KISHIMOTO, HIDEO

KOBAYASHI, TERUO

UEHARA, MAGOSAKU

YAMANOUCHI, NOBUYUKI

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Title ON TREATMENT FOR ACUTE PANCREATITIS(PROPOSAL OF SIMPLE ASPIRATION METHOD)Author(s)KISHIMOTO, HIDEO; KOBAYASHI, TERUO; UEHARA,MAGOSAKU; YAMANOUCHI, NOBUYUKICitation日本外科宝函 (1962), 31(5): 775-778Issue Date1962-09-01URL http://hdl.handle.net/2433/205473RightType Departmental Bulletin PaperTextversionpublisherKyoto University臨床ON TREATMENT FOR ACUTE PANCREATITIS (PROPOSAL OF SIMPLE ASPIRATION METHOD) by HIDEO KISHIMOTO ; TERUO KOBA y ASH! From the Department of Surgery, National Sasayama Hospital and MAGOSAKU UEHARA ; NoBUYUKI Y AMANoucm From the Depertment of Surgery, Kaibara Red Cro話 HospialReαived for Publication Jun. 5, 1962 775 We reported 2四S田 ofacute pancreatitis in 18・and32-year-old women, which we took for acute appendicitis. In these 2 cases, only appendectomy with simple aspiration of peritoneal exsudate was performed by routine ileocoecal incision for appendectomy. After that, the incision wounds were sutured immediately and completely without any drainage. In these 2 cases, former severe pains soon subsided and postoperative courc田 werevery smooth with only routine postoperative treatment for appendectomy, except relatively longer and stricter postoperative inhibition of diet. Similar good effects with this method were also experienced in several伺 S白 ofacute pancreatitis in the surgical clinic of Kaibara Red Cross Hospital. Unexpected excellent results winned by this simple aspiration method impressed us strikingly and compelled us to make some speculation on tr回tmentfor acute pancreatitis. DISCUSSION True etiology of acute pancreatitis is, yet, controversial, but the direct cause of violent distress田 inacute pancreatitis, especially severe pains arise in the disease, seems, to us, to be“leal王ageof pancr回ticjuice into free abdominal cavity”through damaged tisue of pancreas. In general, it is observed that onest of symptoms tends to postpone in acute pancr回咽titis due to accidental trauma. We had also experienced 2 cases of acute pancreatitis due to trauma in a 13-year-old girl (case 1) and in a 10-year-old boy (case 2). In case 1, damage in pancr＇伺tictissue had been slight and not covered with blood clot, and more peritoneal exsudate with more spots of fat necrosis had been found on lsparotomy. In伺 se2, pancr回shad been ruptured longitudinally in its body, and the wound had出encovered so fast with massive clot that it had ap戸aredthere have not occured any leakage of pancreatic juice. There had been only scanty spots of fat necrosis and peritoneal exsudate had been litle in this case. In these two回総sdue to trauma, pain provoked directly by the s位oke(in case 1, the patient had been striked on her abdomen by the bal while she had been playing dodge bal, in case 2 the boy had fallen on his abdomen over a pile) had disap戸filedin 776 TREATMENT FOR ACUTE PANCREATITIS a litle while, and there had been apparent lucid intervals of symptoms within about 36 to 48 hours. Then, abdominal pains had again occured gradually. These patterns of onset of symptoms (pains) seem to indicate that the direct cause of symptoms (pains) in acute pancreatitis is“leakage of pancreatic juice into peritoneal cavity,' because the damaged tissue of pancreas had really existed in the time of such lucid intervals. An actuality might have been thus : secretion activity of pancr回scels had been repre” ssed with reflex action, stimulated by th trauma on pancr白 s, and these repressions had continued during some considerable hours. When the secretion function of pancreas had returned to