セレンディピティ (Serendipity)のすゝめ
上吉原 光 宏， 永 島 宗 晃， 伊 部 崇
竹 吉
泉
要 旨 普段から日常診療活動で注意深く臨床経過や症例経験を観察するような問題意識を持ち, 様々なツールを 利用して事象を探求していくという姿勢が重要である. そのためには常に日常の臨床活動で,「セレンディピ ティ (serendipity)」を信じることが非常に大切である.まさにセレンディピティは学会発表・論文執筆の原動 力といえよう. 論文を単なる業績のひとつと えればそれまでであるが,「自己の知見や技術が国内あるいは 海外でどのように受け入れられ, また微力ながらも貢献できることはあるのか？」というのも学会発表や論 文作成の大きな醍醐味である. 臨床と研究 (学会発表や論文執筆等) は決して相反するものではなく, 「車の 両輪」のように, 互いになくてはならないものである.（Kitakanto Med J 2010；60：49∼56） キーワード：セレンディピティ は じ め に 著者を含め多くの臨床医は日常臨床活動に必至に取り 組んでいる. 多忙な臨床医生活の中で, ともすれば研究 活動はおろそかになりがちであり. それを仕方なしとす る見方もある. しかし著者はあえて, 忙しいからこそ鋭 い洞察力や科学的な視点を維持することの重要性を訴え たい.臨床と研究 (論文執筆や学会発表等)は決して相反 するものではなく, 車の両輪」のように互いになくては ならないものと著者は える. そこで非常に大切なのが, 日常の臨床活動で, 常に「セレンディピティ (seren-dipity)」を信じることである.「セレンディピティ」を持 続・鍛錬し,臨床的に興味疑問を持った所見を,具体的に 短報として報告したい. 症 例Case 1: An Encounter with Persistent Left Superior-Vena Cava
This is a rare case of an encounter with persistent left superior vena cava (PLSVC), which is a rare congenital cardial anomaly. It is found in 0.3％ of the general population and in 3％ to 10％ of patients with congenital
heart disease. It is commonly associated with right SVC and rarely with absent right SVC.
A 63-year old woman fell from the stairs and had a bruise in her right-sided chest.Two days later, she had increasing chest pain and dyspnea, and she came to emergency department in our hospital. She had had no significant medical and family history of heart disease. Results from a 12-lead electrocardiogram and echocardio-gram were not remarkable. Computed tomographic scan of the chest demonstrated a pulmonary contusion of the bilateral lung, pulmonary hematoma and traumatic pneumatocele of the left lung. Moreover, an enhanced CT of the heart showed persistent left SVC and absent right SVC (Fig.1). When central venous catheterization via the right subclavian vein was performed,a catheter in would-be right-sided location by the mediastinum was found left-sided on the chest roentogenogram (Fig.2). These findings confirmed the presence of persistent left superior vena cava; there was no evidence of any other structural abnormalities of the heart. She made a full recovery, and was discharged on 20th hospital day.
Embryologically most of the left sided cardinal
sys-１ 群馬県前橋市朝日町3-21-36 前橋赤十字病院呼吸器外科 ２ 群馬県前橋市昭和町3-39-22 群馬大学大学院臓器病態外科学 平成21年10月19日 受付
tem disappears,and only the coronary sinus and remnant known as the ligament of Marshall. Insufficiency of obliteration of the left anterior cardinal vein results in PLSVC. Although PLSVC is mostly not associated with any major hemodynamic effects, it is important to know about it, as it may cause difficulties in central venous catheterization,pacemaker electrode placement,or during cardiopulmonary bypass. PLSVC is also associated with significant incidence of rhythm disturbance such as sinus node dysfunction and atrioventricular block. Wood found PLSVC in 20％ of cases of tetralogy of Fallot and 8％ of patients with Eisenmengers syndrome. Other anomalies include coarctation of aorta,atrial septal defect, ventricular septal defect, and endocardial cushin defect. Diagnosis can be confirmed by angiography, computed tomography, and magnetic resonance imaging scan allows clear identification of PLSVC and its ana-tomic relationship to other cardiovascular and
medias-tinal structures.
