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1 대한내과학회지 : 제 86 권제 6 호 Insulation-Tipped Diathermic Knife 2를이용한중심성기도폐쇄치료 2예 1 한전병원내과, 2 분당서울대학교병원호흡기내과 고규한 1 김세중 2 박상훈 1 장세헌 1 유승현 1 구남호 1 이승현 1 Two Cases of Central Airway Obstruction Treated with an Insulation-Tipped Diathermic Knife-2 Kyu Han Koh 1, Se Joong Kim 2, Sanghoon Park 1, Se Heon Chang 1, Seung Hyun Yoo 1, Nam Ho Koo 1, and Seung Hyeun Lee 1 1 Department of Internal Medicine, KEPCO Medical Center, Seoul; 2 Division of Respiratory and Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea Central airway obstruction can result from various benign and malignant conditions, and often requires prompt palliation. The efficacies of a variety of bronchoscopic techniques for the treatment of central airway obstruction such as electrocautery, laser, brachytherapy, argon plasma coagulation and cryotherapy have been established. An insulation-tipped diathermic knife-2 (IT knife-2) was initially introduced for gastrointestinal endoscopic submucosal dissection and has been used globally as a safe and effective instrument. However, its use has not been reported for the treatment of endotracheal or endobronchial lesions. Here, we report the case of central airway obstruction in a 65-year-old male due to malignancy and a 52-year-old-female with post-radiation bronchial stenosis that were treated successfully with the IT-knife-2 via flexible bronchoscopy. (Korean J Med 2014;86: ) Keywords: Bronchoscopy; Central airway obstruction; Lung cancer 서론중심성기도폐쇄는다양한양성및악성질환에동반될수있으며무증상에서심한저산소혈증까지다양한임상증상을야기한다. 악성종양에의한중심성기도폐쇄는원발성폐암또는전이성폐암으로발생할수있으며호흡곤란, 객혈, 무기폐, 폐쇄성폐렴등을유발한다 [1]. 양성질환에의한중심성기도폐쇄는매우다양한원인에의해발생하는데삽관후기관협착, 기도이물, 기관연화증에의한것이대부분을차지한다 [2]. 중심성기도폐쇄를호전시키기위해서다양한중재적시술이시행될수있으며이러한시술로는전기소작술, 레이저, 근접치료, 광역동치료, 냉동치료, Received: Revised: Accepted: Correspondence to Seung Hyeun Lee, M.D., Ph.D. Department of Internal Medicine, KEPCO Medical Center, 308 Uicheon-ro, Dobong-gu, Seoul , Korea Tel: , Fax: , humanmd04@hanmail.net Copyright c 2014 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

- The Korean Journal of Medicine: Vol. 86, No. 6, 2014 - 스텐트삽입술등이있다. 이러한중재적시술들은중심성기도폐쇄환자들의증상을완화시키고삶의질을향상시킨다고알려져있으나폐쇄의성격이나위치, 환자의상태, 시술자의경험등을고려하여각각의환자에맞는시술법이신중히선택되어야한다 [3].

이기구는특징적으로세침절개도끝에절연체가있어천공과같은부작용이적고절개력이우수하며비용이저렴하여소화기영역에서내시경적시술에널리사용되고있다 [4]. 하지만본시술을기관지경을이용한기도병변의치료에이용한보고는현재까지없다.

증례증례 1 환자 : 65세남자주소 : 내원 2주전부터시작된기침과호흡곤란현병력 : 10개월전폐편평세포암병기 IV 진단받고 gemcitabine과 cisplatin으로 6회전신항암요법시행후진행없이 외래추적관찰하던분으로내원 2주전부터시작된기침과점진적으로악화되는호흡곤란으로내원하였다. 과거력 : 2년전진단받은만성폐쇄성폐질환으로흡입제및경구약제를복용중이다.

