外傷(Trauma)シリーズ3 RESIDENT COURSE 解答 【症例 TR 15】

小腸損傷(腸間膜損傷・回腸壊死)IIIb. Mesenteric laceration with small bowel necrosis(AAST grade V)






Extravasationは認めない.図1〜図12の※は筋肉よりdensityの高い軟部組織で,凝血塊(血腫)であるが,より溜まりやすい傍結腸溝以外に存在し腸間膜損傷を示唆する.図4〜図10の△の小腸(小腸は臍を中心に右上腹部から左下腹部に引いた斜線を境に左側に空腸が,右側に回腸が位置する傾向が強いのでおそらく回腸)は壁の造影効果を認めず,壊死に陥った回腸である.従って腸間膜損傷とそれに伴う回腸壊死と診断する.図9と図10の↑は壁内気腫ではなく脂肪組織である.図7と図8のニボーを形成しているガス(白矢印)と比較すると,ガスは輪郭(辺縁)が鋭く鮮明で,脂肪組織は輪郭が鈍く不整であり,その違いを認識してほしい.ウィンドウ幅を450〜500に設定し,ウィンドウレベルを調節して脂肪組織がやや白くなるような画像にすればガスと脂肪組織の鑑別は容易で,肺野と縦隔野の2種類の画像を作成する必要もなくなる.手術で回腸腸間膜の裂創と回腸壊死を認めた.図Aが切除標本で,↑間が腸間膜損傷部位で,▲が壊死に陥った回腸.








文献考察:上腸間膜動脈損傷
J Am Coll Surg. 2001 Oct;193(4):354-65; discussion 365-6.
Multiinstitutional experience with the management of superior mesenteric artery injuries.
Asensio JA, Britt LD, Borzotta A, Peitzman A, Miller FB, Mackersie RC, Pasquale MD, Pachter HL, Hoyt DB, Rodriguez JL, Falcone R, Davis K, Anderson JT, Ali J, Chan L.

BACKGROUND: Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullen's classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN: We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS: There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullen's zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullen's ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullen's zone I or II, and multisystem organ failure. CONCLUSION: SMA injuries are highly lethal. Fullen's anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullen's zones I and II, Fullen's maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.PMID: 11584962

Fullen's Zoneとは,Zone I:trunk proximal to first major branch(inferior pancreaticoduodenal), Zone II : trunk between inferior pancreaticoduodenal and middle colic, Zone III : trunk distal to middle colic, Zone III : segmental branches, jejunal, ileac or colic. Fullen's ischemia gradeは,Grade 1(maximal) : jejunum, ileum, right colon. Grade 2(moderate) : major segment, small bowel, right colon, or both. Grade 3(minimal) : minor segment or segments, small bowel or right colon. Grade 4(none) : no ischemic bowel.

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