今日の臨床サポート

腸軸捻転・腸重積

著者: 尾﨑知博1) 鳥取県立中央病院 外科

著者: 池口正英2) 医療法人里仁会 北岡病院

監修: 杉原健一 東京医科歯科大学大学院

著者校正/監修レビュー済:2019/11/14
患者向け説明資料

概要・推奨   

  1. S状結腸軸捻転を疑う患者にはCTを行うことが勧められる(推奨度2)。
  1. 腹部症状・CTで明らかな腸管壊死・穿孔の所見がないS状結腸軸捻転の患者には下部内視鏡検査を行うことが勧められる(推奨度2)。
  1. S状結腸軸捻転の患者に腹膜刺激症状や腸管壊死、穿孔の所見がない場合は減圧・捻転解除目的にフレキシブルスコープを用いた内視鏡処置を行うことが勧められる(推奨度2)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
尾﨑知博 : 未申告[2021年]
池口正英 : 特に申告事項無し[2021年]
監修:杉原健一 : 講演料(大鵬薬品)[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
腸軸捻転:
  1. 腸軸捻転は腸間膜を軸として腸が捻れる疾患で、腸間膜の主幹動脈の閉塞による虚血に加えて、腸閉塞の病態が加わる。
  1. S状結腸が最も多く盲腸と小腸と続く。
  1. S状結腸軸捻転は全腸閉塞の6%と報告され、比較的まれな疾患である。原因としてS 状結腸過長症・高繊維食の摂取・長期間の便秘の既往・長期臥床、併存疾患としてParkinson 病などの神経疾患・巨大結腸症を来す疾患・脳疾患・脊髄損傷・精神疾患などを有する症例に多いとされている。
 
腸重積:
  1. 腸重積症は幼小児に多くみられ、成人の占める割合は6%と比較的まれな疾患である。
  1. 成人腸重積症は小児の腸重積とは成因や臨床像を異にする。
  1. 成人腸重積症は小児と異なり特発性は8~17%とまれで、多くは器質的疾患を有しており悪性腫瘍46~62%、良性腫瘍30~38%と報告されている。小腸では良性腫瘍、大腸では悪性腫瘍が多い。
  1. 成人腸重積症の発生部位は小腸66~88%、大腸6~24%と報告されている。
 
  1. 腸重積 年齢による違い(推奨度2)
  1. まとめ:腸重積の好発年齢である0~6歳の小児、6~18歳までの小児、18歳以上の成人の3グループに分けて特徴を比較した。95人の腸重積のうち、内訳はそれぞれ61人(64%)、12人(13%)と22人(23%)であった。 腹痛はどのグループにも一番多く認められた(74%、92%、86%)。嘔吐は次によく認められた(61%、91%、52%)。発生部位、治療、腸重積の原因は以下の通りであった[1]
 
Location of intussusception

a:腸重積症の部位
b:治療の種類および腸切除率
c:関連所見

出典

img1:  Intussusception in traditional pediatric, nontraditional pediatric, and adult patients.
 
 Am J Emerg Med. 2011 Jun;29(5):523-7. do・・・
 
  1. 成人腸重積の症状、病悩期間、診断方法、病変部位の疫学(推奨度2)
  1. まとめ:平均年齢は48±17歳、男性43%、女性57%であった。最も多い症状は腹痛で72%に認めた。しかし無症状の患者を20%認めた[2]。病悩期間は平均69日(1日~3年)であり、大部分の患者は慢性症状を呈していた。 病悩期間が2週間未満の患者は38%であった。腹痛、腫瘤触知、血便の古典的トリアスは、2%の患者にしかみられなかった[3]。CTにて93%が診断可能であった。発生部位は小腸小腸が最も多く80%で、回腸結腸(11%)、結腸結腸(7%)であった。原因は良性腫瘍・悪性腫瘍・炎症・癒着などさまざまであった[2]。同様に詳細な原因が以下に示されている[3]
 
腸重積症が診断された成人患者の臨床的特徴

出典

img1:  Adult intussusception: presentation, management, and outcomes of 148 patients.
 
 J Emerg Med. 2012 Jul;43(1):1-6. doi: 10・・・
 
成人腸重積症の病因

出典

img1:  Adult intussusception in the last 25 years of modern imaging: is surgery still indicated?
 
