バリウム腹膜炎に対する直腸切除・結腸単孔式人工肛門造設術後に腹腔鏡下結腸直腸吻合再建術を施行した1例

Laparoscopic coloproctostomy after proctosigmoidectomy with single barrel colostomy caused by barium peritonitis : Report of a case

◆要旨：バリウム腹膜炎は消化管造影検査に伴う稀ではあるが重篤な合併症であり，腹腔内のバリウムの残存により炎症の遷延や強固な癒着をきたすとされている．今回筆者らはバリウムによる汎発性腹膜炎に対して穿孔部を含む直腸切除，腹腔ドレナージと結腸単孔式人工肛門造設術を行い救命した後に，人工肛門閉鎖を目的に腹腔鏡下に結腸直腸吻合再建術を安全に施行しえた症例を経験したので報告する．患者は59歳，男性．バリウムを用いた上部消化管造影検査を施行した3日目に突発する下腹部痛が出現し当院へ搬送された．敗血症性ショックや播種性血管内凝固症候群（DIC）を伴う消化管穿孔，汎発性腹膜炎と診断し，緊急開腹術を施行した．直腸S状部に穿孔を認め，穿孔部を含む直腸切除，腹腔ドレナージ術と結腸単孔式人工肛門造設術を施行した．術後炎症反応が遷延したがDICからも回復し術後42日目に一時退院することができた．初回手術後の96日目に人工肛門閉鎖を目的に腹腔鏡下に結腸直腸吻合再建術を施行した．バリウム腹膜炎による高度の炎症性癒着を認めたが，腹腔鏡による拡大視効果を活かした正確な癒着剝離により安全に結腸直腸吻合再建術を施行可能であった．高度癒着が予測される汎発性腹膜炎手術後の二期手術でも腹腔鏡下手術は治療法の選択肢の1つになりうると考えられる．

　Barium peritonitis is a rare and life-threatening complication of gastrointestinal barium contrast studies, causing persistent inflammatory reaction and strong diffuse adhesions. We report a case of successful laparoscopic adhesiolysis followed by coloproctostomy after proctosigmoidectomy with single-barrel colostomy due to barium peritonitis. A 59-year-old man suffering from sudden lower abdominal pain after upper gastrointestinal barium contrast study was admitted to our hospital. The patient was diagnosed as having perforation of gastrointestinal tract with generalized peritonitis, septic shock and disseminated intravascular coagulation, and emergent laparotomy was performed. Operative findings showed generalized peritonits with barium and perforation of the upper rectum. Thus, proctosigmoidectomy with single-barrel colostomy was performed. Postoperative inflammatory reaction prolonged but gradually receded, and the patient was discharged 42 days after the operation. Re-operation of laparoscopic coloproctostomy was performed 96 days after the initial operation. Although severe inflammatory adhesion was observed after generalized peritonitis with barium, laparoscopic coloproctostomy was performed successfully due to minute laparoscopic adhesiolysis made possible by laparoscopically magnified view. This case suggests that laparoscopic surgery might be considered as one of the treatment options for patients with barium peritonitis.