[症例] 子宮穿孔による汎発性腹膜炎にて発症した局所進行直腸癌の1例

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  • ショウレイ シキュウ センコウ ニ ヨル ハンハツセイ フクマクエン ニテ ハッショウ シタ キョクショ シンコウ チョクチョウ ガン ノ 1レイ

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[要旨] 症例は78歳女性。2012年11月嘔吐，下痢，体動困難のため救急車で来院。採血で炎症反応高度のためCTを行うと腹腔内遊離ガス，直腸壁肥厚と子宮留膿腫を認めた。直腸癌の子宮浸潤・留膿腫破裂と診断し緊急手術を行った。術中，子宮体部に1㎝の穿孔を認め，直腸と共に巨大腫瘤を形成していたため，一期的切除は断念し子宮内・腹腔洗浄ドレナージと横行結腸人工肛門造設に留めた。状態安定後精査で切除不能因子はなく2か月後に直腸低位前方切除・子宮両側附属器合併切除術を施行した。病理結果は，中分化管状腺癌T4b（ uterus） N0M0 stage Ⅱ，PM0・DM0・RM0で治癒切除となった。経過良好で5か月後に人工肛門閉鎖術を行い，根治術後2年11か月現在無再発生存中である子宮留膿腫破裂は細菌性腹膜炎を招く緊急性の高い病態である。進行癌に関連した場合，過大侵襲とならない適切な術式選択が要求される。分割手術により救命と癌の根治を目指すことも有用と考えた。

[SUMMARY] The patient was a 78-year-old woman. In November 2012, the patient had vomiting, diarrhea, and impaired mobility, so the patient was brought by ambulance to this hospital. Blood was taken and revealed a severe inflammatory response, so a CT scan was performed. The scan revealed free air in the peritoneal cavity, thickening of the rectal wall, and pyometra. The patient was diagnosed with rectal cancer invading the uterus, pyometra, and rupture of the uterus, and emergency surgery was performed. A 1-cm perforation was noted in the uterine corpus, and a large mass had formed with the rectum. Single-stage resection was foregone. Uterine and peritoneal lavage and drainage were done and a transverse colostomy was performed. After the patient's condition stabilized, further testing revealed no factors precluding resection. Two months later, anterior resection of the rectum and a hysterectomy with bilateral salpingo-oophorectomy were performed. The cancer was Stage II （T4b （invasion of the uterus）, N0, M0） moderately differentiated tubular adenocarcinoma with PM0, DM0, and RM0 in margins of surgical specimens. Curative surgery was performed. The patient's course was satisfactory, and 5 months later the stoma was closed. The patient has survived recurrence-free as of 2 years and 11 months after radical surgery. Pyometra and rupture of the uterus are life-threatening conditions that can lead to bacterialperitonitis. When these conditions are associated with advanced cancer, an appropriate procedure must be selected without being overly invasive. Surgery in stages can be used to first save the patient's life and later treat cancer.

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