谷河 篤

PURPOSE: This study aimed to clarify the timing and motivations behind decisions to pursue a surgical career and identify optimal recruitment strategies. METHODS: A nationwide questionnaire was administered to newly certified surgical trainees. Respondents were classified into two groups based on when they decided to pursue surgery: before junior residency (BJR) or during/after junior residency (DJR). The backgrounds and motivations were compared. RESULTS: Among the 758 respondents (53.8%), 25.6% were female. Male trainees were more likely to decide to pursue surgery before medical school (18.7% vs. 9.4%, p = 0.003), whereas female trainees more often decided during their PGY-2 (35.4% vs. 24.1%, p = 0.002). The DJR group included more women (30.3% vs. 21.7%, p = 0.014) and residents from urban areas (46.6% vs. 36.7%, p = 0.008). The BJR group was more influenced by the images of surgeons and family. Among female residents, those in the DJR group were more influenced by recruitment from the surgeons. CONCLUSIONS: This study demonstrated sex differences in the timing and motivation for pursuing a surgical career. Understanding the optimal timing and appealing factors for recruiting surgeons, particularly women, could inform more effective recruitment strategies.

OBJECTIVE: Selective non-operative management (SNOM) is increasingly used for hemodynamically stable patients with abdominal gunshot wounds (GSW). Although peritoneal signs traditionally mandate emergency laparotomy, the clinical value in the era of computed tomography (CT) remains unclear. This study evaluated the clinical value of peritoneal signs and the adjunctive use of CT for identifying patients requiring therapeutic laparotomy. METHODS: We conducted a retrospective cohort study of patients with abdominal GSW admitted to a Level I trauma center between 2016 and 2023. Patients with systolic blood pressure < 90 mmHg, Glasgow Coma Scale<9 or intubation in the emergency department were excluded. Patients were categorized by the presence of peritoneal signs upon arrival. Clinical data, CT, and operative findings were reviewed. The primary outcome was intra-abdominal injuries requiring therapeutic laparotomy. RESULTS: Among 308 patients, 57 (18.5%) had peritoneal signs. Of those, 50 (89.3%) had therapeutic laparotomy. Peritoneal signs alone demonstrated sensitivity of 36.8% and specificity of 95.9% (95% confidence interval [CI]: 28.7-45.4 and 91.7-98.3, respectively). Among 251 patients without peritoneal signs, 95 underwent laparotomy based on CT findings, with 85 (89.5%) having therapeutic laparotomy. Only two of 157 patients managed non-operatively after CT required laparotomy following clinical observation. Combining peritoneal signs with CT findings yielded sensitivity of 99.3% and specificity of 87.8% (95% CI: 96.0-100.0 and 81.8-92.4, respectively). CONCLUSIONS: Peritoneal signs alone had high specificity but limited sensitivity for detecting intra-abdominal injuries requiring therapeutic laparotomy. With selective CT use, our results supported the safety of SNOM in hemodynamically stable patients with abdominal GSW.

Cardiac tamponade is a life-threatening condition that may require a surgical pericardial window. However, due to the rarity and urgency of such cases, opportunities for hands-on procedural training are limited. We developed and evaluated a physical training model that simulates cardiac tamponade and allows for practice of the pericardial window procedure. The model was constructed using layered anatomical structures and simulated blood to replicate tamponade physiology. Emergency physicians and surgeons performed pericardiotomy using the model, after which a structured survey was conducted to assess its realism, educational value, and the participants' confidence in performing the procedure. Eight emergency or trauma physicians completed the procedure using the model and responded to the survey. The median participant age was 42 years, and three had no prior operative experience. The model received high ratings for both realism and educational value (median Likert score: 4). This simulation model provides a realistic, reproducible, and portable platform for training in rare, high-acuity procedures without the need for live patients. It may help bridge the gap in emergency care and support curriculum development for surgical education.

