J.Jpn. Surg. Soc.. 58(6): 939-982, 1957
宿題報告
SURGERY OF THROMBO-EMBOLISM
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First Department of Surgery, Nagoya University School of Medicine Yoshio HASHIMOTO |
Venous thrombosis
Case 1. Postoperative phlebothrombosis: A 41-year-old male was underwent craniotomy for removal a tumor. Three days postoperatively he showed swelling on the left lower extremity and he died on the morrow. The autopsy revealed thrombus in the v. iliaca communis, sinus sagittalis superior and sinus transversus.
Case 2. Thrombophlebitis migrans: A 31-year-old male developed a thumbsized induration on the left lower thigh. The induration gradually involved various veins. An anticoagulant therapy was fovorably applied and the patient was discharged.
Case 3. Venous thrombosis due to pharmacal origin: A 52-year-old male with lymphogranulomatosis mesenterialis was parenterally administerd with 20 doses of sarcomysin followed by the development of discoloration and edema on the extremities.
Arterial Thromhosis
Case 4. Traumatic arterial thrombosis: A 52-year-old male suddenly developed a discoloration and pain on the right lower extremity 7 days after he had injured the lumbal region. Fourteen days later he showed a blister formation.
Case 5. Peripheral arterial embolism: A 39-year-old male developed gangrene on the toe tips as a sequela to traumatic aneurysm on the right thigh.
Case 6. Suppurative arterial thrombosis: A 12-year-old male. While being treated for endocarditis lenta gangrene developed on the dorsal legs and toes. On his death 20 days later, autopsy revealed suppurative thrombus on the left thigh, and large thrombus on the left radial artery ; infarct on the liver, kidneys and spleen.
Case 7. Buerger's disease: A 40-year-old male noted the obturated thrombus of artery had been moving proximally, despite lumbar sympathectomy and other treatments which had been performed.
Case 8. Arteriosclerosis obliterans: A 74-year-old male noted discoloration on the bilateral dorsal hands resulting in persistent ulceration.
Case 9. Acrosclerosis: A 45-year-old female noted skin atrophy around her lips, cold sensation, peripheral atrophy and gangrene on the extremities.
Incidence
Incidence in chronological factor : The incidence has been found increasing each year in foreign countries. In Japan it is also found increasing on the basis of clinical statistics carried out at 155 hospitals by the author. Venous thrombosis is into postoperative one (42.3%) and spontaneous one (40.0%). The incidence occupies 0.103% of the whole number of operations, and 0.23% of laparotomy. So far as age group is concerned, postoperative venous thrombosis is predominant in the thirties, showing the incidence in females 4 times male. Spontaneous venous thrombosis is predominant in the twenties, showing a slightly superior number in males to females. Venous thrombosis of pharmaceutical origin is the most common in the twenties, showing predominance in males. As to disease classification, surgical aspect and obstetrics and gynecolo gical aspect are approximately even in numbers. The incidence is very often encountered following an abdominal surgical intervention. If a development of thrombosis is established by a developement of edema, it appeared frequently 1-2 weeks after operation ; post-traumatic thrombosis appears rather rapidly, post-partum one appears at the same stage as postoperative one. The side of occurrence is predominant on the left extremity for postoperative thrombosis, and rather frequent on the right extremity for spontaneous thrombosis. Thrombosis has been mostly treated by a palliative therapy. Quite often it requires over a month to cure the disease. The cure rate is only 30%, the mortality rate being 12.4%. Pathological statistics for the past 10 years have shown a yearly increase in thrombo-embolism. So far as age group is concerned fortieth is predominant; male shows about twice the incidence as female. The disease is classified into internal department (61.6%), surgical department (21.5%) obstetric and gynecological departments (5.4%), pediatric department (5.1%), etc. On disease basis, the patients surveyed contain 229 malignant tumor cases, 159 heart cases, 81 infection cases, etc. The cancer cases observed include 58 gastric, 30 hepatic, 21 pulmonary, 21 uterine cases, etc. The cite of thrombosis are the lung (210 cases), peripheral veins (164 cases), heart (141 cases), liver (95 cases), and portal veins (90 cases). Thrombosis in peripheral veins is frequent in lower extremity veins on autopsy; it is observed considerably on the left side, too. Arterial thrombosis occures in the upper extremities as well lower extremities. At the author's department, during the past 6 years 35 post-op erative thrombosis cases and 17 spontaneous thrombosis cases have been operated on. Most of the cases developed following appendectomy and hysterectomy.
