|
文献考察：鈍的腹部外傷の手術適応
１）真栄城優夫：肝外傷の止血，消化器外科専門医への道．手術（別冊），275-284，1997．
沖縄県立中部病院の鈍的腹部外傷の開腹適応，１．腹部に起因するショック，２．腹膜炎（びまん性の腹膜刺激症状），３．腹腔内出血の一部（腹部エコーで計測し500ml以内：保存的療法，500〜1000ml：保存的療法，ただし出血速度が毎時200ml以上，または血圧不安定なものは開腹，1000以上：原則的には開腹，ただしバイタルサインの安定例では保存療法のこともある．），４．腸管穿孔の証明（遊離ガス，後腹膜気腫，消化管造影など），５．その他（胆道破裂，漏尿，主膵管断裂，横隔膜破裂など）．
２）腹部損傷に対する手術 臓器温存・QOLの視点から】 鈍的肝損傷の治療
Author：岸仲正則(九州大学 大学院 臨床腫瘍外科), 千々岩一男, 山口幸二, 中野賢二, 田中雅夫
Source：手術(0037-4423)55巻10号 Page1464-1468(2001.09)
鈍的肝損傷の手術適応は，1．1000ml以上の腹腔内出血，1時間に200ml以上の出血，輸液輸血で安定しない出血性ショック（CTでは右横隔膜下の血腫量が1cmを一応の目安としている），胆汁性腹膜炎，
文献考察：腹部鈍的外傷に対するIVR
【腹部救急疾患におけるIVR】 腹部鈍的外傷に対するIVR
Author：大森浩明(岩手医科大学 第一外科), 旭博史, 井上義博, 入野田崇, 遠藤重厚, 斎藤和好
Source：日本腹部救急医学会雑誌(1340-2242)23巻4号 Page607-612(2003.05)
Abstract：肝・脾・腎損傷,多臓器損傷に対するtranscatheter arterial embolization(TAE)を中心としたIVRの適応,方法について,著者等の自験例を交えて述べた.TAEは循環動態の安定が得られた,単独の実質臓器損傷に対する第一選択の治療法として考慮されるべきである.又,damage controlの概念を拡大した,TAEと手術を併用して治療を行うことも行われている.しかしながら,適応を拡大しTAEにこだわるあまり,逆に侵襲を拡大しIVRの本来の意義を損なうといった問題も懸念されている.又,腹部鈍的外傷は多発外傷を合併している場合が少なくなく,治療の決定には,局所の理学所見や画像所見のみならず,全身状態,出血傾向なども考慮に入れることが重要である．
追記：腹部鈍的外傷における血管造影の適応，１．輸液・輸血などの初期治療によりショックから離脱する，２．造影CTで造影剤の血管外漏出所見を認める，３．推定腹腔内出血量が1000ml以上である，４．III型以上の腎損傷で血腫の増大を認める，５．肉眼的血尿が持続する．
文献考察：脾損傷の保存的療法の適応
１）Am Surg. 2003 Mar;69(3):238-42; discussion 242-3.
Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma.
Meguid AA, Bair HA, Howells GA, Bendick PJ, Kerr HH, Villalba MR.
Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults. PMID: 12678481
２）World J Surg. 2001 Nov;25(11):1393-6.
Factors of failure for nonoperative management of blunt liver and splenic injuries.
Ochsner MG.
A review of the literature describing the management of hepatic and splenic injuries indicates that as many as 67% of exploratory celiotomies for blunt trauma are reported as nontherapeutic. Avoiding unnecessary surgery through nonoperative management offers an attractive alternative. Nonetheless, nonoperative management should not be considered unless the patient meets the following criteria: (1) hemodynamic stability, with or without minimal fluid resuscitation; (2) no demonstrable peritoneal signs on abdominal examination; and (3) the absence on computed tomography (CT) scan of any intraperitoneal or retroperitoneal injuries that require operative intervention. Although a patient may meet these criteria, several additional factors can serve as predictors of failure of nonoperative management. Such predictors among patients with hepatic injuries are hemodynamic instability, liver injury of American Association for the Surgery of Trauma grades IV and V (especially when accompanied by hemodynamic instability), and pooling of contrast on CT scan. Formerly thought to be a predictor of failure of nonoperative management, periportal tracking has not been cited as such in recent reports of hepatic injuries. Among patients with blunt splenic injuries, such predictors include hemodynamic instability, injury of grade IV or higher, large associated hemoperitoneum, and contrast blush on CT scan. Although preexisting splenic disease and age older than 55 years have traditionally been considered predictors of failure, recent reports have shown that these characteristics do not appear to be associated with an increased need for surgical intervention. PMID: 11760740
３）World J Surg. 2001 Nov;25(11):1389-92.
Selection of nonoperative management candidates.
Schwab CW.
The liver and spleen are the most commonly injured intraabdominal organs and comprise most of the injuries to the solid viscera during blunt abdominal injury. The contrast-enhanced computed tomography (CT) scan has emerged as an accurate, safe diagnostic tool for blunt torso trauma, making nonoperative management of even severe injury to the liver and spleen possible. This review concentrates on the trends, patient selection criteria, and some of the risks of nonoperative management of hemodynamically stable patients with blunt liver and spleen injury. PMID: 11760739
追記：脾および肝損傷の保存的療法の適応は上記文献と同様だが，経験豊かな外科医がいること，近代的なCT（ヘリカルまたはMDCT）設備があること，画像を正確に読影できることを条件としている．
まとめ：脾・肝損傷出血のmanagement．１：スクリーニングは腹部エコー検査（FAST：Focused Assessment with Sonography for Trauma）．心タンポナーデの有無，胸水の有無，左右横隔膜下，Morison窩，骨盤腔内の液貯留の有無を見る．来院時収縮期血圧が90mmHg以下で，腹腔内出血や胸腔内出血を認め，初期輸液（2000ml）で安定するrespondersはCT等の検索へ,一過性の安定が得られるtransient respondersは輸液を続行しながら手術やTAEを考慮し,安定しないnon-respondersは直ちに手術室へ搬送する．２：血圧が安定している，または上記respondersはCT検査を行う．造影CTは必須であるが，extravasationの検出率を高めるため，extravasationとpseudoaneurysmとの鑑別を容易にするためdouble phase造影CTが望ましい．３：造影CTでextravasationを認める，または推定腹腔内出血量が1000ml以上であれば塞栓術を目的に血管造影を，すぐに血管造影が出来ない施設では手術の適応である．
|