AIM: Minimizing radiation exposure and preventing pseudoaneurysm rupture are crucial for pediatric patients with delayed pseudoaneurysm following blunt liver and/or spleen injuries. However, the radiation exposure from follow-up CT scans in patients managed conservatively or with prophylactic embolization remains unclear. This study aimed to evaluate radiation exposure from CT scans based on these management strategies. METHODS: This research was a secondary analysis of a multicenter, retrospective observational study that included pediatric patients (≤16 years old) who sustained blunt liver and/or spleen injuries at 83 institutions in Japan from 2008 to 2019. Patients diagnosed with delayed pseudoaneurysm, defined as a newly detected pseudoaneurysm on or after the second day post-injury, were included. This descriptive study compared CT-related radiation exposure and rupture rates between patients with and without prophylactic embolization, with radiation exposure assessed using dose length product. RESULTS: Fifty patients had delayed pseudoaneurysm. Of these, 28 (56%) did not receive prophylactic embolization. The sum of dose length product in patients with delayed pseudoaneurysm not receiving prophylactic embolization was 4203 (1802-7503) mGy·cm, compared with 2492 (1258-4457) mGy·cm in those receiving prophylactic embolization (p = 0.12). Then, pseudoaneurysm rupture occurred in 32% of no prophylactic embolization patients, whereas no ruptures were observed in the embolization group (p = 0.003). CONCLUSION: Pediatric patients not receiving prophylactic embolization trended to have high radiation exposure from CT scans and had a higher rate of ruptured delayed pseudoaneurysm compared to those receiving embolization. These findings support further study of strategies to reduce rupture risk and radiation exposure.

BACKGROUND: Medical advances in intensive care units (ICUs) have resulted in the emergence of a new patient population-those who survive the initial acute phase of critical illness, but require prolonged ICU stays and develop chronic critical symptoms. This condition, often termed Persistent Critical Illness (PerCI) or Chronic Critical Illness (CCI), remains poorly understood and inconsistently reported across studies, resulting in a lack of clinical practice use. This scoping review aims to systematically review and synthesize the existing literature on PerCI/CCI, with a focus on definitions, epidemiology, and outcomes for its translation to clinical practice. METHODS: A scoping review was conducted using MEDLINE and Scopus, adhering to the PRISMA-ScR guidelines. Peer-reviewed original research articles published until May 31, 2024 that described adult PerCI/CCI in their definitions of patient populations, covariates, and outcomes were included. Data on definitions, epidemiology, and outcomes were extracted by a data charting process from eligible studies and synthesized. RESULTS: Ninety-nine studies met the inclusion criteria. Of these studies, 64 used the term CCI, 18 used PerCI, and 17 used other terms. CCI definitions showed greater variability, while PerCI definitions remained relatively consistent, with an ICU stay ≥ 14 days for CCI and ≥ 10 days for PerCI being the most common. A meta-analysis of the prevalence of PerCI/CCI among the denominators of "all ICU patients", "sepsis", "trauma", and "COVID-19" showed 11% (95% confidence interval 10-12%), 28% (22-34%), 24% (15-33%), and 35% (20-50%), respectively. A meta-analysis of in-hospital mortality was 27% (26-29%) and that of one-year mortality was 45% (32-58%). Meta-analyses of the prevalence of CCI and PerCI showed 17% (16-18%) and 18% (16-20%), respectively, and those for in-hospital mortality were 28% (26-30%) and 26% (24-29%), respectively. Functional outcomes were generally poor, with many survivors requiring long-term care. CONCLUSIONS: This scoping review synthesized many studies on PerCI/CCI, highlighting the serious impact of PerCI/CCI on patients' long-term outcomes. The results obtained underscore the need for consistent terminology with high-quality research for PerCI/CCI. The results obtained provide important information to be used in discussions with patients and families regarding prognosis and care options.

BACKGROUND: Hybrid emergency department (ED), which are equipped with fluoroscopy and computed tomography has been developed in Japan as a novel emergency care room. Although hybrid ED is effective in improving the outcomes of severe trauma, its influence on the management of out-of-hospital cardiac arrest (OHCA) requiring extracorporeal cardiopulmonary resuscitation (ECPR) remains unclear. OBJECTIVES: The aim of this study was to elucidate the impact of hybrid ED on ECPR procedures and outcome in OHCA patients focusing on time from hospital arrival to establishment of ECPR. METHODS: A retrospective single-center cohort study was conducted, including adult OHCA patients who underwent ECPR between April 2013 and March 2022. Patients treated in conventional ED were compared with those in hybrid ED. Primary outcome was time from hospital arrival to ECPR initiation. Secondary outcomes included favorable neurological outcome at 30 days and incidence of cannulation-related adverse events. RESULTS: Hybrid ED installation led to a significant decrease in time to ECPR initiation. In the interpreted time series analysis for the time from hospital arrival to establishment ECPR, there was statistically significant upward level change and downward trend change after the installation of hybrid ED. These results mean the time from hospital arrival to the establishment of ECPR was prolonged just after installation of hybrid ER, and the time from hospital arrival to the establishment of ECPR was shortened over time. There were no statistically significant differences between the conventional and hybrid ED groups on the favorable neurological outcome and cannulation-related adverse events. CONCLUSIONS: The installation of hybrid ED was associated with shortened time from hospital arrival to establishment of ECPR. Further evaluation is needed to elucidate the effects of hybrid ED on OHCA and determine an optimal strategy.

