膿腎症に対する腎摘除術後に発症した難治性十二指腸皮膚瘻の1例

Abstract

56歳女性.右膿腎症により近医で経皮的右腎瘻造設術後, 約3ヵ月後に発熱と右側腹部痛・腫脹で入院となった.腎瘻カレーテル抜去部から膿排出を認め, CT所見より腎周囲膿瘍を伴う右膿腎症と診断し, 膿培養ではProteus mirabilisが確認された.そのため, 感染コントロール後に右腎摘除術を施行したが, 術後出血が生じ, ドレーンチューブのクランプと輸血を行うもCTでガス産生を伴う後腹膜膿瘍を認め, ドレナージ術を施行し, 膿培養にてStaphylococcus epidermidis, Candida albicansが検出された.さらにドレーン排液が暗緑色を呈し, 上部消化管造影で十二指腸瘻(径約15mm)が確認され閉鎖術を行ったが, その4日後ショック状態となりCTで血腫の再形成を認め手術を行った.約6ヵ月後, 急性胆嚢炎が発症したものの, 胆嚢摘除術と十二指腸瘻孔閉鎖術を施行し, 術後は経過順調で30日目に退院となった

A 56-year-old woman was admitted to our hospital for treatment of right stone pyonephrosis with a perirenal abscess. After right nephrectomy for the pyonephrosis, the patient suffered from post-operative bleeding, which was stopped by closing off the drain tube with a clamp. However, a right retroperitoneal abscess with gas formation developed nine days after the operation, necessitating an operative procedure for drainage. Pus culture revealed Staphylococcus epidermidis and Candida albicans. Discharge from the drain tube became dark green days after the drainage procedure. Upper gastrointestinal series revealed a duodenal fistula, which could not be closed using a retroperitoneal approach, so the operative wound was left open. Because of the volume of discharge (800-1, 400 ml/day), somatostatin analogue, 100 micrograms, was injected subcutaneously twice a day. Discharge decreased by one-half within 2 weeks of the administration of somatostatin analogue. However, the duodenocutaneous fistula had not resolved over a period of 8 months. Since the patient developed acute cholecystitis, both cholecystectomy and closure of the duodenocutaneous fistula were performed transperitoneally. The duodenocutaneous fistula, which was closed with Endo GIA (35 mm), had protruded from a descending portion of the duodenum like the diverticulum. The postoperative course was uneventful. We speculated that the fistula occurred as a result of the inflammation with the abscess formation.