 J Gastrointest Surg. 2011 Oct;15(10):169・・・
 
  1. 結腸腸重積は小腸腸重積より死亡率が高い(推奨度2)
  1. まとめ:平均入院期間は7.9日と7.8日であり有意差は認めなかった。
    死亡率は2.52%、0.74%と結腸腸重積で有意に高かった(P =.018)[4]
  1. 結論:結腸腸重積は小腸腸重積より死亡率が高い。
 
NISを用いた腸重積症手術患者の背景および転帰データ

出典

img1:  Profiling adult intussusception patients: comparing colonic versus enteric intussusception.
 
 Am J Surg. 2011 Oct;202(4):487-91. doi: ・・・
 
  1. 結腸軸捻転の動向、アウトカム、死亡予測因子について
  1. まとめ:米国のNISデータベース(2002~2010年)より結腸軸捻転のretrospectiveな検討が行われた[5]。結腸腸捻転は腸管閉塞1.9%を占めていた。経時発生率において盲腸軸捻転は増加しS状結腸軸捻転は不変であった。S状結腸軸捻転は70歳以上の男性高齢者、アフリカ系アメリカ人、糖尿病患者と精神・神経疾患に多かったのに対し、盲腸軸捻転は60代の女性で多かった。死亡率はS状結腸軸捻転:9.4%、盲腸軸捻転:6.6%、S状結腸軸捻転+盲腸軸捻転:17%、横行結腸腸捻転:18%であった。死亡予測因子として腸管壊死と腹膜炎、凝固障害、年齢、ストーマ作成、慢性腎不全が抽出された。
 
問診・診察のポイント  
腸軸捻転:
  1. S状結腸軸捻転には急性型・亜急性型・慢性型が存在するが、大多数は腹痛・腹部膨満を自覚症状として発症し、排ガスの停止・便秘・嘔気・嘔吐・下痢・発熱を伴うことが多い。

