山中 雅也, 杉本 博行

Masaya YAMANAKA, Hiroyuki SUGIMOTO

小牧市民病院外科

Department of Surgery, Komaki City Hospital

キーワード : hepatic encephalopathy, splenic rupture, occlusion of shut

門脈大循環シャントによる脳症はしばしば見逃されることがあり，高齢者においては認知機能の低下として処理されることがある．今回，術中超音波検査所見を指標とし脾摘術と同時に門脈大循環シャント閉鎖術を施行した外傷性脾破裂症例を経験したので報告する．症例は84歳女性．近医入院中に転倒し左肋骨骨折を生じた．その後退院となったが受傷後11日目に，意識消失のため当院救急外来に搬送された．遅発性脾破裂および腹腔内出血と診断し，緊急脾摘出術を施行した．脾摘後，術中超音波検査で門脈左枝を観察すると門脈逆流を認めた．脾腎シャントが著明に拡張しており，シャント血管を遮断したところ順行性の門脈血流となったため，シャント血管の結紮を行った．今回，緊急症例であり十分な術前検査を行う余裕はなく，術中にシャント閉鎖の適応を判断する必要があったが，術中超音波検査を判断材料とし，シャント閉鎖術を施行した．術後も門脈血流は順行性を維持し意識状態も速やかに改善しており，緊急での門脈大循環シャント閉鎖術は有効であった．術中超音波検査は，簡便にリアルタイムでの血流動態のモニタリングが可能であり，緊急門脈大循環シャント閉鎖術の適応の判断に有用であると示唆された．

Portosystemic encephalopathy is often overlooked, being treated as a decrease in cognitive function in elderly patients. We herein report a case of traumatic splenic rupture with a portosystemic shunt. We resected the spleen and resolved the occlusion of the portosystemic shunt via intraoperative ultrasound. An 84-year-old woman was transported to the emergency room with loss of consciousness. She had fallen and fractured a rib 11 days earlier. Emergency splenic resection was performed following a diagnosis of late-onset splenic rupture and intra-abdominal bleeding. Before the surgery, we confirmed the splenic renal shunt and diagnosed her with portosystemic encephalopathy. We confirmed portal reflux in the left branch of the portal vein with intraoperative ultrasonography. The splenic renal shunt was ligated due to antegrade portal blood flow when the shunt became occluded. Because of the emergent nature of the surgery, preoperative inspections were inadequate. We carefully evaluated whether or not we could resolve the occlusion of the splenic renal shunt via intraoperative ultrasound. After surgery, the portal vein blood flow remained antegrade, and her level of consciousness rapidly improved. Emergency occlusion of the portosystemic shunt was therefore deemed effective. Because intraoperative ultrasound can be used to monitor the blood flow in real time, we successfully resolved the occlusion of the splenic renal shunt effectively and safely. We therefore considered that intraoperative ultrasonography was useful.