Press through package（PTP）の誤飲によるS状結腸腸間膜内穿通に対する腹腔鏡補助下S状結腸切除術の1例

A case of laparoscopy-assisted sigmoidectomy for perforation due to press through package aspiration

◆要旨：患者は82歳，女性．下痢，発熱などを主訴に受診した．腹部CTでS状結腸憩室腸間膜内穿通と診断した．腹膜刺激症状がなく，炎症が限局していたため保存的治療を選択した．第7病日のCTで穿孔部の増悪が，下部消化管造影でS状結腸からの造影剤漏出が確認されたため，腹腔鏡補助下S状結腸切除を施行した．結腸壁はpress through package（PTP）により潰瘍を形成し穿孔しており，術後に発症1週間前にPTPを誤飲していたことが判明した．PTPの材質によってはCTでは描出不能な場合もあり，消化管穿孔の原因としてPTPの誤飲も念頭に置く必要がある．また，結腸穿孔であっても病巣が限局している場合は，腹腔鏡による一期的切除吻合も可能であると考えられた．

We report here a case of colonic perforation with a focal lesion that was treated by laparoscopy-assisted sigmoidectomy. An 82-year-old woman presented with diarrhea, vomiting and fever that had persisted for five days. The abdomen was tender in the left lower quadrant, but no sign of peritoneal irritation was elicited. An abdominal CT scan of the abdomen revealed thickening of the sigmoid colon wall with many diverticula, a high density of fatty tissue around the sigmoid colon, and some free air in the mesocolon sigmoideum. We diagnosed perforation of the sigmoid diverticulum, and administered conservative therapy due to the focal nature of the inflammation. After seven days, abdominal CT scans showed that the perforated sigmoid diverticulum had not improved, and lower GI X-ray series revealed leakage from the sigmoid colon. Therefore, a laparoscopy-assisted sigmoidectomy was performed. Macroscopic examination of a surgically obtained specimen revealed that the perforation was caused by the lodgment of the edge of a press through package（PTP）in the sigmoid colon wall. A detailed interview with the patient after the operation revealed that she had accidentally swallowed a PTP twelve days ago. This condition was difficult to diagnose before operating because of the radiotransparency of the PTP. Therefore, we recommend that ingestion of a PTP should always be suspected as a possible cause of perforation.