their former activities, damaged tissue of pancr伺 shad been already covered fast with blood coagulation or had been rearranged in some degree with its regeneration process同 soas only litle leakage of the juice had occured. Such processes of the disease may proportionate to vague, in some caces, hardly recognisable patterns of symptoms in acute pancreatitis due to trauma. According to old but excellent experimental studies in Japan, leakage of pancreatic juice into peritoneal回 Yity,provoked by cuting out main pancratic duct, resulted in deaths of al experimental dogs within 30 hours.2l If our hypothesis above mentioned is true on the gen白isof symptoms in the disease and if pancreatic juice is so toxic also in human being as in dogs, then a question natu-rally arises “why most of this disease can be successfully treated only with conservative symptomatic therapy ？”The possibility to anwer this question may lie in assuming next two conditions. One is to assume that amount of the juice leaked out is so small, and the other is to assume that the leakage occurs so temporarily only at initial s也geof the disease, therefore the toxicity of the juice can be soon weakened to become clinical nontoxic by vigrous exsu-dation from peritoneum . .Jn rare cas田 ofacute pancreatitis, the leakage of the juice may occ町 profuseor continuously and, of cource, al such patients may die before long (Group 1 after Paxton and Payne). In such foudroyant cases of the disease, nothing may be left except to make desperate efforts to isolate peritoneal cavity from contamination with pancreatic juice. One way to meet this purpose rhay be to conduct the juice out from peritoneal cavity, for example, by continuous drainage of peritoneal cavity with water帽tight omental barri-αde. The other may be to derive the juice into alimentary canal, for instance, with pancreaticogastrostomy or pancreaticojejunostomy performed al over the damaged area of pancreatic tisue, if infection could be controlled successfully, which may be .provoked in pancreas through such anastomosis. Our method of direct application of antibiotics to anastomosis by means of a fine tube inserted into alimenary canal may s宇rvewell t~ control even such infection. From the view points hereto stated, the excellent effects obtained in our c回目 withsimple aspiration method can be accepted as due to aspiration of pancreatic juice leaked out into peritoneal cavity. However, continuous drainage of peritoneal cavity is not neceseary, unless there is an abscess, because the leakage of juice is only temporary. Mor田 ver,it is some times TREATMENT FOR ACUTE PAN CREA TITIS 771 hazardous, inviting secondary infection to the pancr田 s. Generally speaking, acute pan-er回 titisis not primarily infectious in origin and so needs no continuous drainage at al. Furthermore, any manipulation on the damaged tissue of pancreas at laparotomy is also hazardous, giving arise to leakage of the juise once more. Recent treatment in acute pancreatitis is divided into 2 ways. If infection or abscess o_r some conditions to claim immediate surgery, for example, co-existence of biliary caluculus is suspected or apparent, then immediate laparotomy must be done. In other most cases, nonoperative treatment is universally accepted as a method of choice. But, we propose such simple aspiration of peritoneal exsudate by laparotomy at the initial stage of the disease with succeeding internal therapy as rational and stil more “better” treatment in relatively severe cac白 ofacute pancreatitis not accompanied with infection, though such procedures have been porformed here and there by chance, perhaps without any