腹腔鏡下に経腹的な子宮ドレナージが有用であった穿孔性子宮留膿腫の1例—COVID-19流行による婦人科受け入れ困難かつ婦人科医不在の状況下で消化器外科医にできること

Successful laparoscopic transabdominal uterine drainage for perforated pyometra : A case report

◆要旨：COVID-19の感染拡大に伴う医療現場の逼迫は続いており，必要な転院搬送ができず苦慮している．症例は78歳，女性．腹痛と発熱を主訴に当院夜間外来を受診した．腹部全体に腹膜刺激症状を認め，血液検査では炎症反応高値だった．CTでは上腹部を中心にfree airを認め，消化管穿孔を疑った．汎発性腹膜炎の診断で緊急手術を行った．審査腹腔鏡で骨盤内に混濁した腹水と子宮底部に5mm径の穿孔を認め，穿孔性子宮留膿腫と診断した．当院には婦人科がなく，COVID-19の影響で婦人科のある近隣の病院は受け入れ停止になっていた．腹腔鏡下に子宮穿孔部から子宮内に減圧チューブを留置した．婦人科癌の合併はなく，ドレーン洗浄と頸管ドレナージを行い治癒した．

　With the spread of COVID-19, the hospitals continue to be under pressure, and clinicians are struggling to transfer patients to other hospitals as necessary. The present patient was a 78-year-old woman who presented to our hospital's nighttime outpatient clinic with complaints of abdominal pain and fever. Signs of peritoneal irritation were observed throughout the abdomen, and a blood test showed a high level of inflammatory reaction. Computed tomography showed free air in the upper abdomen, and gastrointestinal perforation was suspected. An emergency operation was performed under a diagnosis of generalized peritonitis. Laparoscopic examination revealed turbid ascites in the pelvis and a perforation of 5 mm in diameter at the fundus of the uterus, leading to the diagnosis of perforated pyometra. Our hospital does not have a gynecology department, and due to the influence of COVID-19, hospitals with gynecology departments in our area have stopped accepting patients. Thus, a drainage tube was placed laparoscopically in her uterus through the uterine perforation. There was no underlying gynecologic cancer, and the patient was treated and cured by cervical drainage.