経皮内視鏡的胃瘻造設術後の胃結腸瘻に対して腹腔鏡下手術が有用であった1例

Gastrocolic fistula : A complication of percutaneous endoscopic gastrostomy

症例は81歳，男性．多発性脳梗塞，廃用症候群に伴う摂食障害があり，2002年7月に当院で経皮内視鏡的胃瘻造設術（percutaneous endoscopic gastrostomy : PEG）を施行した．その際に鎮静困難なため全身麻酔を使用した．2003年4月に内視鏡下に胃瘻交換を行ったが容易ではなく，ガイドワイヤーを使用した．同年7月頃より水様性下痢，胃瘻より便臭を伴う排液を認め当院に入院した．腹部CTで胃瘻が胃から逸脱しており，胃瘻および注腸造影で胃結腸瘻の診断となった．保存的治療を行ったが改善せず，手術を施行した．腹腔鏡下に腹壁と横行結腸，胃体部と横行結腸の瘻管を自動縫合器で切除した．腹腔鏡補助下にPEGを再施行した．術後経過は良好であった．PEG施行の際は重篤な合併症である内臓誤穿刺を起こさない工夫が必要である．また，胃結腸瘻の治療として腹腔鏡下手術は有用であった．

　An 81-year-old male patient with cerebral infarction and disuse syndrome underwent insertion of a percutaneous endoscopic gastrostomy （PEG） because of eating disorder in 2002. The surgery was performed under general anesthesia because sedation was difficult. Nine months after PEG insertion, replacement of a new gastrostomy button was performed using the endoscope. Because exchanging the button was difficult, we used a guide wire to insert a new one. The patient was referred to our hospital because of watery diarrhea and stool-like fluid coming out from the gastrostomy button. The abdominal CT scan showed that the button was dislocated from the stomach. The radiographic contrast from the gastrostomy and enema showed a gastrocolic fistula. Conservative therapy did not improve the patient's condition, thus laparoscopic surgery was performed. The fistulous tracts were resected with the auto-suturing device and laparoscopic-assisted PEG was performed. Post operative course was uneventful. It is necessary to prevent serious complications such as puncturing other organs when performing PEG. Moreover, laparoscopic surgery was useful for gastrocolic fistula that occurred as a complication of PEG.