Kock回腸膀胱における輸入脚の合併症とその再建

Abstract

1)術後1年以上長期観察されたKock回腸膀胱42症例につき, 晩期合併症としての輸入脚機能不全の有無を検討した.2) 42例中11例(26%)に輸入脚の合併症が認められた.10例で輸入脚合併症に起因する上部尿路の拡張があり, 7例に上部尿路感染がみられた.3)輸入脚合併症のあった11例中5例はDacron collarのpouch内脱出であり, 輸入脚の狭窄と間欠的閉塞がそれぞれ3例ずつ認められた.4) collarの脱出した5例中4例で外科的にこれを摘出した.狭窄例でも1例でcollar摘出が行われ, 閉塞例では1例で内視鏡的治療が行われた.5)輸入脚の合併症の大きな原因としてnipple valve形成に使用されたDacron collarが考えられ, これに腸管の蠕動運動が深く関与していることが推測された

Construction of a continent ileal urinary reservoir (Kock pouch) is associated with a high incidence of late complication because of malfunction of the nipple valve, the efferent limb in particular. We have so far experienced several types of afferent nipple malfunction. We herein report on the unexpected complications of the afferent nipple valve in patients with a post operative observation of 1 year or more. From 1984 through 1989, urinary diversion via a Kock pouch was performed on 47 patients at Kyoto University Hospital and Public Toyooka Hospital. The study group comprises 42 patients with a mean observation of 40 months (range 14 to 60 months). The late complications of the afferent nipple valve were observed in 11 of the 42 (26%) patients. These included erosion of Dacron fabric used as a collar (5 patients), afferent nipple stenosis (3 patients) and afferent nipple obstruction by mucous plug or fungus ball (3 patients). Removal of Dacron collar was performed in 4 of the 5 patients with collar erosion and in 1 of the 3 patients with nipple stenosis. Nipple obstruction was relieved by endoscopic manipulation or diuresis. All of the 11 patients had no problems with their efferent nipples. Our results suggest that the use of nonabsorbable material as a collar and peristaltic direction of the afferent limb are mainly involved in the complications of the afferent nipple. A more reliable and simpler procedure for antireflux anastomosis should be considered.