Case 2: Spontaneous epidural emphysema
This highlights a case of epidural emphysema,which is seen in male adolescents and it is usually due to alveolar rupture and, but the most common cause in children is asthma. Therefore, spontaneous epidural emphysema is very rare.
A 17-year-old man developed chest pain and short-ness of breath early in the morning. Six hours later, he noticed swelling of his neck and anterior chest and came to our emergency room. He had no history of asthma, cough, or bruising. An x-ray (Fig.3) and computed tomography(Fig.4) showed not only
mediastinal,subcu-Fig.1.CTof a patient, who fell at stairs, demonstrates a hemothorax and persistent left SVC and absent right SVC.
Fig.2.When central venous catheterization via the right sub-clavian vein is performed, a catheter in would-be right-sided location of the mediastinum is found left-sided on chest rentogenography.
Fig.4.Computed tomography shows not only mediastinal, subcutaneous, and extrapleural emphysema but also a linear radiolucent stripe in the spinal canal indicating epidural emphysema.
Fig.3.An x-ray shows subcutaneous, mediastinal, and pericardial emphysema.
taneous, and extrapleural emphysema but also epidural emphysema. The patient did not develop any neurologic findings. His general condition remained good. His oxygen saturation and the laboratory data were normal. He was treated conservatively and remained at rest, and his symptoms improved within a few days. Eleven days later, the emphysema had resolved spontaneously.
Case 3: Esophageal submucosal dissection presenting as wall thickening of the entire esophagus This is a unique case,which esophageal submucosal dissection demonstrates presenting as wall thickening of the entire esophagus. Initially, we had suspected descending necrotizing mediastinitis but abscess that should be drained was not observed. The main inflam-matory lesion was existed in submucosal layer through the esophagus.
A 60-year-old male was referred to our hospital because of dyspnea. He had a history of alcohol-related liver injury and diabetes mellitus but had been left untreated for several years. He had had a sore throat since a fishbone got stuck in his throat. Two days later, he went to previous hospital because of a chest pain. A diagnosis of deep neck and mediasitinal abscess had been made and he had received a penicillin antibiotic. On physical examination,the blood pressure was 160/106mm Hg ; the oxygen saturation was 92％ in room air. Labo-ratory evaluation revealed the following values: WBC, 5700/mm and CRP,20.6mg/dL. Chest computed tomo-graphy(CT)showed mucosal thickening in the esophagus ranging from the cervical region to the cardiac portion
(Fig.5).
After the airway is cleared by emergency tra-cheotomy,we performed upper esophagogastroduodenos-copy, which revealed esophageal submucosal dissection with bleeding extending the posterior wall measuring about 5 cm in length (Fig.6). The fiberscope could not be inserted any more. Through the mucosal tear, the muscular layer of the esophagus was observed. A diag-nosis of esophageal submucosal dissection was made due to a foreign body of the pharynx. The patient was treated with supplemental oxygen,broad-spectrum antibi-otics,and fasting. Percutaneous endoscopic gastrostomy was done one month after his hospitalization because esophageal stenosis was observed in an endoscopic find-ing. His tracheostomy orifice was closed and discharged on the 76th day. This is a very rare case of esophageal submucosal dissection with thickening of wall thickening of the entire esophagus.
Case 4: Horseshoe liver
This is a unique and rare case,which demonstrates a kind of a liver anomaly. These findings confirmed a liver anomaly, but we cannot find an appropriate name for it. Therefore,we have tentatively named this anatom-ical variation a horseshoe liver.
A 23-year-old woman had a bruise on the right side of her chest. Six days later,she had increasing back pain and came to the emergency department in our hospital. She had no significant medical or family history of liver disease. Computed tomography (CT) of the chest showed right rib fractures. By chance,the enhanced CT
Fig.5.Computed tomography shows mucosal thickening of the entire esophagus from the cervical to the cardiac portion (arrows).