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文献 

著者: Alexis A Cochran, George L Higgins, Tania D Strout
雑誌名: Am J Emerg Med. 2011 Jun;29(5):523-7. doi: 10.1016/j.ajem.2009.11.023. Epub 2010 Apr 2.
Abstract/Text STUDY OBJECTIVES: We sought to determine the rate of intussusception in 3 age groups (traditional pediatric-age [T], nontraditional pediatric-age [N], and adult-age [A]) and to compare group characteristics.
METHODS: We conducted a retrospective records review for patients discharged with diagnosis of intussusception between October 1999 and June 2008.
RESULTS: Ninety-five cases of intussusception were diagnosed as follows: 61 T (64%), 12 N (13%), and 22 A (23%). Bloody stool was more common in T patients (P = .016). Air contrast enema (36%) and ultrasound (33%) were the most common diagnostic tests in T, whereas computed tomography was most common in N (83%) and A (68%) patients. Bowel resection occurred more often in older (T) patients (P = .001). The most frequent causative pathologic conditions were adenitis (T), Peutz-Jeghers polyp (N), and carcinoma (A) and prior gastric bypass in 10 A patients.
CONCLUSIONS: The incidence of intussusception is substantially higher in nontraditional age groups than previously reported. Symptoms, management strategies, and causative pathologic conditions varied with age. All adults with intussusception require definitive diagnostic testing to determine the cause, given the concerning list of possibilities we observed.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 20825824  Am J Emerg Med. 2011 Jun;29(5):523-7. doi: 10.1016/j.aj・・・
著者: Rachel A Lindor, M Fernanda Bellolio, Annie T Sadosty, Frank Earnest, Daniel Cabrera
雑誌名: J Emerg Med. 2012 Jul;43(1):1-6. doi: 10.1016/j.jemermed.2011.05.098. Epub 2012 Jan 12.
Abstract/Text BACKGROUND: Intussusception is a predominantly pediatric diagnosis that is not well characterized among adults. Undiagnosed cases can result in significant morbidity, making early recognition important for clinicians.
STUDY OBJECTIVES: We describe the presentation, clinical management, disposition, and outcome of adult patients diagnosed with intussusception during a 13-year period.
METHODS: A retrospective study of consecutive adult patients diagnosed with intussusception at a tertiary academic center was carried out from 1996 to 2008. Cases were identified using International Classification of Diseases, 9(th) Revision codes and a document search engine. Data were abstracted in duplicate by two independent authors.
RESULTS: Among 148 patients included in the study, the most common symptoms at presentation were abdominal pain (72%), nausea (49%), and vomiting (36%). Twenty percent were asymptomatic. Sixty percent of cases had an identifiable lead point. Patients presenting to the emergency department (ED) (31%) had higher rates of abdominal pain (relative risk [RR] 5.7) and vomiting (RR 3.4), and were more likely to undergo surgical intervention (RR 1.8) than patients diagnosed elsewhere. There were 77 patients who underwent surgery within 1 month; patients presenting with abdominal pain (RR 2.2), nausea (RR 1.7), vomiting (RR 1.4), and bloody stool (RR 1.9) were more likely to undergo surgery.
CONCLUSIONS: Adult intussusception commonly presents with abdominal pain, nausea, and vomiting; however, approximately 20% of cases are asymptomatic and seem to be diagnosed by incidental radiologic findings. Patients presenting to an ED with intussusception due to a mass as a lead point or in an ileocolonic location are likely to undergo surgical intervention.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22244289  J Emerg Med. 2012 Jul;43(1):1-6. doi: 10.1016/j.jemerme・・・
著者: Edwin Onserio Onkendi, Travis Edward Grotz, Joseph A Murray, John Harrington Donohue
雑誌名: J Gastrointest Surg. 2011 Oct;15(10):1699-705. doi: 10.1007/s11605-011-1609-4. Epub 2011 Jul 6.
Abstract/Text BACKGROUND: Because most adult intussusceptions are reportedly due to malignancy, operative treatment is recommended. With current availability of computed tomography, we questioned the role of mandatory operative exploration for all adult intussusceptions.
METHODS: This study is a retrospective review of all adults treated from 1983 to 2008 at a large tertiary referral center for intussusception.
RESULTS: One hundred ninety-six patients had intussusception over the 25-year study period. Computed tomography was obtained in 60% of patients. Neoplasms [malignant, (21%); benign, (24%)] were the commonest etiology; 30% cases were idiopathic. One hundred twenty (61%) patients underwent operative treatment for intussusception. Six of the 58 idiopathic or asymptomatic cases were operated on with negative findings in all. Palpable mass (OR 4.56, p < 0.035), obstructive symptoms (OR 9.13, p < 0.001) or obstruction (OR 9.67, p < 0.001), GI bleeding (OR 14.41, p < 0.001), and a lead point on computed tomography (OR 10.08, p < 0.001) were associated with the need for operation.
CONCLUSION: In the current era of computed tomography, idiopathic or asymptomatic intussusception is being seen more commonly; however, the majority of adult intussusceptions still have pathologic lead points. From our experience, all patients with palpable mass, obstructive symptoms or obstruction, gastrointestinal bleeding, or a lead point on computed tomography should undergo operative exploration.

PMID 21830152  J Gastrointest Surg. 2011 Oct;15(10):1699-705. doi: 10.・・・
著者: Richard Alexander, Purnell Traverso, Oluwaseyi B Bolorunduro, Gezzer Ortega, David Chang, Edward E Cornwell, Terrence M Fullum
雑誌名: Am J Surg. 2011 Oct;202(4):487-91. doi: 10.1016/j.amjsurg.2011.02.006.
Abstract/Text BACKGROUND: Adult intussusception is a rare entity representing 1% of all adult bowel obstruction, hospital admissions secondary to intussusception historically has ranged between .003% and .02%. There is limited knowledge regarding enteric and colonic surgical intussusception patients and their associated conditions.
METHODS: A retrospective study was conducted using data from the National Inpatient Sample from 1998 to 2006. The inclusion criteria were surgical patients with intussusception.
RESULTS: A total of 1,178 cases of intussusception requiring surgery were isolated from the database. The mean patient age was 49.57 years, about 58% were females, 99.43% of this population was insured, and the overall mortality rate was 1.70%. Colonic resection was associated with greater mortality compared with the enteric resection group (P = .018).
CONCLUSIONS: This was a large study on surgical adult intussusception patients conducted in the United States. We show differences in demography, comorbidities, and potential causes between colonic and enteric intussusception.

