術前の血栓溶解療法にもかかわらず腹腔鏡補助下横行結腸切除後に肺血栓塞栓症が再発した1例

A case of recurrence of pulmonary thromboembolism after laparoscopic-assisted resection for transverse colon cancer, which occurred in spite of thrombolytic therapy before surgery

◆要旨：患者は，72歳，女性．貧血の精査の結果，進行横行結腸癌の診断で外科紹介となった．術前のCT検査にて無症候性の肺血栓塞栓症（PTE）と左深部静脈血栓症（DVT）が認められた．ヘパリン持続静注を1週間行い，PTEの消失とDVTの縮小を認め，D3郭清を伴う腹腔鏡補助下横行結腸切除後を施行した．第2病日からヘパリン持続静注および離床を開始した．ICUにて厳重な監視のもと，歩行・排尿を行ったが異常は認められず，第4病日に一般病棟に帰棟した．同日，排便直後に突然胸痛を訴え，冷汗・低酸素血症が出現し，画像所見よりPTEの再発およびDVTの増悪と診断された．緊急で経皮的血栓吸引術を施行し，症状は速やかに改善した．その後は大きな問題なく経過し，ヘパリンをワルファリンに置換して，術後約1か月で軽快退院となった．術前PTE，DVTを認める患者に対する治療，予防に関して非常に示唆に富む症例であったため報告する．

A 72-year-old woman who was referred for further examination of anemia was found to have advanced transverse colon cancer. Preoperative CT findings showed pulmonary thromboembolism（PTE） and deep vein thrombosis（DVT） of the left leg. After continuous intravenous injection of heparin for one week, disappearance of PTE and size reduction of the DVT were observed. Laparoscopic-assisted resection for transverse colon cancer with D3 lymph node dissection was performed. On the 2nd postoperative day（POD）, she started ambulation with continuous intravenous injection of heparin. After she was done walking and urination under the strict observation at intensive care unit, she returned to the general ward on 4th POD. On the same day, she suddenly complained of chest pain with cold sweat and hypoxemia immediately after defecation. She was diagnosed as a recurrence of PTE and regrowth of DVT on CT. Her symptoms were improved immediately after emergency percutaneous thrombus aspiration. Other operative courses were without major problems, and warfarin was replaced with heparin. She recovered and was discharged in about one month after surgery.