内視鏡的胃瘻造設術の空腸誤穿刺による腸閉塞に対する腹腔鏡下手術の経験

A case of laparoscopic surgery for ileus caused by misplacement of percutaneous endoscopic gastrostomy in the jejunum

◆要旨：患者は72歳，男性．他院にて慢性硬膜下血腫による嚥下障害に対し内視鏡的胃瘻造設術を施行された．チューブ抜去後2年2か月後に発症した腸閉塞にて入院となった．イレウス管造影にて胃瘻刺入部に小腸狭窄を生じていたため，癒着性腸閉塞の診断にて腹腔鏡下手術を行った．胃腹壁間に小腸が癒着しており，胃瘻瘻管は小腸壁を貫通していた．自動縫合器を用いて瘻管を切離した後，小腸部分切除術を行った．病理組織診断では小腸漿膜下に線維化から成る索状部が存在し瘻管を形成したものと推察された．胃瘻に起因した腸閉塞に対し，腹腔鏡下手術は低侵襲でQOLを損なうことなく施行し得る方法と考えられた．

　Generally, gastrostomy is performed by percutaneous endoscopic gastrostomy（PEG）and ileus is a rare complication. We report a case of laparoscopic surgery for ileus caused by PEG. A 72-year-old man underwent PEG because of dysphagia at a different hospital and PEG tube was removed later. He was admitted to our hospital with a diagnosis of ileus. Because contrasting with a long tube showed that the small intestine was adhered to the abdominal wall at the site of PEG, we performed laparoscopic operation. Laparoscopic surgery revealed adhesion between jejunum and abdominal wall at the site of PEG. The fistula of gastrostomy was penetrated through the jejunum to the abdominal wall. The fistula was divided, then, adhesiotomy and partial resection of the damaged jejunum were carried out. Histological examination revealed a funicular structure in the intestinal wall, so that the presence of penetration was suggested as well. PEG is a useful technique, but careful manipulation is required to avoid complications. Laparoscopic surgery is a minimally invasive treatment and quite useful for treatment of ileus caused by PEG.