鯉沼 広治

＜文献概要＞症例1は57歳,男性.直腸癌(Rab)に対し腹腔鏡下低位前方切除+回腸人工肛門造設術を施行した.症例2は54歳,男性.直腸癌(Ra)に対し腹腔鏡下低位前方切除術を施行した.症例3は67歳,男性.直腸癌(Rb)に対し腹腔鏡下直腸切断術+左側方郭清を施行した.体位は砕石位で両下腿に間欠性空気圧迫装置を装着し,頭低位・右側低位としていた.手術時間は各々575分,310分,619分でいずれも術直後より左下腿の硬結・圧痛を認めた.CTで左下腿筋の造影不良・浮腫を認め下肢コンパートメント症候群と診断し,保存的治療にて軽快した.下肢コンパートメント症候群は時に後遺障害を残すことのある重篤な合併症である.文献的考察を踏まえ,筆者らの対応策を含めて報告する.

INTRODUCTION: Transverse colon resection is one of the most difficult laparoscopic procedures because of anatomic hazards such as variations in the mesenteric vascular anatomy and the complex structure of organs and surrounding membranes. METHODS: We evaluated the short-term surgical outcomes of laparoscopic transverse colon resection using a creative approach. This approach included preoperative surgical simulation using virtual surgical anatomy by CT, a four-directional approach to the mesentery, and 3-D imaging during laparoscopic surgery. RESULTS: A total of 45 consecutive patients who underwent laparoscopic resection for transverse colon cancer from June 2013 to December 2017 were enrolled in this study. All procedures were completed safely, with minor postoperative complications, including two patients with anastomotic stenosis, two with intra-abdominal phlegmon, one with delayed gastric emptying, and one with pneumonia, all treated non-operatively. There were no conversions to open resection. Operation time was 203 min (range, 125-322 min), and the estimated blood loss during surgery was 5 mL (range, 0-370 mL). The mean postoperative hospital stay was 10 days (range, 7-21 days), and no patients required readmission. CONCLUSION: Short-term surgical outcomes after laparoscopic transverse colon resection demonstrated that this creative approach was safe and feasible. The four-directional approach to the meso-transverse attachment combined with preoperative radiological simulation can facilitate laparoscopic transverse colon surgery.

INTRODUCTION: Laparoscopic lateral pelvic lymph node dissection (LPLD) is technically challenging because of the complicated anatomy of the pelvic wall. To overcome this difficulty, we introduced preoperative 3-D simulation. The aim of the study is to investigate the usefulness of preoperative 3-D simulation for the safe conduct of laparoscopic LPLD for rectal cancer. METHODS: After undergoing colonoscopy, patients were brought to the radiology suite where multi-detector row CT was performed. Three-dimensional images were constructed at a workstation and showed branches of the iliac artery and vein, ureter, urinary bladder, and enlarged lymph nodes. All members of the surgical team participated in preoperative simulation using the 3-D images. RESULTS: A total of 10 patients with advanced lower rectal cancer and enlarged lateral pelvic lymph nodes underwent laparoscopic unilateral LPLD after total mesorectal excision, tumor-specific mesorectal excision, or total proctocolectomy. Four of the 10 patients (40%) had variations in pelvic vascular anatomy. The median operative time for unilateral LPLD was 91 min (range, 66-142 min) and gradually declined, suggesting a good learning curve. The median number of lateral pelvic lymph nodes harvested was nine (range, 3-16). The median estimated blood loss was 13 mL (range, 10-160 mL). No conversion to open surgery or intraoperative complications occurred. No patient had major postoperative complications. CONCLUSION: Preoperative 3-D simulation may be useful for the safe conduct of laparoscopic LPLD, especially for surgeons with limited prior experience.

We report three cases of colonoscope incarceration in a left inguinal hernia. In the first case, colonoscopy could be successfully performed with manual compression. The colonoscope could not be inserted in the other two cases. It is important to obtain a careful history and physical examination before colonoscopy. The scope must be carefully removed in patients with an inguinal hernia.

大腸内視鏡が左鼠径ヘルニアに嵌入し挿入困難になった3例を経験した。症例はいずれも高齢の男性であった。1例は慎重に抜去を行った後、脱出した腸管を徒手整復手技に準じて還納することで全大腸内視検査が施行可能であったが、その他2例は検査の継続が不可能であった。大腸内視鏡は広く普及している手技であるが、検査中に内視鏡が鼠径ヘルニアに嵌入した報告は極めて少ない。大腸内視鏡検査を行う上で、高齢の男性では陰嚢腫脹を伴う外鼠径ヘルニアの病歴聴取が重要である。大腸内視鏡検査中に予期せず内視鏡が鼠径ヘルニアに嵌入した場合は、一旦手技を中断し、鼠径部痛などの臨床症状の確認を行った後、慎重に抜去するのが望ましい。(著者抄録)

RATIONALE: Although systemic lupus erythematosus (SLE) can be complicated by various gastrointestinal tract diseases, it is rarely associated with lupus enteritis and protein-losing enteropathy (PLE). We report here the successful surgical treatment of lupus enteritis and therapy-resistant and refractory PLE in a patient with SLE. We also provide a review of relevant literature. PATIENT CONCERNS: A 16-year-old girl presenting with polyarthritis, malar rash, and palmar erythema was indicated for steroid therapy on the basis of positive results for antinuclear, anti-Smith, and antiphospholipid antibodies, which confirmed the diagnosis of SLE. During the course of steroid therapy, the patient developed acute abdomen and hypoalbuminemia. DIAGNOSES: Computed tomography and Tc-labeled human serum albumin scintigraphy revealed abnormal findings, and a diagnosis of lupus enteritis and PLE was made. Steroid treatment was continued but no significant improvement was observed, and the patient was referred and admitted to our hospital. Double-balloon enteroscopy revealed multiple ischemic stenoses and mucosal necroses in the small intestine, suggesting that PLE was associated with ischemic enteritis due to antiphospholipid syndrome. The patient received steroids, immunosuppressive drugs, and antithrombotic therapy, with no improvement in symptoms. Thus, the disease was judged to be refractory and resistant to medical therapy, and the patient was indicated for surgical treatment. INTERVENTIONS: Partial small intestinal resection was performed by removing the segment of the small intestine presenting PLE lesions, and a double-end ileostomy was created. OUTCOMES: Multiple stenotic lesions were confirmed in the resected segment. Histopathology evaluation revealed marked inflammatory cell infiltration in the intestinal tract wall and recanalization of the vessels, suggesting a circulatory disorder caused by vasculitis and antiphospholipid syndrome. Postoperatively, the clinical course was good. Serum albumin levels and body weight increased as nutritional status improved significantly. Secondary enteroenterostomy with ileostomy closure could be performed at 2 months after the initial surgery. LESSONS: Timely surgical treatment can be successful in managing therapy-resistant and refractory PLE in patients with SLE.