Fig.6.Upper gastrointestinal endoscopy demonstrates the esophageal submucosal dissection, which measured about 5 cm in length (arrow), with bleeding extending to the posterior wall. Through the mucosal tear,the muscular layer of the esophagus was observed.
also showed the liver in the subdiaphragmatic region (Fig.7). In a coronal section, the left lobe of the liver was elongated to the left side,as if the liver straddled the stomach (Fig.8). The hepatic vasculature,portal system, and biliary duct system were normal variants. There was no evidence of any other structural abnormalities of the organ. The position of the liver shifted the spleen down-ward and the stomach backdown-ward,and made the left chest broader than the right chest. These findings confirmed a liver anomaly, but we cannot find an appropriate name for it. Therefore,we have tentatively named this anatom-ical variation a horseshoe liver.
Case 5: Spontaneous pericardial abscess
This highlights a massive pericardial abscess without trauma, which is of special interest because the pericar-dium was an uncommon primary site of infection,and in
addition,a massive abscess compressed and displaced the thoracic organ, and protruded into the thorax.
A 67-year-old woman developed a high fever and was administered antibiotics. Two weeks later, she presented with progressively worsening dyspnea and chest discomfort. An abnormal cardiac silhouette was noted on a chest x-ray (Fig.9). The patient had untreated diabetes mellitus. Computed tomography of the chest showed loculated pericardial fluid collected around the heart. A mass compressed and displaced the heart and lung, and protruded into the thorax (Fig.10). Broad-spectrum antibiotics were given. Then, a thoracotomy was performed and more than 1000mL of loculated and walled pus were drained, and a pericardiectomy was performed on the thickened pericardium. The pericar-dium is an uncommon primary site of infection, and is commonly infected secondarily after cardiac surgery. In this case,the uncontrolled diabetes mellitus might have led to a spontaneous pericardial abscess via
hemato-Fig.7.The enhanced CT also shows the liver in the subdia-phragmatic region.
Fig.8.In a coronal section, the liver is elongated to the left side, as if the liver straddles the stomach
Fig.9.A chest x-ray shows an abnormal cardiac silhouette.
Fig.10. Computed tomography of the chest shows loculated pericardial fluid collected around the heart. A mass compresses and displaces the heart and lung, and protrudes into the thorax
genous spread, direct spread from adjacent structures. Case 6:Before-and-after imaging of multiple rib
frac-tures using three-dimensional computed tomo-graphy
This highlights the imaging obtained using a 64-row multislice CT scanner and Mennen plates used for the treatment of non-weight-bearing bones.
A 37-year-old man injured his right chest when he fell down a ladder. He complained of severe chest pain. His thorax was deformed and dented around the bruised area. A mild flail chest was observed,but it did not lead to serious respiratory failure. A chest x-ray showed segmental fractures of the fourth to seventh ribs. Preoperative three-dimensional computed tomography (3DCT) shows the fracture lines and bone dislocation (arrowheads), mirroring the multiple fractures and the extent of the thoracic deformity simultaneously(Fig.11: A, anterior; B, right anterolateral; C, right lateral; D, right anteroposterior view). Three days after his hospi-talization,a right hemothorax developed,and a chest tube was inserted in the right thorax,which drained 2 liters of a hemorrhagic pleural effusion.
We repaired the ribs surgically because the deforma-tion of the right thorax was remarkable and his pain was ongoing. Through a lateral incision, the fractured fifth to seventh ribs were repositioned and fixed using three Mennen plates (Fig.12A, intraoperative finding). The total operating time was 120 minutes and the blood loss was 450g. His subsequent postoperative course was uneventful and he was discharged on POD 23.
Postoper-ative 3DCT shows almost complete correction of the ribs (Fig.12: B, anterior; C, right lateral view).
In this case,the imaging was obtained using a 64-row multislice CT scanner (Aquilion 64, Toshiba Medical Systems, Tokyo, Japan). 3DCT revealed the details of the fracture line and bone dislocation well, showing the multiple fractures and the extent of the thoracic deformity simultaneously. Mennen plates are mainly used for the treatment of non-weight-bearing bones. The plate consists of a central ridge with paired finger-like projec-tions on each side,which are squeezed into the bone with a crimping tool. The technique is simple and the operat-ing time is short.
