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文献考察１：肝損傷と出血
肝動脈塞栓術が奏効した日本外傷学会分類III b型肝損傷の1例(原著論文/症例報告)
Author：井原信麿(亀田総合病院 放射線科), 八代直文, 葛西猛, 阿部理恵
Source：救急医学(0385-8162)28巻6号 Page745-748(2004.06)
肝損傷に伴う出血源としては肝動脈，門脈および肝静脈がある．低圧系の門脈と肝静脈の末梢分枝の損傷は，凝固機能障害がなければ周囲に血腫が形成され，組織内圧が上昇しタンポナーデ効果で自然に止血する．一方，高圧系である肝動脈や，低圧系でも近位部の肝静脈や中枢部の太い門脈の損傷では血流が豊富なため，タンポナーデ効果による自然止血は得られにくい．従って，肝損傷ではTAEで止血できる動脈性出血だけでなく，肝静脈と門脈からの出血も念頭に置いて診断治療を進める必要がある．
文献考察２：肝静脈・肝後面下大静脈損傷を伴うIIIb型肝損傷
【救命止血を要する腹部救急傷病の初療の工夫(消化管出血を除く)】肝静脈・肝後面下大静脈損傷を伴うIIIb型肝損傷
Author：中村達也(大阪府立中河内救命救急センター), 尾中敦彦, 田伏久之
Source：日本腹部救急医学会雑誌(1340-2242)21巻4号 Page667-674(2001.05)
Abstract：肝静脈・肝後面下大静脈損傷を伴うIII b型肝損傷の治療においては,損傷部の的確な評価とショック状態よりの離脱が救命の第一歩であり,更に手術野の出血制御が手術の成否を左右する.何らかの補助手段なしに,出血量の少ない手術野を得ることや,静脈修復を行うことは極めて困難である.肝及び肝後面下大静脈の血行遮断のために,肝後面下大静脈一時バイパス法を用い,静脈損傷部の縫合止血を行う.一時バイパス法としての動脈洞シャントには開胸操作やシャントチューブの術前準備が必要となるが,手術手技やシャントチューブの使用の習熟によりこれらの問題は克服し得るdeadly triad（.深部体温の低下・代謝性アシドーシスの進行・血液凝固障害など）が出現する以前に全ての手術操作を終了することが救命の鍵となる．
文献考察３：肝硬変と腹部外傷：予後は悪い
J Am Coll Surg. 2004 Oct;199(4):538-42.
Liver cirrhosis in patients undergoing laparotomy for trauma: effect on outcomes.
Demetriades D, Constantinou C, Salim A, Velmahos G, Rhee P, Chan L.
BACKGROUND: There is little published work on the effect of cirrhosis on outcomes in trauma patients undergoing laparotomy. The aim of this study was to evaluate the risk of death or serious complications in cirrhotic trauma patients undergoing laparotomy as compared with that in a similar group of patients without cirrhosis. STUDY DESIGN: During a 12-year period, there were 46 patients with the diagnosis of liver cirrhosis made during laparotomy for trauma. Each patient was matched with two noncirrhotic controls on the basis of 7 criteria: age (>55, =55 years), gender, mechanism of injury (blunt, penetrating), Injury Severity Score (=15, 16-25, >25), head Abbreviated Injury Score (/=3), chest Abbreviated Injury Score (/=3), and abdominal Abbreviated Injury Score (/=3). Six cirrhotic patients were excluded because matching was not possible. The remaining 40 patients were matched with 80 noncirrhotic control patients selected from a pool of 4,771 patients who had trauma laparotomies. Outcomes included mortality, ARDS, pneumonia, renal failure, abdominal sepsis, disseminated intravascular coagulopathy, ICU and hospital stay, and hospital charges. Outcomes between the two study groups were compared with conditional logistic analysis. Hazard ratio (95% CI) and adjusted p value with the stepdown Bonferroni method were derived. RESULTS: The overall mortality in the cirrhotic group was significantly higher than that in the matched noncirrhotic group (45% versus 24%, hazard ratio: 7.60 [2.00, 28.94], p = 0.021). Mortality in patients with Injury Severity Score =15 was 29% in the cirrhotic group and 5% in the noncirrhotic group (p = 0.013) and in patients with Injury Severity Score 16-25, mortality was 56% and 11%, respectively (p = 0.024). The incidence of any of the predetermined complications was 45% in the cirrhotic group and 23% in the noncirrhotic group (p = 0.110). The mean surgical ICU stay was 11.5 days and 6.6 days, respectively (p = 0.037), and the mean hospital charges were 1,210 and ,884, respectively (p = 0.031). CONCLUSIONS: Cirrhotic trauma patients undergoing laparotomy are at high risk of serious complications and death, even after fairly minor injuries. This group of patients should be admitted to the ICU for close monitoring and aggressive management irrespective of the severity of injuries. PMID: 15454135
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