Published by Elsevier Inc.
PMID 21943949  Am J Surg. 2011 Oct;202(4):487-91. doi: 10.1016/j.amjsu・・・
著者: Wissam J Halabi, Mehraneh D Jafari, Celeste Y Kang, Vinh Q Nguyen, Joseph C Carmichael, Steven Mills, Alessio Pigazzi, Michael J Stamos
雑誌名: Ann Surg. 2014 Feb;259(2):293-301. doi: 10.1097/SLA.0b013e31828c88ac.
Abstract/Text INTRODUCTION: Colonic volvulus is a rare entity associated with high mortality rates. Most studies come from areas of high endemicity and are limited by small numbers. No studies have investigated trends, outcomes, and predictors of mortality at the national level.
METHODS: The Nationwide Inpatient Sample 2002-2010 was retrospectively reviewed for colonic volvulus cases admitted emergently. Patients' demographics, hospital factors, and outcomes of the different procedures were analyzed. The LASSO algorithm for logistic regression was used to build a predictive model for mortality in cases of sigmoid (SV) and cecal volvulus (CV) taking into account preoperative and operative variables.
RESULTS: An estimated 3,351,152 cases of bowel obstruction were admitted in the United States over the study period. Colonic volvulus was found to be the cause in 63,749 cases (1.90%). The incidence of CV increased by 5.53% per year whereas the incidence of SV remained stable. SV was more common in elderly males (aged 70 years), African Americans, and patients with diabetes and neuropsychiatric disorders. In contrast, CV was more common in younger females. Nonsurgical decompression alone was used in 17% of cases. Among cases managed surgically, resective procedures were performed in 89% of cases, whereas operative detorsion with or without fixation procedures remained uncommon. Mortality rates were 9.44% for SV, 6.64% for CV, 17% for synchronous CV and SV, and 18% for transverse colon volvulus. The LASSO algorithm identified bowel gangrene and peritonitis, coagulopathy, age, the use of stoma, and chronic kidney disease as strong predictors of mortality.
CONCLUSIONS: Colonic volvulus is a rare cause of bowel obstruction in the United States and is associated with high mortality rates. CV and SV affect different populations and the incidence of CV is on the rise. The presence of bowel gangrene and coagulopathy strongly predicts mortality, suggesting that prompt diagnosis and management are essential.

PMID 23511842  Ann Surg. 2014 Feb;259(2):293-301. doi: 10.1097/SLA.0b0・・・
著者: H C Burrell, D M Baker, P Wardrop, A J Evans
雑誌名: Clin Radiol. 1994 May;49(5):317-9.
Abstract/Text The aim of this study was to evaluate the plain abdominal radiographs of patients thought clinically to have a sigmoid volvulus. Strict diagnostic criteria based on the findings at barium enema and/or surgery were applied to establish or refute a diagnosis of sigmoid volvulus. The presenting plain abdominal radiographs were assessed for 10 radiological signs considered valuable in the diagnosis of sigmoid volvulus. Of the 17 patients with a volvulus, 88% had 6 or more signs, and in the 5 patients without a volvulus, 80% had 4 signs or less. Five signs achieved significance in differentiating between the groups. Three signs, apex of the loop under the left hemi-diaphragm, inferior convergence on the left and the left flank overlap sign, were 100% specific as well as being highly sensitive. The signs which were least specific were a distended ahaustral sigmoid loop and an air fluid ratio greater than 2:1.

PMID 8013194  Clin Radiol. 1994 May;49(5):317-9.
著者: D Feldman
雑誌名: Radiology. 2000 Jul;216(1):178-9. doi: 10.1148/radiology.216.1.r00jl17178.
Abstract/Text
PMID 10887245  Radiology. 2000 Jul;216(1):178-9. doi: 10.1148/radiolog・・・
著者: Jeffrey M Levsky, Elana I Den, Ronelle A DuBrow, Ellen L Wolf, Alla M Rozenblit
雑誌名: AJR Am J Roentgenol. 2010 Jan;194(1):136-43. doi: 10.2214/AJR.09.2580.
Abstract/Text OBJECTIVE: The purpose of this study was to evaluate the features of sigmoid volvulus on CT scanograms and cross-sectional images.
MATERIALS AND METHODS: We retrospectively reviewed 21 cases of sigmoid volvulus in 15 men and six women. Three radiologists evaluated scanograms and cross-sectional images for several classic and two novel imaging signs of volvulus: crossing sigmoid transitions (called the X-marks-the-spot sign) and folding of the sigmoid wall by partial twisting (called the split-wall sign). A general impression was assigned to scanograms and cross-sectional images. CT findings suggesting bowel compromise were compared with pathologic and endoscopic findings.
RESULTS: The most sensitive scanogram findings were absence of rectal gas (19 of 21 cases, 90%) and an inverted-U-shaped distended sigmoid (18 of 21 cases, 86%) followed by the coffee bean sign and disproportionate sigmoid enlargement (both 16 of 21 cases, 76%). The most sensitive cross-sectional findings were one sigmoid colon transition point (20 of 21 cases, 95%) and disproportionate enlargement of the sigmoid (18 of 21 cases, 86%). The X-marks-the-spot and split-wall signs were present in nine of 21 (43%) and 11 of 21 (52%) patients, but one of the two signs was present in 18 of 21 patients (86%). Classic radiographic and definitive cross-sectional findings were seen in 11 of 21 (52%) and 16 of 21 (76%) patients. CT findings were definitive in five of seven patients (71%) with indeterminate scanogram findings. Imaging signs suggesting bowel compromise correlated poorly with clinical ischemia, but CT features were present in all three patients with frank necrosis.
CONCLUSION: Sigmoid volvulus has a spectrum of imaging findings. A classic appearance is absent on approximately one half of scanograms and one fourth of CT scans. Use of new signs that model the pathophysiologic characteristics of volvulus (X-marks-the-spot sign for more complete twisting and split-wall sign for less severe twisting) may improve diagnostic confidence.

