内容紹介
Summary
The patient was an 81—year—old man. Laparoscopic sigmoidectomy was performed for a sigmoid colon cancer(S, type 2, pT3[SS], INF a, Ly0, V0, BD1, Pn0, pPM0, pDM0, RM0, pN0, pM0, pStage Ⅲa, R0, Cur A). One year after the surgery, a blood test showed CEA as high as 68.9 ng/mL, and an abdominal enhanced computed tomography revealed a hepatic tumor showing marginal contrast in the 4th liver segment. Positron emission tomography showed an accumulation of SUVmax 19.0 at the same site, and a metastatic liver tumor was diagnosed. A laparoscopic medial hepatectomy was performed. Bleeding from the hepatectomy site increased significantly after completion. Subcutaneous emphysema spreading from the face to the trunk and thigh was observed, and blood tests revealed a pH of 7.172, PaCO2 of 71.0 mmHg, lactate of 67 mg/dL, mixed acidosis, D—dimer of 118 μg/mL, and a disseminated intravascular coagulation(DIC)syndrome was diagnosed. Following the difficulty of hemostasis, the surgery was changed to laparotomy and terminated by gauze packing. We encountered a case of acidosis exacerbated by hypercapnia that progressed to DIC during laparoscopic medial hepatectomy.
要旨
症例は81歳,男性。結腸癌[S,type 2,pT3(SS),INF a,Ly0,V0,BD1,Pn0,pPM0,pDM0,RM0,pN0,pM0,pStage Ⅲa,R0,Cur A]に対して腹腔鏡下S状結腸切除術を施行した。1年後に施行した血液検査にてCEA 68.9 ng/mLと高値を認め,腹部造影CT検査で肝S4に30×30 mm大の辺縁造影効果を示す腫瘤を認めた。PET—CT検査で同部位にSUVmax 19.0の集積を認め転移性肝腫瘍の術前診断となり,腹腔鏡下肝内側区域切除術を施行した。手術開始から高乳酸血症による代謝性アシドーシスが進行していた。肝切離終了後より肝切離面からの出血が徐々に増加した。顔面から体幹部,大腿に広がる皮下気腫を認め,血液検査でpH 7.172,PaCO2 71.0 mmHg,乳酸67 mg/dLと混合性アシドーシスであると同時にD—ダイマーが118 μg/mLと播種性血管内凝固症候群(disseminated intravascular coagulation:DIC)を来していた。腹腔鏡下では止血困難と判断し開腹移行し,ガーゼパッキングにて手術終了とした。腹腔鏡下肝内側区域切除術中に高二酸化炭素血症に伴いアシドーシスが増悪し,DICへ進展した1例を経験した。
目次
The patient was an 81—year—old man. Laparoscopic sigmoidectomy was performed for a sigmoid colon cancer(S, type 2, pT3[SS], INF a, Ly0, V0, BD1, Pn0, pPM0, pDM0, RM0, pN0, pM0, pStage Ⅲa, R0, Cur A). One year after the surgery, a blood test showed CEA as high as 68.9 ng/mL, and an abdominal enhanced computed tomography revealed a hepatic tumor showing marginal contrast in the 4th liver segment. Positron emission tomography showed an accumulation of SUVmax 19.0 at the same site, and a metastatic liver tumor was diagnosed. A laparoscopic medial hepatectomy was performed. Bleeding from the hepatectomy site increased significantly after completion. Subcutaneous emphysema spreading from the face to the trunk and thigh was observed, and blood tests revealed a pH of 7.172, PaCO2 of 71.0 mmHg, lactate of 67 mg/dL, mixed acidosis, D—dimer of 118 μg/mL, and a disseminated intravascular coagulation(DIC)syndrome was diagnosed. Following the difficulty of hemostasis, the surgery was changed to laparotomy and terminated by gauze packing. We encountered a case of acidosis exacerbated by hypercapnia that progressed to DIC during laparoscopic medial hepatectomy.
要旨
症例は81歳,男性。結腸癌[S,type 2,pT3(SS),INF a,Ly0,V0,BD1,Pn0,pPM0,pDM0,RM0,pN0,pM0,pStage Ⅲa,R0,Cur A]に対して腹腔鏡下S状結腸切除術を施行した。1年後に施行した血液検査にてCEA 68.9 ng/mLと高値を認め,腹部造影CT検査で肝S4に30×30 mm大の辺縁造影効果を示す腫瘤を認めた。PET—CT検査で同部位にSUVmax 19.0の集積を認め転移性肝腫瘍の術前診断となり,腹腔鏡下肝内側区域切除術を施行した。手術開始から高乳酸血症による代謝性アシドーシスが進行していた。肝切離終了後より肝切離面からの出血が徐々に増加した。顔面から体幹部,大腿に広がる皮下気腫を認め,血液検査でpH 7.172,PaCO2 71.0 mmHg,乳酸67 mg/dLと混合性アシドーシスであると同時にD—ダイマーが118 μg/mLと播種性血管内凝固症候群(disseminated intravascular coagulation:DIC)を来していた。腹腔鏡下では止血困難と判断し開腹移行し,ガーゼパッキングにて手術終了とした。腹腔鏡下肝内側区域切除術中に高二酸化炭素血症に伴いアシドーシスが増悪し,DICへ進展した1例を経験した。