firm intention. SUMMARY 1) It was assumed that : a) direct四usefor symptoms (pains) in acute pancr回 titiswas the “leakge of pancreatic juice into peritoneal cavity" through damaged tissue of pancreas. b) Such leakage of the juice was in most回sesonly litle and temporary. c) but, in foudroyant group of the disease this leakage was profuse or continuous. d) The keypoint in treatment of acute pancreatitis lay in controlling such l伺 kageof pancreatic juice into peritoneal回vity.2) Under such hypothesis, several cas白 ofacute pancreatitis, experienced in the clinic of both National Sasayama and Kaibara Red Cross Hospitals were inspected throughly, especially 2 cas田 dueto traume : and it was found that, with such hypothesis, various clinical patterns of the disease could be clearly and monisticaly understood. 3) Under such a view point and with our own experiences, we proposed to perform simple aspiration of peritoneal exsudate by laparotomy at the initial stage of the disease without any succeding drainage of peritoneal cavity.羽Tebelive this method may be rational and stil more“better”treatment than pure nonoperative therapy, for severe回 sesof acute pancreatitis with no infection. 4) Under same point of view, it was emphasized that continuous drainage of peritoneal 伺 vitywas unnecessary and moreover hazardous, because it might invite secondary infection to pancreas. Besides, it was also emphasized that any manipulation on damaged tissue of pancreas at laparotomy was hazardous, giving arise to new leakage of the JUICe once again. 5) It was suggested that in foudroyant C前回 ofthe disease, the only way to do might be to guard periteneal 回 vityfrom contamination with pancreatic juice leaked out profusely, e. g. by m回 nsof continuous drainage of peritoneal cavity with omental barricade or with pancreatico-gastrostomy or -jejunostomy performed al over the de-maged area of pancreas. 778 日本外科宝函第31巻第5号Literature 1) Hideo Kishimoto et al. : Zwei Falle der akuten Pancreatitis, welche der akuten Appendicitis an den Symptomen nahekam, Arch. f. Jap. Chir. xxx1 Band, 2. Heft, 1, Mar. 1962. 2) Kiyoshi Sugiyama : Experimental Studies on Peritonitis of the Pancreatic Origin. J. Jap. Soc. Surg. Vol. 38. Nn. 9, P. 1167. 1937 (in Japanese). 3) Hideo Kishimoto et al. : Protection of anastomosis by means o'. direct and intermittent application of antibiotics through a tube inserted into the alimentary canal. Arch. f. Jap. Chir. xxv1. Band. Heft. 1. Jan. 1957. 和文抄録急性勝炎の治療について（単純吸引療法の提唱）国立篠山病院外科（院長岸本秀雄）岸本秀雄・小林照雄柏原日赤病院外科（院長竹下一雄）上原孫作・山内信幸(1) われわれはp 急性豚炎の病態ならびに治療に関して次の諸点を仮定した．a) 急性腺炎の症状p ことにその激痛の直接の原因は遊離腹腔への病巣部よりの豚液洩出である．b) このような豚液洩出は，しかし大多数の急性勝炎の症例においてはp 少量かつ一過性である．の しかしながらP 少数のいわゆる電撃型の症例では，この豚液洩出は，大量であるか乃至は持続性である．d) 急性解炎における治療の要点は，この際液の腹腔への洩出を制禦することにある．(2）以上の仮定にもとづいてP われわれが国立篠山病院および柏原日赤病院で経験した急性降炎の諸症例，殊に外傷による2例を詳細に検討した結果p 上記の仮定によってP これ等諸症例の病態が）1"吉に明白かっ一元的に理解できることを発見した．(3）以上の検討とP われわれの自験例にもとづいて1り われわれは，感染を伴っていない急性豚炎のうちで，重症例に対しては，従来の非手術的療法よりも，病初開腹しp 腹腔浸出液の単なる吸引を行った後p 術創は排膿管を挿入することなし直ちに完全に閉鎖する方法を行うべきことを提唱し，このような単純吸引療法が合理的かつよりよき方法であると恩考される理由について述べた． （従来も偶然の機会にこのような単純排液法が行われていたが，明白な根拠を欠いていたと考える）．(4) また同様の観点から，感染を伴わぬ急性解炎に対して，腹腔に持続排膿管を挿入することは，不必要なだけでなし豚への2次感染を招来するので行うべきでないことP および開腹時に勝病巣にp たとえばp掻把その他の一切の操作を加えることは，再び新たな勝液洩出を誘起するので，危険であることを強調しfこ．(5) いわゆる電撃型急性i豚炎に対してはp 当然この大量乃至は持続的な際液遊出から，腹膜隆を遮断しなければならないaこの遮断の方法として，大網によるバリケードを作った後p この中に排液管を入れて持続的に洩出伴液を腹腔外に排除する方法や，豚病巣部を広く覆う豚胃乃至豚空腸吻合を行って洩出勝液を消化管睦へ誘導する方法を示唆した．またこの際，吻合を通じて起る際病巣部の感染の予防に，われわれが提唱した細管を遜じての吻合部への抗生剤直接注入法が有効と信じることを述べた3).

急性膵炎の治療について : 単純吸引療法の提唱

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急性膵炎の治療について : 単純吸引療法の提唱

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