PMID 20028915  AJR Am J Roentgenol. 2010 Jan;194(1):136-43. doi: 10.22・・・
著者: J B Peoples, J C McCafferty, K S Scher
雑誌名: Dis Colon Rectum. 1990 Aug;33(8):643-6.
Abstract/Text The medical records of 54 patients treated for sigmoid volvulus from 1983 to 1987 were reviewed. Patient demographics were very similar to previously published results. Four patients (7.4 percent) underwent emergency resection for gangrene with a mortality of 75 percent. Of the 50 patients who presented without ischemia, 23 (46 percent) were managed by nonoperative detorsion while 3 (6 percent) detorsed spontaneously. Fourteen of these 26 patients received no further treatment. Nonoperative mortality was 0 percent. Celiotomy was performed on 36 patients. The type of operative procedure performed had no significant bearing on outcome. Fifteen patients underwent resection and anastomosis; two of these patients died (13 percent). Fifteen patients underwent resection and colostomy with two deaths (13 percent), and six had open detorsion alone with one death (17 percent). The two factors associated with adverse outcome after surgical intervention were patient age and history of previous volvulus. All five deaths occurred in patients older than 70 years presenting with a first episode of volvulus (N = 15, mortality = 33 percent). No deaths occurred among patients younger than 70 years regardless of volvulus history or among those older than 70 years who were being treated for a recurrence (P less than or equal to 0.01). Patients older than 70 years with a first episode of volvulus represent a high risk if subjected to surgical intervention. Nonoperative detorsion alone should be considered for this subgroup of patients.

PMID 2376219  Dis Colon Rectum. 1990 Aug;33(8):643-6.
著者: B N S Bhatnagar, C L N Sharma, A Gautam, A Kakar, D C S Reddy
雑誌名: Int J Colorectal Dis. 2004 Mar;19(2):134-42. doi: 10.1007/s00384-003-0534-8. Epub 2003 Sep 4.
Abstract/Text BACKGROUND AND AIMS: This study investigated the clinical picture of gangrenous sigmoid volvulus presented by Indian patients to describe the various patterns of gangrene and to identify the risk factors leading to the very high mortality from this disease.
PATIENTS AND METHODS: A structured protocol including nine parameters was used to study risk factors in 76 patients treated at two major teaching hospitals in India. The clinical picture of patients at the two hospitals did not differ significantly.
RESULTS: Contrary to expectations, we found gangrene in 26% of cases extending beyond the area of constriction into the rectum/descending colon. This extension was sometimes patchy and had an ill defined line of demarcation, which may lead to an error in judgment and cause a failure of anastomosis, which can be fatal. Risk factors were age over 60 years, the presence of shock on admission and a history of previous episodes of volvulus.
CONCLUSION: This study identified three risks for survival. It is suggested that all patients with nongangrenous sigmoid volvulus undergo a recurrence-prevention procedure immediately or electively. We also found that extension of gangrene beyond the confines of the constriction is not uncommon, calling for caution on the part of the treating surgeon.

