1978年から1990年までの13年間に国立水戸病院救命救急センターでは50例の膵外傷手術例を経験した。主膵管損傷の有無と十二指腸損傷合併の有無によりI, II, III型に大別し,さらにII, III型を膵周囲主要血管損傷の有無よりそれぞれII a, II bおよびIII a, III bと2つに分けるという損傷形態分類を試みた。この分類は簡便で,形態別に手術術式とおよそ対応した。つまり,I型には膵縫合・ドレナージ,II型には膵体尾部切除,III型には膵体尾部切除,膵切離膵空腸吻合などの膵の処置に,十二指腸損傷の処置を加えればよいということである。また,この分類は死亡率からみた予後もよく反映した。手術術式は,膵縫合・ドレナージを30例(60%)に,膵切除術のなかでは膵体尾部切除を11例(22%)に,膵頭十二指腸切除を1例(2%)に,またRouxen-Yにて膵空腸吻合(Letton-Wilson法),十二指腸空腸吻合を合わせて7例(14%)に行った。膵外傷の治療は,その機能の保全より安全をより重視する基本方針をとっており,膵体尾部切除を11例(22%)と多用する傾向がみられた。膵損傷の際,膵切除量80%以下の体尾部切除に伴う糖尿病は11例中1例(9%)のみで,また消化吸収障害は1例もなかった。また,膵体尾部切除後の合併症発生頻度(36%)も縫合・ドレナージ術後の頻度(38%)と同程度であった。膵体尾部切除は簡便で手術時間が短縮でき,安全であり膵機能の面からも問題は少なく,膵断裂・挫傷例に基本術式とできると考えられた。全体として死亡率は16%,術後合併症率は42%であった。死亡例(8例)の検討では,その原因は膵周囲主要血管からの出血と術後のMOFであった。予後の改善のためには,損傷形態に基づいた適切な術式を選択することにより術後合併症の減少と受傷早期に膵周囲主要血管からの出血をコントロールすることが必要である。
Appropriate surgical management, selected from various options, is still controversial as the number of accumulated cases of bile duct injury due to blunt abdominal trauma is small. Furthermore, is seems that no single surgical intervention can be justified as the best management for delayed stricture of the common bile duct (CBD). This report describes an illustrative case of blunt trauma leading to delayed stricture of the CBD after immediate celiotomy for liver trauma and minor CBD injury at the intra-pancreatic portion, treated by left lateral segmentectomy and cholecystostomy. An initial postoperative cholangiogram through the cholecystostomy revealed no leakage and good passage of bile into the duodenum. However, follow-up cholangiography demonstrated stricture of the CBD and subsequent complete obstruction on the 31st postoperative day. In this case, the patient was managed conservatively with external bile drainage through the cholecystostomy. Spontaneous reopening of the CBD was evident by the 94th postoperative day. A review of 36 cases of blunt bile duct injury reported in the Japanese literature and our case suggested the possibility that conservative management for delayed stricture of the CBD may result in spontaneous reopening, especially when the stricture developed within 1 month after blunt trauma.
A 69-year-old man who had been taking glycyrrhizin for chronic hepatitis had been suffering from watery diarrhea for several weeks. After retrograde urethrography for dysuria, he developed shock and was transferred to our hospital. His blood pressure was 72/44 mmHg and his ECG showed atrial fibrillation, ventricular extrasystoles and non-sustained and then sustained polymorphic ventricular tachycardia(torsade de pointes: TdP). Electrical cardioversion restored sinus rhythm, and the QTc interval was prolonged to 0.62 with a change in T and U waves (slow wave). The serum potassium level was 2.9mEq/l and the serum free calcium level was 0.7mEq/l, but other electrolyte levels were normal. He was diagnosed with TdP occurring in hypopotassemia-induced QT prolongation. He was treated with KCl, dobutamine and dopamine. The TdP attack was diminished within a few days, but the QTc interval returned to 0.42 0n the 20th day. He had no organic heart disease. TdP occurred in the manner of the pause-dependent type, and was accompanied with the prolongation of QTc interval and the fusion of T and U waves. This QT prolongation was produced by hypopotassemia induced by glycyrrhizin-related pseudoaldosteronism and probably hypomagnesemia accompanied by chronic diarrhea. This is the first case, to our knowledge, in which TdP occurred after retrograde urethrography.
We report the case of a 17-year-old young woman who developed acute myocardial infarction with myocardial contusion following a blunt chest trauma sustained in a motorcycle accident. The chest roentgenogram on admission was normal. Electrocardiogram showed complete right bundle branch block and pathologic Q waves with ST elevation in leads I, aVL and V1 to V5. Two-dimensional echocardiogram revealed akinesis of the anterior wall and hypokinesis of the posterior wall of the left ventricle, consistent with extensive anterior myocardial infarction with myocardial contusion of the posterior wall. Coronary angiography revealed an abrupt, severe stenosis with delayed antegrade filling in the proximal left anterior descending artery, suggesting an intimal flap in the vessel wall. Technetium-99m pyrophosphate myocardial scintigraphy demonstrated diffuse tracer uptake in the left ventricular wall. Follow-up coronary angiography performed one year after the accident showed only minor stenosis without any filling defects of contrast medium at the site of the initial lesion. In this report, we discuss the spontaneous resolution of coronary artery dissection due to a blunt chest trauma together with its management and treatment.
Flumazenil, a potent benzodiazepine antagonist, was administered to a patient who showed prolonged coma after sedation with diazepam. In this study, flumazenil was considered to be useful for differentiating sedation from anoxic encephalopathy. We recommend the use of flumazenil in evaluating the cause of prolonged coma in patients in the Intensive Care Unit who were sedated with benzodiazepine to control conditions such an status asthmaticus or brain injury.