A 65-year old man was consulted to the emergency department of our hospital with a chief complaint of sudden abdominal pain. He was alert, had diffuse abdominal pain, and showed slight peritoneal signs. He had undergone total gastrectomy with Roux-Y reconstruction. The liver function was slightly impaired and the serum amylase level was markedly increased. Abdominal CT with contrast showed dilatation of the intestine and wall thickening of the intestine in the left abdomen, but blood flow in the intestinal wall was maintained. A long tube was inserted. Abdominal pain was still present five hours after admission, and abdominl CT was performed, whic revealed the dilatation of duodenum to anastomosis site of the small intestine. Intraoperative findings showed that the small intestine on the anal side was tucked inward to the space between the mesenterys at the afferent small bowel anastomosis site, and it had caused the internal hernia. As bowel necrosis was not observed, the intestine was restored, hernial orifice was closed, and surgery was completed. There are few reported cases of internal hernia after total gastrectomy, and so we report this case, along with a literature review.
要旨 症例は66歳の男性。吐血を主訴に救急搬送された。上部消化管内視鏡検査で胃3型腫瘍からの出血と診断され経過観察目的に入院した。搬入10時間後,1L以上の吐血を来し出血性ショックとなり,大動脈閉塞バルーン留置下で緊急開腹した。胃穹窿部後壁に潰瘍化した腫瘍を認め, 同部位から出血が持続していた。縫合止血が困難であり胃内ガーゼパッキングで一時止血を得た。集学的管理で全身状態を改善させ,2日後に再開腹しガーゼを抜去すると,腫瘍が脾動脈に浸潤しており,同部位からの再出血を認めた。腫瘍は膵尾部・脾門部・横隔膜に浸潤しており,胃全摘術・膵尾部脾合併切除術を行った。病理組織検査で非特定型末梢性T細胞リンパ腫と診断した。胃原発悪性リンパ腫は稀に大量出血を来すことがあり,damage control strategyが要求される可能性がある。胃腫瘍からの大量出血に対するdamage control surgeryとして胃内ガーゼパッキングが有用であると考えられる。
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