PMID 12955417  Int J Colorectal Dis. 2004 Mar;19(2):134-42. doi: 10.10・・・
著者: M Turan, M Sen, K Karadayi, A Koyuncu, O Topcu, C Yildirir, M Duman
雑誌名: Rev Esp Enferm Dig. 2004 Jan;96(1):32-5.
Abstract/Text BACKGROUND/AIMS: The sigmoid colon is the most frequent site for a volvulus. In this report, we review our experience with sigmoid colon volvulus.
METHODOLOGY: We present our experience of 81 cases of sigmoid volvulus admitted to our department.
RESULTS: Preoperative endoscopic volvulus detortion was attempted in all patients, and in 39 of them the procedure was successful. The success rate of endoscopic detortion for sigmoid colon volvulus with a flexible colonoscope (60%) was higher than with a rigid rectosigmoidoscope (42%). In 19 of these 39 non-operatively devolvulated patients, sigmoid resection with primary anastomosis was performed within 7-10 days after reduction, but 20 patients did not accept the elective operation after a non-operative treatment. Among the 61 patients undergoing urgent or elective operation for sigmoid volvulus, there were 17 laparotomies with only detortion, 19 resections with elective anastomosis, 6 resections with primary anastomosis, and 19 resections with a Hartmann's pouch. There were 9 deaths (21%) among 42 patients who underwent an emergency operation, and one (5.2%) among the 19 patients who had elective surgery died because of a cerebral embolus.
CONCLUSIONS: Initial therapy with endoscopy affords decompression and an adequate preparation of patients for surgical resection, and a flexible colonoscope has notable advantages over rigid instruments for the detortion process.

PMID 14971995  Rev Esp Enferm Dig. 2004 Jan;96(1):32-5.
著者: Durkaya Oren, S Selçuk Atamanalp, Bülent Aydinli, M Ilhan Yildirgan, Mahmut Başoğlu, K Yalçin Polat, Omer Onbaş
雑誌名: Dis Colon Rectum. 2007 Apr;50(4):489-97. doi: 10.1007/s10350-006-0821-x.
Abstract/Text PURPOSE: This study was designed to review the outcomes of emergent treatment of sigmoid colon volvulus.
METHODS: The records of 827 patients were reviewed retrospectively.
RESULTS: The mean age was 57.9 years (range, 10 weeks to 98 years), and 688 patients (83.2 percent) were male. Nonoperative reduction was applied in 575 patients (barium enema in 13, rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all patients). The results were as follows: success of 78.1 percent, mortality of 0.9 percent, complication of 3 percent, and early recurrence of 3.3 percent. Surgical treatment was performed on 393 patients (detorsion in 46, mesosigmoidopexy in 56, exteriorization in 4, resection with Hartmann's procedure in 146, resection with Mikulicz procedure in 14, resection with primary anastomosis in 51, tube cecostomy and colonic cleansing with resection in 75, and laparotomy in 1). The results were as follows: mortality of 15.8 percent, complication of 37.2 percent, early recurrence of 0.8 percent, and late recurrence of 6.7 percent.
CONCLUSIONS: Nonoperative reduction is the initial treatment of sigmoid colon volvulus, and flexible sigmoidoscopy with rectal tube placement can be used successfully. Patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful need emergency surgery. In surgical treatment, resection and primary anastomosis is the first choice, and it can be performed with acceptable mortality and morbidity rates if the patient is stable and a tension-free anastomosis is possible. Nondefinitive procedures have high recurrence rates; thus, definitive surgical techniques must be preferred.

PMID 17205203  Dis Colon Rectum. 2007 Apr;50(4):489-97. doi: 10.1007/s・・・
著者: R Das, R W Hagger
雑誌名: Ann R Coll Surg Engl. 2008 Jul;90(5):425-6. doi: 10.1308/rcsann.2008.90.5.425.
Abstract/Text
PMID 18642417  Ann R Coll Surg Engl. 2008 Jul;90(5):425-6. doi: 10.130・・・
著者: G H Ballantyne
雑誌名: Dis Colon Rectum. 1982 Jul-Aug;25(5):494-501.
Abstract/Text
PMID 7047106  Dis Colon Rectum. 1982 Jul-Aug;25(5):494-501.
著者: T E Madiba, S R Thomson
雑誌名: J R Coll Surg Edinb. 2000 Apr;45(2):74-80.
Abstract/Text The epidemiology and clinical pattern of sigmoid volvulus are well defined. Although clinical manifestations of acute volvulus are often clear-cut, diagnostic doubt is not uncommon and, if gangrene supervenes, mortality rises appreciably. While gangrene requires resectional surgery, the management of the viable colon related to a volvulus episode has a variety of options. These, particularly non-resectional alternatives, require more critical reappraisal in the light of advances in minimally invasive techniques.

