腹腔鏡下結腸切除術中に偶然発見された無症候性魚骨小腸穿孔の1例

A symptomatic small intestinal perforation caused by a fishbone accidentally found during laparoscopic colectomy : a case report

◆要旨：患者は74歳，女性．下行結腸・S状結腸癌に対して2009年6月，腹腔鏡下結腸切除術を実施した．腹腔内は肝表面と腹壁の間にカーテン状の癒着を認め，クラミジア感染によるFitz-Hugh-Curtis症候群を疑った．視野の確保を行っていた際，トライツ靭帯から約30cmの空腸から魚骨と思われる異物が腹腔内に露出していた．穿孔部の周囲には炎症物質の付着や癒着は認めなかった．腹腔鏡下に異物を除去し，結腸切除後に同部の切除を行った．自験例は術前に発熱や腹膜炎症状はなく，術前日まで経口摂取を問題なく行っており，無症候性に経過していたと考えられた．無症状に経過した魚骨による消化管穿孔の論文報告は，筆者らが海外を含めて検索した限り自験例が初めてのため，今回報告する．

　A 74-year-old woman was admitted to our hospital in May, 2009 for elective colectomy for descending and sigmoid colon cancer. Except for appendectomy for acute appendicitis in her fifties, her past medical history was unremarkable. Descending and sigmoid colectomy was performed in June, 2009. Intraoperatively, curtain-like fibrous perihepatic adhesions were identified and Fitz-Hugh-Curtis syndrome was suspected. After adhesiolysis, a fishbone-like foreign body penetrating the jejunal wall at approximately 30 cm distal to the ligament of Treitz was encountered. The serosa at the penetration site was whitish, but neither inflammatory reactions nor adhesions were found in the surrounding tissue. The foreign body was laparoscopically removed, and following colectomy, the penetrated part of the jejunum was resected segmentally. The foreign body removed was whitish, 18 mm in size, and confirmed to be a fishbone. Prior to the elective colectomy, the patient was afebrile without symptoms or signs of peritonitis. To the best of our knowledge, this is the first report of incidentally identified intenstinal perforation by a fishbone. We also discuss relevant cases in the literature.