BACKGROUND: This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). METHODS: This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). RESULTS: A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. CONCLUSION: Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. LEVEL OF EVIDENCE: Level 4; Therapeutic/Care management.

INTRODUCTION: In out-of-hospital cardiac arrest (OHCA) patients with extracorporeal cardiopulmonary resuscitation (ECPR), the association between low-flow time, the duration between the initiation of conventional cardiopulmonary resuscitation and the establishment of ECPR, and outcomes has not been clearly determined. METHODS: This was a secondary analysis of the retrospective multicenter registry in Japan. This study registered patients ≥18 years old who were admitted to the emergency department for OHCA and underwent ECPR between January, 2013 and December, 2018. Low-flow time was defined as the time from initiation of conventional cardiopulmonary resuscitation to the establishment of ECPR, and patients were categorized into two groups according to the visualized association of the restricted cubic spline curve. The primary outcome was survival discharge. Cubic spline analyses and multivariable logistic regression analyses were performed to assess the nonlinear associations between low-flow time and outcomes. RESULTS: A total of 1,524 patients were included. The median age was 60 years, and the median low-flow time was 52 (42-53) mins. The overall survival at hospital discharge and favorable neurological outcomes were 27.8% and 14.2%, respectively. The cubic spline analysis showed a decreased trend of survival discharge rates and favorable neurological outcomes with shorter low-flow time between 20 and 60 mins, with little change between the following 60 and 80 mins. The multivariable logistic regression analyses showed that patients with long low-flow time (>40 mins) compared to those with short low-flow time (0-40 mins) had significantly worse survival (adjusted odds ratio 0.42; 95% confidence intervals, 0.31-0.57) and neurological outcomes (0.65; 0.45-0.95, respectively). CONCLUSIONS: The survival discharge and neurological outcomes of patients with low-flow time shorter than 40 min are better than those of patients with longer low-flow time.

AIM: Hypoglycemia at admission is associated with high mortality in sepsis patients. However, the influence of body mass index (BMI) on this association remains unknown. Therefore, this study assesses the association of hypoglycemia at admission with mortality in patients with sepsis according to BMI. METHODS: This was a secondary analysis of a multicenter, prospective cohort study of 59 intensive care units in Japan. We included 1184 patients (age ≥16 years) with severe sepsis and excluded those with missing data on glucose level, BMI, or survival at discharge. The initial blood glucose level of <70 mg/dL was defined as hypoglycemia. Patients were assigned to the hypoglycemia or non-hypoglycemia group as per BMI category (<18.5 [low], 18.5-24.9 [normal], and ≥25 [high] kg/m2). The main outcome was in-hospital mortality. Multivariate logistic regression models were used to evaluate BMI category-by-hypoglycemia interactions. RESULTS: Overall, 1103 patients, including 65 with hypoglycemia, were analyzed. In the normal BMI group, patients with hypoglycemia had a higher in-hospital mortality rate (18/38, 47.4%) than those without (119/584, 20.4%). There was a significant interaction between normal BMI and hypoglycemia affecting in-hospital mortality; however, this effect was not observed for other BMI categories (odds ratio, 2.32; 95% confidence interval, 1.05-5.07; p-value for interaction = 0.0476). CONCLUSION: The relationship between patients with sepsis and hypoglycemia on admission may differ according to BMI. Hypoglycemia on admission may be associated with high mortality in patients with normal BMI, but not in those with low or high BMI.

