潰瘍性大腸炎の外科的治療

Surgical Treatment for Ulcerative Colitis

　潰瘍性大腸炎患者は近年本邦においても増加の傾向にあり，厚生省特定疾患調査研究班の調査によると1974年までに約2,000例が集計されている．一般に本症は保存的治療では完全治癒が得られず，難治な疾患と考えられているとおり，1974年度以前に発症した1,442例の1974年度における転帰をみると，緩解の得られたものは30.6％にすぎない．20．3％が手術治療を受け，43.1％は治療を継続している．死亡例は86例6％で，このうち術後死亡が47例，手術を受けずに死亡したものが22例，計69例と，死亡例の8割近くが手術に関係した原因で死亡している¹⁾（Fig. 1）．

　この事実から，今後より効果的な内科的治療法を開発することはもちろんであるが，外科側として現段階では，どのような症例を手術適応とすべきかの正しい診断と手術時期の適切な判断が治療成績向上につながる当面の課題であろう．

　Indicatien of surgical treatment for ulcerative colitis is not obvious. To settle some criteria of indication and timing of operation is important. Various clinical features of our own 68 cases and the results of medical treatment of them were studied. The results are as follows.

　In our clinic 73 patients were treated in recent three years (June, 1973～March, 1976). 68 cases of them were studied.

　Age at onset ranges from 9 to 60 years old. The incidence rate rises up to the age of 20 or 30 and then begins to fall. There are 18 cases of involving the total colon (total colitis), 20 cases of implicating the left half of the colon (left sided colitis), and 30 cases of being restricted to the rectum (proctitis). Mean age at onset is youngest in total colitis patients. (26.8 years).

　Total colitis patients often accompanied with various systemic and local complications such as hypoalbuminemia, anemia, pseudopolyposis, stricture, massive hemorrhage, and acute colonic dilatation. They often failed in medical treatment. Left sided colitis and proctitis accompanied with much less complications than total colitis. All of these patients remitted by medical treatment and did not require operation.

　Operative treatment was only done in the patients with total colitis.

　Fulminant type cases should be operated if any improvement is not recognized by an intensive medical treatment of a few days duration.

　Most of the severe total colitis patients did not go into remission by four weeks intensive medical treatment and required operation. Therefore, operation is often preferable for these cases.

　10 cases of all patients (14.7％) underwent surgical treatment. Rectum-retaining operation was done in 8 cases. Overall results of this type of operation were satisfactory, notwithstanding some medically controllable anal bleeding was noticed after operation. This procedure is recommendable to over half of the cases with ulcerative colitis which require operation.

　Acute dilatation of the colon is one of the severe and life-threatening complications of ulcerative colitis and needs urgent operation. Decompression colostomy and diverting ileostomy (Turnbull's operation) was done in 21-year-old female. After one week anal bleeding and toxic signs completely disappeared, and general status was greatly improved. Total colectomy and ileorectal anastomosis was done successfully 45 days after the previous operation. Turnbull's operation may be one of life-saving procedures applicable to these cases with acute colonic dilatation.