察
「セレンディピティ (serendipity)」とは,「interesting or valuable discoveries are made by accident」, すなわち 「何かを探しているときに, それとは別の価値あるもの を見つけること」を表す言葉である.但し,それはただ単 に偶然や幸運などを意味する言葉ではない. 普段から物 事に対する「洞察力」や「察知力」を研ぎ澄ました状態 の中で,「偶然」とのシナジー効果によって何かに「気付 く」ことである. それは日常臨床活動の中でわれわれ臨 床医が必須とする大切な資質・姿勢であろう. 著者は現在の病院に赴任してから 11年以上が経過し (2009 年 9 月現在), 積極的に症例報告を行ってきた. す でに出版されたものはここで再掲載するわけにはいかな いため, 実際には論文にまでは至っていないが, 著者が 文献を収集するきっかけとなった症例をここで紹介し た. 論文を単なる業績のひとつと えればそれまでであ
Fig.11. Preoperative three-dimensional computed tomogra-phy (3DCT) shows the fracture lines and bone dis-location (arrowheads), mirroring the multiple frac-tures and the extent of the thoracic deformity simulta-neously(A,anterior; B,right anterolateral; C,right lateral; D, right anteroposterior view).
Fig.12. Through a lateral incision, the fractured fifth to seventh ribs were repositioned and fixed using three Mennen plates (A, intraoperative finding). Pos-toperative 3DCT shows almost complete correction of the ribs (B, anterior; C, right lateral view).
る.しかし,「自己の知見や技術が国内あるいは海外で,ど のように受け入れられ, そして貢献できるのか」という のも学会発表や論文作成の大きな醍醐味である. 医学を 含めた科学 野は日進月歩を っている. とりわけ近年, 外科学においては art& scienceという言葉が用いられる 傾向にある. 著者が外科学専攻のためなおさら常に感じ ていることであるが,「science」は時代を経て古臭くなる 部 もあるが,「art」は永遠であり続けると えている.芸 術界でも絵画や彫刻などの美術品は何世紀にも渡り輝き 続けているのと同様であろう. 普段から日常診療活動で注意深く臨床経過や症例経験 を観察するような問題意識を持ち, 様々なツールを利用 して事象を探求していくという姿勢が重要である. まさ にセレンディピティは学会発表・論文執筆の原動力と なっていると言えよう. ま と め 日常診療の中でセレンディピティを持ち続けること は, 臨床医にとって必要不可欠である. 謝 辞 今までに多くの御指導をいただきました, 群馬大学医 学部附属病院 森下靖雄 前病院長, 群馬大学大学院医 学系研究科臓器病態外科学教室員の先生方, 兵庫県立が んセンター名誉院長 坪田紀明先生, 昭和病院外科 平 井利和先生, そして学会発表・論文執筆に多大な理解を して下さってます前橋赤十字病院 宮﨑瑞穗院長, 池谷 俊郎副院長, また多くの患者様をご紹介くださってます 地域の先生方, 前橋赤十字病院呼吸器内科 滝瀬 淳部 長ならびに医局の先生方, さらにいつも真摯に治療に取 り組んで下さっております前橋赤十字病院外来・8号病 棟・手術室をはじめ多くのスタッフの皆様に深く感謝い たします. 文 献
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Promote Serendipity!
Mitsuhiro Kamiyoshihara,
Toshiteru Nagashima,
Takashi Ibe,
Izumi Takeyoshi
1 Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Gunma, Japan 2 Division of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine,
Maebashi, Gunma, Japan
It is very important to observe the clinical course of patients and the experiences involved in daily medical activities on a routine basis, and to study them using a variety of tools, including the Internet. Doing this will help to promote serendipity, that is, a natural ability to make interesting or valuable discoveries,by accident,in your daily life.Serendipity could lead to a medical presentation or publication of a paper. One might say that writing a paper is simply an achievement and leave it at that. However, it is also a real joy to know the extent to which your idea or technique has been recognized in Japan,as well as in the wider world. Clinical practice and research do not necessarily conflict with one another; rather, they are like two wheels on one cart .（Kitakanto Med J 2010；60：49∼56）
