外科からみた非手術的止血法への批判

A Criticism of Non-surgical Treatment of Hemorrhage Seen from the Side of Surgeons

　表題のような内容について記載するようにと編集室から御連絡をいただいたが，私にはとても“非手術的止血法の批判”などを書く資格はなさそうである．むしろ，最近はいろいろと工夫して非手術的止血法が積極的に検討されつつあることに敬服の念をいだいているからである．もし外科からみて申し上げたいことがあるとすれば，非手術的止血法に専念するあまり，その間の循環管理などを中心とした全身管理が不十分となり，手術適応として外科へ送られて来たときにはショック状態となっていて，手術により止血しえたものの腎不全の状態になったとか，hypoxiaが続いたために術後縫合不全を起こしたとか，大量輸血のために血清肝炎を併発したというような症例があることである．状態が不良のまま手術せざるを得なかったとしても，死亡の原因や合併症発生の原因はすべて外科医の責任となる．結局は，非手術的止血法そのものについての批判というものは少なく，手術適応の判定時期や全身的な管理・治療に問題があることになる．したがって，必ずしも表題に合致した内容ではないかもしれないが，思うところを述べさせていただきたい．

　Non-surgical methods of arresting hemorrhage from the digestive tract are performed not only by internists but by surgeons as well. Some of these methods are performed either as a means of diagnosis or emergency procedure preceding surgery. What is written here is therefore more of “opinion” than of “criticism”. If there are some problems that come under the heading of “criticism”, they would be whether or not the time of judgement for surgical indication was pertinent or whether sufficient general management was done during the procedure of nonsurgical control of bleeding.

　The “criticism” is written centering on two or three of the most frequent diseases among those responsible for bleeding from the digestive tract. In chronic gastroduodenal ulcer where blood vessels are exposed, the patient is apt to fall into shock. In gastric ulcer in elderly patients bleeding could be controlled for the time being, but in the long run re-bleeding is frequent. Therefore, in both instances when the patients' general conditions are good, it would be better to have recourse decisively to surgical intervention. Control of hemorrhage by vascular catheterization would be an effective measure in the future. The results of direct operative measure to ruptured varices of the esophagus are so good that it is recommended to check up on the present results and not on those in the past. Injection of vasoconstrictive agents by vascular catheterization or artificial embolism is useful as a preliminary measure before surgery. When the liver is highly impaired, these methods and injection of hardening substances are useful. If subtotal gastrectomy plus vagotomy or total gastrectomy be done in an early stage without scruple, the rate of re-bleeding would be low and so would be mortality. Hemorrhage from early gastric cancer is seen in no small numbers in all the patients with gastric carcinoma. For these patients examination for diagnosis must be done hand in hand with non-surgical control of bleeding.