内容紹介
Summary
A 70s man was admitted to another hospital with a complaint of abdominal pain, and was diagnosed with a gastrointestinal perforation based on the presence of free air in the abdominal cavity on computed tomography. The patient was transferred to our hospital in shock and underwent emergency surgery. Operative findings showed a perforation of the rectosigmoid colon and rectal cancer at the anal side of the perforation site. As his general condition was unstable due to septic shock, only the segments of the colon including the perforation site and rectal cancer were resected for source control. The abdominal wall was kept open, and intraperitoneal contamination was managed with an open management method using negative pressure wound therapy. Systemic treatments for septic shock were performed in the intensive care unit with a vasopressor and polymyxin-B hemoperfusion. The general condition became stable with intensive care by postoperative day 3. We performed additional lymph node dissection and one-step rectal sigmoidoscopic anastomosis on postoperative day 4. The pathological results confirmed pT4aN1M0, pStage Ⅲa disease. Although the course was complicated by postoperative pneumonia, the patient was discharged on postoperative day 28. We experienced a case in which curative resection with radical lymph node dissection and one-step anastomosis were performed after infection and source control with open abdomen management.
要旨
症例は70代,男性。腹痛を主訴に近医を受診した。CTで直腸周辺にfree airを認め,当院に転院搬送となった。来院時ショック状態であったが,穿孔性腹膜炎にて試験開腹の方針となった。直腸Raに腫瘍を認め,その口側の直腸S状結腸部に2 cmの穿孔を認めた。手術中循環動態が不安定であったため可及的に病巣部の腸管切除(source control)を行い,開腹のまま陰圧閉鎖療法(negative pressure wound therapy)によるopen abdomen managementにて集中治療室に帰室した。エンドトキシン吸着を含めた集中治療で,全身状態が安定した第4病日に追加リンパ節郭清および直腸S状結腸吻合術を施行した。病理組織結果では,pT4aN1M0,pStage Ⅲaの診断であった。術後肺炎を併発したものの,第28日目に自宅退院となった。手術におけるsource controlとopen abdomen managementによる感染コントロール後に根治術を施行した1例を経験した。
目次
A 70s man was admitted to another hospital with a complaint of abdominal pain, and was diagnosed with a gastrointestinal perforation based on the presence of free air in the abdominal cavity on computed tomography. The patient was transferred to our hospital in shock and underwent emergency surgery. Operative findings showed a perforation of the rectosigmoid colon and rectal cancer at the anal side of the perforation site. As his general condition was unstable due to septic shock, only the segments of the colon including the perforation site and rectal cancer were resected for source control. The abdominal wall was kept open, and intraperitoneal contamination was managed with an open management method using negative pressure wound therapy. Systemic treatments for septic shock were performed in the intensive care unit with a vasopressor and polymyxin-B hemoperfusion. The general condition became stable with intensive care by postoperative day 3. We performed additional lymph node dissection and one-step rectal sigmoidoscopic anastomosis on postoperative day 4. The pathological results confirmed pT4aN1M0, pStage Ⅲa disease. Although the course was complicated by postoperative pneumonia, the patient was discharged on postoperative day 28. We experienced a case in which curative resection with radical lymph node dissection and one-step anastomosis were performed after infection and source control with open abdomen management.
要旨
症例は70代,男性。腹痛を主訴に近医を受診した。CTで直腸周辺にfree airを認め,当院に転院搬送となった。来院時ショック状態であったが,穿孔性腹膜炎にて試験開腹の方針となった。直腸Raに腫瘍を認め,その口側の直腸S状結腸部に2 cmの穿孔を認めた。手術中循環動態が不安定であったため可及的に病巣部の腸管切除(source control)を行い,開腹のまま陰圧閉鎖療法(negative pressure wound therapy)によるopen abdomen managementにて集中治療室に帰室した。エンドトキシン吸着を含めた集中治療で,全身状態が安定した第4病日に追加リンパ節郭清および直腸S状結腸吻合術を施行した。病理組織結果では,pT4aN1M0,pStage Ⅲaの診断であった。術後肺炎を併発したものの,第28日目に自宅退院となった。手術におけるsource controlとopen abdomen managementによる感染コントロール後に根治術を施行した1例を経験した。