回腸導管造設術後18年目に上行結腸が嵌頓壊死をきたした傍ストーマヘルニアの1例

Abstract

78歳女。18年前に回腸導管造設術を施行しており, 腹部膨隆の間欠的出現と腹痛, 欠尿で受診した。右横隔膜下にフリーエリアを認め, ストーマ周囲の皮下に拡張した腸管脱出を認めた。以上より, 傍ストーマヘルニア嵌頓, 消化管穿孔と診断し, 緊急手術を施行した。腹水は認めず小腸の拡張を認め上行結腸が肝彎曲付近にて10cmにわたり壊死し, 一部穿孔しており回盲部から上行結腸は後腹膜に固定されていなかった。壊死腸管を含めて上行結腸と横行結腸の一部を切除し, 腹腔内を十分に洗浄し, 大網を充填後に閉鎖し, 回腸人工肛門を左下腹部に造設した。術後, 敗血症, 播種性血管内凝固症候群を発症したが治癒し, 術後78日目に退院し術後5ヵ月経過したがヘルニアの再発は認めていない。

A 78-year-old woman had undergone radical cystectomy and construction of ileal conduit because of bladder cancer in 1988. Eighteen years after the operation, she was referred to our hospital with the chief complaint of abdominal pain and oliguria. She had a mass just superolateral to the stoma with tenderness and reddish skin. Abdominal X-ray and computed tomographic scanning showed free air and peristomal intestinal dilation in the subcutaneous area. With a diagnosis of incarcerated parastomal hernia and intestinal perforation, emergency operation was performed. The orifice of the hernia was located in the superolateral aspect of the stoma. The ascending colon was locally necrotic and perforated. Usually, the orifice of parastomal hernia is so wide that incarceration rarely occurs. Parastomal hernia treated with emergency operation is rare, with only 9 cases, including our case, reported in the Japanese literature. Three cases had ileal conduit, and the content of the hernia was the ascending colon only in our case.