【はじめに】近年, Virtual reality (VR) を用いた医学教育の学習効果が期待されている. 【目的】外傷診療におけるVR教育のニーズや課題を探索する. 【方法】第36回日本外傷学会総会・学術集会イブニングセミナー (2022年6月30日) にて3施設からのVRを用いた外傷診療に関する講義を行い, アンケート調査を実施した. 対象は医師とし, 所属施設別と年代別で検討した. 【結果】セミナー参加者は102名, 医師からの有効回答数は79であった. 治療手技に焦点を当てたコンテンツが79名中32名 (40.5%) と最もニーズはあったが, 大学病院所属者からのニーズは30名中8名 (26.7%) と少なかった. VR動画の編集時間に関しては, 所属施設や年代に関係なく作業時間がとれないまたは作業時間がとれても週に2時間未満という回答が約60%であった. 【結論】治療手技のニーズは全体では高いが, 所属施設別での検討では異なった. VR教育への期待は高いが, VRの編集時間の確保が課題となった.

BACKGROUND: Resuscitative thoracotomy is a lifesaving procedure for trauma patients that are hemodynamically unstable. Cross-clamping of the descending thoracic aorta is an essential procedure performed during resuscitative thoracotomy in patients with impending cardiac arrest. Although complications related to resuscitative thoracotomy have been reported, there is no report on avulsion of aortic branches related to cross-clamping of the descending aorta and its appropriate management. CASE PRESENTATION: We present the case of a 42-year-old woman who sustained blunt trauma due to an accidental fall. The patient was hemodynamically unstable and required resuscitative thoracotomy with cross-clamping of the thoracic aorta. However, hemorrhage from avulsion of aortic branches related to aortic cross-clamping was identified. Initially, transcatheter arterial embolization was attempted to achieve hemostasis; however, when that proved ineffective, thoracic endovascular aortic repair was performed, which resulted in successful hemorrhage control without any sequelae. CONCLUSIONS: Thoracic endovascular aortic repair may be a management option for aortic branch avulsion due to cross-clamping of the descending aorta during resuscitative thoracotomy.

Computed tomography (CT) is a sensitive and specific test for thoracic aortic injury, and is the choice of diagnostic test for adult patients. However, the diagnostic accuracy of conventional CT in pediatric patients has not been elucidated, and the diagnostic strategy has not been clarified. We present the case of an eight-year-old patient who had a thoracic injury, with left open pneumothorax, pulmonary contusion, and multiple left-sided rib fractures. Although the findings on conventional CT were insufficient either to diagnose or deny as having thoracic aortic injury, additional examination using electrocardiogram-gated CT angiography and three-dimensional reconstruction revealed a localized enlarged aortic diameter with an intimal flap. Electrocardiogram-gated CT may be useful for diagnosing thoracic aortic injury in pediatric patients.

Retropharyngeal hematoma is a potentially life-threatening condition because it can easily lead to airway obstruction. Most of the previously reported cases of retropharyngeal hematoma are caused by predisposing factors such as head and neck trauma, the use of anticoagulants, or the presence of underlying bleeding diathesis. Herein, we report a case of retropharyngeal hematoma in a patient with chronic alcoholism, where we could not confirm any predisposing factors at the time of examination. A 61-year-old man with chronic alcoholism presented to our emergency department with convulsive seizures. He was diagnosed with alcohol withdrawal and transferred to a secondary hospital after the seizure resolved. However, a few hours later, he returned to our department with a persistent cough and complained of pain and swelling in the neck. One hour later, he suddenly developed dyspnea; therefore, emergency intubation was performed. Although initially computed tomography (CT) showed normal findings, contrast-enhanced CT revealed a retropharyngeal hematoma. He was managed conservatively and transferred to a specialty hospital for intensive care. Chronic alcoholism may be a predisposing factor for retropharyngeal hematoma due to the high incidence of head trauma, neck hyperextension by convulsion, and hemostatic disorders. However, taking an accurate patient history is sometimes difficult because of the effects of intoxication or alcohol withdrawal. If a patient with chronic alcoholism presents with symptoms of airway compression, then a retropharyngeal hematoma should be suspected, and emergency intubation should be considered.

