Kawashima Kazumasa, Hikichi Takuto, Fujiwara Tatsuo, Gunji Naohiko, Nakamura Jun, Watanabe Ko, Katakura Kyoko, Ohira Hiromasa
Department of Gastroenterology, Fukushima Medical University School of Medicine.
Department of Endoscopy, Fukushima Medical University Hospital.
Fukushima J Med Sci. 2018 Dec 8;64(3):157-162. doi: 10.5387/fms.2018-04. Epub 2018 Sep 8.
A 66-year-old man was diagnosed from colonoscopy as having a 40-mm elevated tumor in the cecum. With a preoperative diagnosis of intramucosal carcinoma, endoscopic submucosal dissection (ESD) was performed. The tumor was resected en bloc, yielding a specimen with a 66-mm diameter. No perforation was detected during the operation.Although neither abdominal pain nor fever was observed immediately after ESD, abdominal pain developed on the following day. Two days after ESD, the abdominal pain ceased. The patient was managed conservatively with fasting and intravenous antibiotic treatment. Four days after ESD, abdominal X-ray revealed marked gas retention. Computed tomography revealed pneumoperitoneum and a pelvic abscess, leading to a diagnosis of delayed perforation after colonic ESD and paralytic intestinal obstruction. A decompression tube was then inserted transnasally into the small intestine. Because a gradual decrease occurred in intestinal gas, the decompression tube was removed. Oral ingestion was resumed 13 days post-ESD.Delayed perforation after colonic ESD often requires emergency surgery. The present case was managed conservatively, despite paralytic intestinal obstruction. This approach is rarely employed for this condition and is therefore worth reporting.
一名66岁男性经结肠镜检查诊断为盲肠有一个40毫米的隆起性肿瘤。术前诊断为黏膜内癌，遂行内镜黏膜下剥离术（ESD）。肿瘤被整块切除，得到一个直径66毫米的标本。手术过程中未发现穿孔。ESD术后即刻虽未观察到腹痛和发热，但次日出现了腹痛。ESD术后两天，腹痛停止。患者通过禁食和静脉注射抗生素进行保守治疗。ESD术后四天，腹部X线显示有明显的气体潴留。计算机断层扫描显示有气腹和盆腔脓肿，诊断为结肠ESD术后迟发性穿孔和麻痹性肠梗阻。随后经鼻插入一根减压管至小肠。由于肠道气体逐渐减少，减压管被拔除。ESD术后13天恢复经口进食。结肠ESD术后迟发性穿孔通常需要急诊手术。本病例尽管存在麻痹性肠梗阻，但仍采用保守治疗。这种方法在这种情况下很少使用，因此值得报道。
