特発性食道破裂の再建術後に発症した収縮性心膜炎の1剖検例

A Case of Constrictive Pericarditis after Surgical Reconstruction for Idiopathic Esophageal Perforation

　患者は54歳，男性．1987年に特発性食道破裂の診断で食道再建術を施行された．9年後の1996年6月より労作時の息切れ感が出現し，中旬には全身浮腫になり，心不全・肝不全の診断で入院治療を受けた．しかし，加療後も改善がみられず当院へ転院してきた．入院時の心エコー図検査では心外膜の肥厚がみられ，胸部X線CT検査で石灰化は確認されなかったものの，やはり肥厚した心外膜がみられた．心臓カテーテル検査では右心系の圧上昇と左心系との拡張期等圧化現象，および心室内圧波形にてdip ＆ plateau現象を認めた．収縮性心膜炎との診断で内科的治療を開始し，同時に根治術としての心膜剥離術を予定したが，急性腎不全が悪化し死亡した．剖検では，心外膜の線維性肥厚が著明で，右心系が著明に拡大していた．収縮性心膜炎が心臓手術後に発症する症例は多いが，食道再建術後に発症する例は極めて稀である．

　A case of chronic constrictive pericarditis after surgical reconstruction due to idiopathic esophageal perforation (rupture) was reported. In 1987, a fifty-five-year old man underwent a plastic reconstruction of the esophagus. Nine years after the operation, he complained of appetite loss, exertional dyspnea and edema, and was admitted to another hospital for the treatment of heart failure and liver dysfunction. His symptoms and laboratory data deteriorated progressively, and he was transferred to our hospital. On admission to our hospital, his dilating jugular veins presented Kussmaul's sign, and liver dysfunction was noticed. Echocardiogram and chest computed tomographic image revealed thickening of the pericardium and dilatation of the vena cava with a small amount of pericardial effusion. The left and right ventricular pressure recordings obtained from cardiac catheterization showed an early diastolic dip followed by a plateau during mid to late diastole and an equalization of pressures during diastole between both ventricles. There are many causes of constrictive pericarditis, such as viral, tuberculous, uremic and traumatic pericarditis. To our knowledge, constrictive pericarditis after esophageal surgery is extremely rare and a long time to manifest itsself. A wareness of and care for this disease should be continued for several years after surgery of the mediastinum.