Percutaneous needle biopsy is minimally invasive and widely performed. Bleeding is an important complication of needle biopsy. Because the wound created by the needle is small, the recognition of bleeding in the body may be delayed, and this delay can lead to hemorrhagic shock and death. We report two cases of hemorrhagic shock in which the trauma triad of death developed after needle biopsy and the patients required resuscitation and damage control surgery. Needle biopsy is less invasive but cannot stop bleeding, and so surgery should be considered to ensure hemostasis in a compromised patient.

症例は79歳女性で、30年前にくも膜下出血で開頭クリッピング術後、水頭症で脳室-腹腔シャント(VPS)が留置されていた。1ヵ月前に転倒による右股関節痛で当センターに搬送となり、右大腿骨頸部骨折の診断で大腿骨頭置換術を行ったが、入院中に発熱と右季肋部に圧痛を認めた。腹部CTで胆嚢壁の肥厚と肝床部に液体貯留を認め、壊疽性胆嚢炎の所見であった。シャントチューブが上腹部より腹腔内に挿入され、炎症がある胆嚢に接していた。以上より、VPS留置下の急性胆嚢炎と診断した。胆汁瘻によるシャントチューブの逆行性感染のリスクを考え胆嚢ドレナージは施行せず、同日緊急で胆嚢摘出術の方針とした。シャントチューブが右腹部にあることや腹腔内観察の目的で開腹手術ではなく腹腔鏡下胆嚢摘出術(LC)を選択した。通常のLCと同様に体位は頭高位左ローテーションとし、気腹圧は最大12mmHgとした。通常通りの胆嚢摘出術を行い、肝床部に閉鎖式ドレーンを留置した。術中に頭蓋内圧の亢進を疑う所見は認めなかった。術後3日目より食事を開始、胆汁瘻がないことを確認して術後5日目にドレーンを抜去した。逆行性感染や頭蓋内圧亢進といったシャント感染や閉塞を疑う臨床所見は認めなかった。

当院は地域の救急医療を担う中核病院で、救命救急センターと外科は密接に連携をとり、日中の診療や手術だけでなく、昼夜を問わず救急車の受け入れや緊急手術、集中治療を行っている。しかし、手術室では近年、麻酔科医の不足などにより定時手術は削減傾向で、緊急手術の対応も困難なことが多い。一方で、救命救急センターは拡充により重症患者の初療対応や集中治療を担っており、人工呼吸器や体外式膜型人工肺など様々なデバイスを使用している重症患者の治療を積極的に行っている。今回、2015年4月から2017年3月までの2年間に、患者の全身状態不良や手術室で対応困難などの理由によりICUで手術を行った6例について後方視的に調査した。結果、open abdomenに対する腹腔内観察や閉腹といった比較的短時間の手術から、腸管切除や膵切除といった難易度の高い手術まで多岐にわたっていた。スタッフ不足という課題はあるものの、手術室で対応困難な場合にはICUで手術を行うことが必要と考えられた。

A 74-year-old male was diagnosed with transverse colon carcinoma with idiopathic mesenteric phlebosclerosis (IMP). Extended right hemicolectomy with regional lymph node dissection was performed. It has been reported that IMP develops after taking Chinese herbs containing SANSIS for a long time. In this case, the patient had taken such an herb for more than 3 years. In Japan, total 6 cases have been reported on a tumor with IMP, including this case. Immunohistological examination showed that the IMP findings were particularly strong around the tumor. Thus, this case suggests that there is a link between the tumor and IMP.

若年男性のコンタクトスポーツによる外傷性腎損傷に続発した尿嚢腫例(61歳男)を経験した。腹部エコーを繰り返し施行することで早期に尿嚢腫を疑うことができ、逆行性腎盂造影で診断を確定し、尿管ステントによる低侵襲治療に結びつけることができた。

49歳男。37歳時に強直性脊椎炎(AS)と診断された。一過性の意識消失を起こし、壁に前頭部を打撲した。後頸部から両肩にかけての自発痛で救急要請となった。MRIではC7にT1WIで低信号、T2WI高信号域があり、C7椎体前面に血腫を認め、軽度の脊柱管狭窄状態であった。頸椎カラーでの固定は継続し、第8病日に頭椎前方固定術を施行した。第9病日、ハローベストを装着した。術後経過は良好で、リハビリも順調に行うことができ、知覚鈍麻、筋力低下は徐々に改善した。第92病日、骨癒合は良好であることを確認し、ハローベストを解除した。第100病日、独歩で自宅退院した。