PURPOSE: The high mortality associated with ileosigmoid knotting prompted us to review the collected experiences of three university hospitals in order to establish a more rational approach to the problem. METHOD: The clinical records of 68 patients with ileosigmoid knotting from 1970 to 1990 were reviewed with respect to incidence, etiopathogenesis, clinical features, treatment, and clinical outcome. RESULTS: The most common type of ileosigmoid knotting was Type IA (48.5 percent), in which the active ileum encircled the passive sigmoid in a clockwise manner. Fifty (73.5 percent) patients developed a gangrenous bowel whereas 18 patients did not show any definite evidence of impairment of bowel viability. En bloc removal of gangrenous knot and reestablishment of intestinal continuity by enteroenteric or enterocolic anastomosis combined with the Hartmann procedure, which was employed in 20 (42.6 percent) cases, constituted the most frequently preferred operation. The mortality rate in this series was 30.9 percent (21/68) and toxic shock, which ultimately resulted in multiple organ failure, was the major cause of death. It was remarkable to note that there was an inverse correlation between the duration of symptoms and the mortality rate reflecting the dramatic rapidity and severity of symptoms due to tightness of the knot which led to early and extensive gangrene, thus inevitably urged the patients to seek medical help without delay. CONCLUSION: The performance of prompt, individualized surgical treatment in conjunction with the use of advanced measures of critical care to combat the disastrous consequences of multiple organ failure would contribute greatly to improve survival rate in victims of this dreadful entity.