Symtoms and diagnosis
Family history for venous thrombosis compries a considerably high incidence such as cerebral hemorrhage and hypertention. Of clinical findings, chief features are pain on motion subjectively and edema aud swelling objectively. Most of venous thrombosis cases show a shortening of clotting time; there are observed an increase in platelets and acceleration of their viscosity; prothrombin remains unchanged; tolerance against heparin is observed; Thorn's test generally reveals normal. Estrogen is higher in males; urinary 17-ketosteroid and 17-hydroxycorticoid are mostly within normallimits; excreted adrenalin is normal in amount; excreted noradrenalin is higher in the patient than in a normal subject. The author's special test on thrombelastography has revealed that venous thrombosis causes a shortening of the beginning of clot and shortening of clot-retraction saccharine metabolism. Blood suger remains unchanged but suger disposal function is slightly decreased. Lipometabolism : Whole cholesterin is slightly high as well as phosphatides; cephalin is the highest. At the author's department, thrombosis also studied as to capillarography, electroplethysmography, angiography, etc. As a result, transmedullary phlebography is advocated in taking picture of deep veins; the importance of enlargement photography is discussed in an observation of peripheral blood vessels; the so-colled functional phlebography designated by the author, i.e., a serial photography with certain intervals, is found necessary in studing dynamic conditions of blood circulation; case reports are made on functional phlebography, seriarography and cinematography bases. A simple gastrocunemius region binding test is also discussed for an early diagnostic method of lower extremity thrombosis.
Application of radioactive isotopes: Three isotopes, P32, I131 and Na24 are used for studying circulation index, S/F ratio, C/F ratio and Th/F ratio and local clearance. Circulation index generally shows a normal value in venous thrombosis but a high value in Buerger's disease suggesting arterial circulation disturbances. It is almost within a normal limits in Th/F ratio, but is slightly high S/F ratio. It is still higher in C/F ratio suggesting venous circulation disturbances. Local clearance shows a low value in venous thrombosis hinting at the significance of an effective flow.
Pathology of thrombosis
Clinical and experimental studies are made on vascular walls, blood circulation velocity, and blood coagulation factors as to their changes, in an attempt to classify the etiology of thrombosis. As influential factors for the formation of thrombosis, histamin and serotonin are counted as well as heparin. These seem to play an important role in the formation of thrombosis an humoral basis. These seem considerably subject to influences of surgical intervention. As is the case with other diseases, thrombo-embolism seem to occur when a certain physiological defense is diminished, possibly due to an unbalance of between blood-coagulability and fiblinolytic function. Changes in blood circulation velocity especially those in the intima seem more responsible for the formation of thrombosis. It is assumed then that intimal changes are attributable to humoral chemical substances besides to physical influences and inflammatory mechanism of the body.
Histopathology of blood vessels
A further study is made of thrombosis on histochemical basis. It is revealed that all cases, irrespective of known duration, show some changes in the nerves of the vascular wall reminding one of the importance of such findings of the vascular wall.
Complication
Experimental and preventive studies are made on plumonary embolism as a complication of venous thrombosis on the basis of ligature of the vena cava. It is revealed that there is a close relationship between pulmonary embolism and serotonin, and that a ligature distal to the bifurcation of the renal vein on the vena cava gives no life huzard.
Anticoagulants
Clinical and experimental studies are made of heparin, coumarin, and phenylindandion. The experimental result of dextra sulfat, a newly introduced product by the author is also reported. The new product has a similar blood coagulant action to heparin and has efficacy lasting 5 times as long as the latter.
Prevention and treatment
As favorable preventiv e procedures recommendation is made for Unna's paste boot, vitamin E, Kalliklein, Cortisone, and Hirudoid, etc. Trypsin is highly claimed to favorable treatment of serious ulcer due to venous flow disturbances. As to anticoagulant therapy, experience with heparin, tromexan, and sintrom are discussed;
surgically a report is made of sympathectomy, thrombectomy, and removal of th e occluded vein giving a favorable illustration of vein graft with a successful case report for thrombosis of long standing. It is strongly suggested that a thrombosis team be established to combat the disease.
(author's abstract)
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