PMID 10822915  J R Coll Surg Edinb. 2000 Apr;45(2):74-80.
著者: V Raveenthiran, T E Madiba, S S Atamanalp, U De
雑誌名: Colorectal Dis. 2010 Jul;12(7 Online):e1-17. doi: 10.1111/j.1463-1318.2010.02262.x. Epub 2010 Mar 10.
Abstract/Text AIMS: The current status of sigmoid volvulus (SV) was reviewed to assess trends in management and to assess the literature.
METHOD: The literature on SV was retrieved using PubMed, Embase, Scopus, Pakmedinet, African Journals online (AJOL), Indmed and Google scholar. These databases were searched for text words including 'sigmoid', 'colon' and 'volvulus'. Relevant nonindexed surgical journals published from endemic countries were also manually searched. We focused on original articles published within the last 10 years; but classical references prior to this period were also included. Seminal papers published in non-English languages were also included.
RESULTS: Sigmoid volvulus is a leading cause of acute colonic obstruction in South America, Africa, Eastern Europe and Asia. It is rare in developed countries such as USA, UK, Japan and Australia. Characteristic geographic variations in the incidence, clinical features, prognosis and comorbidity of SV justify recognition of endemic and sporadic subtypes. Controversy on aetiologic agents can be minimized by classifying them into 'predisposing' and 'precipitating' factors. Modern imaging systems, although more effective than plain radiographs, are yet to gain popularity. Emergency endoscopic reduction is the treatment of choice in uncomplicated patients. But it is only a temporizing procedure, and it should be followed in most cases by elective definitive surgery. Resection of the redundant sigmoid colon is the gold standard operation. The role of newer nonresective alternatives is yet to be ascertained. Although emergency resection with primary anastomosis (ERPA) has been controversial in the past, it is now increasingly accepted as a safe option with superior results. Management in elderly debilitated patients is extremely difficult. Paediatric SV significantly differs from that in adults. SV is frequently associated with neuropsychiatric diseases, diabetes mellitus and Chagas disease. The overall mortality in recent studies is < 5%.
CONCLUSION: There are almost no randomised controlled studies. According to the grading system of Oxford Center for Evidence Based Medicine (CEVM), available published evidence is at level 4. The recommendations resulting form this review are of 'C' grade.

PMID 20236153  Colorectal Dis. 2010 Jul;12(7 Online):e1-17. doi: 10.11・・・
著者: B N Bhatnagar, C L Sharma
雑誌名: Dis Colon Rectum. 1998 Mar;41(3):381-8.
Abstract/Text PURPOSE: Recurrence in sigmoid colon volvulus is a very vexing problem, because it occurs after all types of treatment including a resection of the sigmoid. A nonresective procedure that prevents recurrence in the long term has been devised and tried during the period 1968 to 1992.
METHODS: The procedure involves extraperitonealization of the whole sigmoid colon via a left paracolic gutter incision in a manner akin to an extraperitonealized colostomy and placing it in the left half of the infraumbilical abdominal wall. This article presents a study of 84 patients who underwent this operation and who were followed-up. Some very useful practical points for ensuring the success of the procedure are also presented.
RESULTS: The subjects comprised 58 male and 26 female patients, aged 10 to 81 (median, 60) years. The operating time ranged from 40 to 70 (median, 50) min. The operative mortality (9 percent) and morbidity of the procedure including cardiopulmonary complications (7 percent), incidence of small-bowel obstruction (1 percent), and incisional hernia formation (2.3 percent), were reasonably low. The incidence of wound-healing problems was significantly (P < 0.02) reduced in the 1980s and 1990s. Seventy-six patients were available for follow-up ranging from 0.5 to 25 (mean+/-standard error, 6.671+/-0.573; median, 6) years. Forty-eight patients were followed-up for five or more years. No patients developed recurrence of volvulus during the entire follow-up period.
CONCLUSIONS: This nonresective, recurrence-free procedure provides a cure for nongangrenous sigmoid volvulus. It may be performed safely, even in relatively poor-risk patients, with acceptably low morbidity and mortality rates.

