Nobuhiko Okamoto

Simultaneously Diagnosed and Successfully Treated Rectovaginal and Vesicovaginal Fistulae after Low Anterior Resection with Concomitant Resection of Female Genitalia

Rectovaginal fistula (RVF) and vesicovaginal fistula (VVF) are infrequent but distressing complications after pelvic surgery. However, their adequate treatment is not well described. Here, we simultaneously encountered and successfully treated RVF and VVF after radical surgery for rectal cancer. A 70-year-old woman underwent low anterior resection (LAR) combined with resection of the uterus, the bilateral adnexa, and the upper side of the vagina, as well as diverted ileostomy for rectal cancer. A month after the surgery, she developed urinary incontinence and underwent medical treatment, but her symptoms did not improve. Evaluation with contrast enema before stoma closure revealed the presence of RVF and VVF. We repaired the VVF and RVF via transabdominal and transperineal approaches. After 6 months, ileostomy was closed and the patient had no recurrence of cancer and fistula. In LAR with hysterectomy and resection of the vaginal wall, there is a risk of RVF and VVF. The excision and closure of the fistula tract and omental flap can be effective to treat both fistulae.

Successful Resection of Isolated Para-Aortic Lymph Node Recurrence from Advanced Sigmoid Colon Cancer following 156 Courses of FOLFIRI Regimen

Isolated para-aortic lymph node (PLN) recurrence from colorectal cancer (CRC) is rare, with no currently validated treatments. Few reports have described the successful resection of isolated PLN involvement from CRC following chemotherapy. We report the case of a 63-year-old man who underwent sigmoidectomy for sigmoid colon cancer at our hospital. Pathological examination demonstrated advanced sigmoid colon cancer with metastatic involvement in both of the tested PLNs. Palliative chemotherapy was initiated four weeks after surgical resection, with administration of the FOLFIRI regimen. Four years after the operation, computed tomography (CT) revealed an enlarged PLN below the left renal vein. As PLN enlarged to 15 mm in the minor axis on a CT scan in 2014 after receiving a total of 156 courses of the FOLFIRI regimen, we considered the enlarged PLN to represent an isolated metastasis. Accordingly, lymph node resection was performed with microscopically negative margins. The patient maintained a good quality of life without any side effects throughout the whole course of his treatment and remains disease-free at 24 months without chemotherapy after resection of the isolated PLN. Curative resection following chemotherapy may improve survival of carefully selected advanced CRC patients with locoregional recurrence, such as isolated PLN involvement.

A case report: Asymptomatic pulmonary embolism diagnosed before sigmoid colon cancer operaion

症例は73歳の男性で, S状結腸癌と診断され精査・手術目的にて入院した. 術前の胸部CTにて, 右肺動脈本幹および左肺底動脈に浮遊血栓を認め, 肺血流シンチおよび下肢静脈造影検査にて下肢深部静脈血栓症および無症候性肺塞栓症と診断し, ヘパリンによる抗凝固療法を開始した. ヘパリン投与開始14日目に施行した肺動脈造影検査にて左右肺動脈内に血栓を認めなかったため, 術前日に下大静脈フィルターを留置し手術を施行した. 術式はS状結腸切除術で, 術中はヘパリン低用量投与 (200単位/時間) および弾性ストッキングを使用した. 術後2日目よりヘパリンを400単位/時間にて投与しワーファリンを術後8日目より開始しINRが2.0を超えた時点でヘパリンを中止し維持療法を続行した. 消化器外科領域では手術を必要とする患者は肺塞栓症の高リスク群であり無症候性肺塞栓症の可能性も念頭にいれ周術期の管理を行うことが求められる.