術前診断が可能であった胆囊結腸瘻に対し腹腔鏡下手術を施行した1例

A case of preoperatively diagnosed cholecystocolic fistula which was treated successfully by laparoscopy-assisted excision

◆要旨：患者は68歳，男性．全身倦怠感と発熱を主訴に来院した．CTでは4年前に指摘された胆囊結石を認めず，胆囊内気腫像が指摘された．注腸造影にて肝彎曲部に胆囊結腸瘻を示唆する造影剤の流出が認められ，胆囊結腸瘻と診断し腹腔鏡下に手術を開始した．癒着を鈍的に剝離し，胆囊結腸瘻を同定，胆囊摘出後病変部を腹腔外へ挙上して瘻孔を含め横行結腸を部分切除した．患者は術後経過良好で第7病日目に退院した．

　胆囊結腸瘻は他の内胆汁瘻と比較し手術手技が容易であり，腹腔鏡下手術のよい適応と考えられる．しかし，悪性疾患を合併することもあり，その可能性がある場合は胆囊管処理を先行し，腹腔外で瘻孔を切除することで安全に施行しうると考えられた．

　A 68-year-old man with a history of gallstones spanning approximately 4 years was admitted to the hospital because of general fatigue and high fever. Computed tomography of the abdomen revealed the absence of stones seen in the gallbladder previously, pneumobilia, and gas in the gallbladder with thickened wall. Barium enema showed leakage of contrast medium, which suggested cholecystocolic fistula in the hepatic flexure of the colon. Therefore, an operation under laparoscopy was carried out. At surgery, blunt dissection enabled the cholecystocolic fistula to be identified and cholecystectomy was done after intraoperative cholangiography. The gallbladder and the transverse colon were exteriorized through the additional incision and partial resection of transverse colon was performed. The postoperative course was uneventful, and the patient was discharged 7 days after operation.

　This report describes that laparoscopic surgery for cholecystocolic fistulas, which sometimes involve malignant disease, can be adopted as the first treatment choice, and our procedure, in which cholecystectomy precedes extracorporeal resection of transverse colon, is considered to be safe and feasible, in case of diagnostic difficulties of malignant tumor.