PMID 9514437  Dis Colon Rectum. 1998 Mar;41(3):381-8.
著者: J-T Liang, H-S Lai, P-H Lee
雑誌名: Surg Endosc. 2006 Nov;20(11):1772-3. doi: 10.1007/s00464-005-0665-9.
Abstract/Text BACKGROUND: The laparoscopic approach for the treatment of sigmoid volvulus has been a rare surgical indication. This phase 2 study investigated the feasibility and surgical outcomes of elective laparoscopic surgery for sigmoid volvulus.
METHODS: Patients with sigmoid volvulus were first offered colonoscopic decompression for their acute colonic obstruction. If the colonic decompression was successful, complete bowel preparation was performed, followed by elective laparoscopically assisted sigmoidectomy. The details of the laparoscopic procedures are shown in the video. Briefly, the redundant sigmoid colon is totally mobilized by a laparoscopic medial-to-lateral dissection sequence, after which it is exteriorized, transected, and reconstructed by end-to-end anastomosis. In the authors' experience, the medial-to-lateral approach is highly efficient for the laparoscopic mobilization of the redundant sigmoid colon. We believe that the longer the lateral abdominal wall attachment of the sigmoid colon is preserved, the better the exposure and the easier the dissection. If the risk of anastomotic leakage is considered high in a specific case, protective ileostomy is selectively preformed. Before entering the current study, the patients were well informed about the advantages and disadvantages of laparoscopic surgery. The enrollment of patients was selective according to the appropriate eligibility criteria. This study was approved by the Institutional Review Board of the National Taiwan University Hospital. The patients' clinicopathologic data and surgical outcomes were prospectively evaluated.
RESULTS: Between August 2001 and April, 2005, a total of 14 patients (10 men and 4 women) with sigmoid volvulus were treated with the described procedure. The age distribution of the patients was 68.4 +/- 12.2 years. The attack of sigmoid volvulus was the first episode for eight patients, the second episode for 4 patients, and the third episode (or more) for two patients. The body mass index (BMI) of the patients was 26.8 +/- 4.4 kg/m(2). The physical status (classification of American Society of Anesthesiology [ASA]) was 1 for five patients, 2 for eight patients, and 3 for 1 patient. During the laparoscopy, all the patients presented with the pathognomonic findings of sigmoid volvulus including redundant sigmoid colon, narrow sigmoid mesenteric pedicle, and mesosigmoiditis with mesenteric fibrosis and scarring, as shown in the video. The length of the resected colon was 32 +/- 6 cm. The operation time was 194.6 +/- 32.4 min, and the blood loss was 44.0 +/- 12.4 ml. The abdominal wound consisted of four 5 to 12 mm working ports and a 5 cm major wound for exteriorization of the sigmoid colon. Some surgeons have shown that a sigmoid volvulus can be resected through a 5-cm left lower quadrant incision with very little mobilization of the colon because of its redundancy. In this context, the laparoscopic approach competed with the minilaparotomy method in terms of adequate sigmoid resection, lysis of mesosigmoid adhesion, and tension-free colorectal anastomosis. Protective ileostomy was performed for the only patient with a physical status of ASA 3. There was no mortality in this case series. However, pneumonia developed postoperatively in one patient, acute myocardial infarction in one patient, and wound infection in two patients. Excluding the two patients who experienced postoperative pneumonia and acute myocardial infarction, the duration of the postoperative ileus was 48 +/- 12 h, the postoperative hospitalization was 7 +/- 1 days, and the degree of postoperative pain was 3.5 +/- 0.5 according to the visual analog scale. The return to partial activity required 18 +/- 2.5 days, and the return to full activity required 28.4 +/- 5.6 days. As compared with the overall costs for a conventional sigmoid colectomy, which are completely covered by the National Bureau of Health Insurance of Taiwan, the expenses for the patients undergoing laparoscopic procedures were significantly higher by approximately 24,000.0 NT dollars +/- 2,635.0 (1 U.S. dollar = 32 NT dollars). These higher expenses must be borne by the patients themselves.
CONCLUSION: Considering that patients with sigmoid volvulus often are elderly and chronically ill, laparoscopic elective surgery after a successful colonoscopic decompression may be a good choice for a selected group of patients in terms of minimized surgical complications and quick convalescence.

PMID 17024540  Surg Endosc. 2006 Nov;20(11):1772-3. doi: 10.1007/s0046・・・

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