Jones DT, et al：Comparison of Postoperative Pain in Pediatric Patients Undergoing Coblation Tonsillectomy versus Cautery Tonsillctomy. Otolaryngol Head Neck Surg 144：972-977, 2011

23）Tan AKL, et al：Coblation vs electrocautery tonsillectomy：Postoperative recovery in adults. Otolaryngol Head Neck Surg 135：699-703, 2006

24）Shapiro NL, et al：Cold Dissection Versus Coblation-Assisted Adenotonsillectomy in Children. Laryngoscope 117：406-410, 2007

25）Parker D, et al：A randomized controlled trial to compare postoperative pain in children undergoing tonsillectomy using cold steel dissection with bipolar heamostasis versus coblation technique. Clin Otolaryngol 34：225-231, 2009

26）Saengpanich S, et al：Comparison of pain after radiofrequency tonsillectomy compared with conventional tonsillectomy：a pilot study. J Med Assoc Thai 88：1880-1883, 2005

27）Hasan H, et al：Randomized study comparing postoperative pain between coblation and bipolar scissor tonsillectomy. Eur Arch Otorhinolaryngol 265：817-820, 2008

28）Burton MJ, et al：Coblation versus other surgical techniques for tonsillectomy. Cochran Database Syst Rev 2007；（3）：CD004619.

29）Shah UK, et al：Tonsillectomy by Means of Plasma-Mediated Ablation Prospective, Randomized, Blinded Comparison With Monopolar Electosurgery. Arch Otolaryngol Head Neck Surg 128：672-676, 2002

30）Lowe D, et al：National Prospective Tonsillectomy Audit Tonsillectomy technique as a risk for postoperative haemorrhage. Lancet 364：697-702, 2004

31）Modi VK, et al：Histologic assessment of thermal injury to tonsillectomy specimens：a comparison of electrocautery, coblation, harmonic scalpel, and tonsillotome. Laryngoscope 119：2248-2251, 2009

32）Hopkins C, et al：Post-tonsillectomy haemorrhage：a 7-year retrospective study. Eur Arch Otorhinolaryngol 260：454-455, 2003

33）Shah UK, et al：Coblation for tonsillectomy an evidence-based review. ORL 69：349-357, 2007

34）Walner DL, et al：Past and present instrument use in pediatric adenotonsillectomy. Otolaryngol Head Neck Surg 137：49-53, 2007

35）Benninger M, et al：Coblation：improving outcomes for children following adenotonsillectomy. Clin Cornerstone 9：13-23, 2007