2 - The Korean Journal of Medicine: Vol. 86, No. 6, 스텐트삽입술등이있다. 이러한중재적시술들은중심성기도폐쇄환자들의증상을완화시키고삶의질을향상시킨다고알려져있으나폐쇄의성격이나위치, 환자의상태, 시술자의경험등을고려하여각각의환자에맞는시술법이신중히선택되어야한다 [3]. Insulation-tipped diathermic knife (IT knife) 는조기위암을위시한소화기종양의내시경적점막하박리술용으로개발된전기수술용절개도이며 IT knife-2는 IT knife의단점을보완하여절개효율과시술시간을줄인개량형이다. 이기구는특징적으로세침절개도끝에절연체가있어천공과같은부작용이적고절개력이우수하며비용이저렴하여소화기영역에서내시경적시술에널리사용되고있다 [4]. 하지만본시술을기관지경을이용한기도병변의치료에이용한보고는현재까지없다. 저자들은진행성폐암및방사선치료의합병증으로발생한중심성기도폐쇄를가진두환자를굴곡성기관지내시경과 IT knife-2를이용하여성공적으로치료하였기에문헌고찰과함께보고하는바이다. 증례증례 1 환자 : 65세남자주소 : 내원 2주전부터시작된기침과호흡곤란현병력 : 10개월전폐편평세포암병기 IV 진단받고 gemcitabine과 cisplatin으로 6회전신항암요법시행후진행없이 외래추적관찰하던분으로내원 2주전부터시작된기침과점진적으로악화되는호흡곤란으로내원하였다. 과거력 : 2년전진단받은만성폐쇄성폐질환으로흡입제및경구약제를복용중이다. 가족력 : 특이소견없었다. 사회력 : 35갑년의흡연력이있으나만성폐쇄성폐질환진단받은 2년전부터금연상태이다. 신체검사소견 : 혈압 110/70 mmhg, 맥박수 104회 / 분, 호흡수 24회 / 분, 체온 36.5 의생체징후를보였다. 의식은명료하였고급성병색을띄고있었다. 가슴청진상심박동은규칙적이었으며심잡음은들리지않았으나우폐야에천명음이들렸다. 검사소견 : 말초혈액및일반생화학검사에서특이소견은없었다. 동맥혈가스분석에서 ph 7.46, PaCO mmhg, - PaO mmhg, HCO mmol/l, SaO % 이었다. 방사선학적소견 : 단순흉부방사선사진에서우상엽의치유된결핵으로인한섬유화와우하엽에종양으로인한음영증가소견이관찰되었고 (Fig. 1A) 흉부전산화단층촬영에서비후된용골하림프절과이로인한우중간기관지의협착소견이관찰되었다 (Fig. 1B). 기관지경소견 : 좌측기관지는정상이었고우중간기관지의입구가외부에서압박하는종괴로인해심하게좁아진소견이었다 (Fig. 2A). 치료및임상경과 : 소화기내과세부전문의의감독하에직경 5 mm 굴곡형기관지경 (Olympus BF type 1T 260, Tokyo, Figure 1. (A) Chest radiography shows a fibrous change in the right upper lobe and increased opacity due to a cancer mass in the right lower lobe. (B) Chest computed tomography shows stenosis of the right bronchus intermedius compressed by an enlarged subcarinal lymph node. (C) Follow-up chest radiography on post-bronchoscopy day 2 shows decreased opacity in the right lower lobe

- Kyu Han Koh, et al. IT knife-2 in central airway obstruction - Figure 2.

(B, C) Bronchoscopy shows the insulation-tipped diathermic knife-2 during the procedure and the recanalized

(A) Chest radiography shows atelectasis of the right middle and lower lobes, and consolidation in the right

(B) Chest computed tomography shows severe narrowing of the right bronchus intermedius with atelectasis of the

(C) Follow-up chest radiography on post-bronchoscopy day 1 shows improved atelectasis of the right middle and

8 mm 채널로 IT knife-2 (Olympus Medical Systems, Tokyo, Japan) 를삽입하고 VIO 3000 고주파전원발생장치 (ERBE, Tübingen, Germany)

3 - Kyu Han Koh, et al. IT knife-2 in central airway obstruction - Figure 2. (A) Bronchoscopy shows near total obstruction due to external compression of the right bronchus intermedius. (B, C) Bronchoscopy shows the insulation-tipped diathermic knife-2 during the procedure and the recanalized right bronchus intermedius after tissue removal. Figure 3. (A) Chest radiography shows atelectasis of the right middle and lower lobes, and consolidation in the right upper lobe. (B) Chest computed tomography shows severe narrowing of the right bronchus intermedius with atelectasis of the right middle and lower lobes, with a small amount of pleural effusion. (C) Follow-up chest radiography on post-bronchoscopy day 1 shows improved atelectasis of the right middle and lower lobes. Japan) 의 2.8 mm 채널로 IT knife-2 (Olympus Medical Systems, Tokyo, Japan) 를삽입하고 VIO 3000 고주파전원발생장치 (ERBE, Tübingen, Germany) 를이용하여기관지내종괴를절제하여협착을완화시켰다 (Fig. 2B and 2C). 통전강도와고주파모드는일반적인내시경적점막하박리술시에사용하는것과같았으며 (20W, swift coagulation mode) 시술시간은약 20분이었다. 내원 2일째추적단순흉부방사선사진에서우하엽의음영은감소되었다 (Fig. 1C). 시술당일및입원중출혈등시술에따른합병증은없었으며호흡곤란은소실된상태에서퇴원하였고외래에서 2차항암치료로써 gefitinib을 복용하면서현재까지경과관찰중이다. 증례 2 환자 : 52세여자주소 : 대량객혈및호흡부전에따른심정지현병력 : 13년자궁경부암으로타병원에서전자궁절제및보조항암방사선치료후 10년전우측폐전이발생하여우측폐문부에외부조사방사선치료및 docetaxel과 cisplatin 전신항암치료 3회시행받고타병원추적관찰중인분으로내원당일 500 cc 가량의객혈후발생한심정지상태로본원

- 대한내과학회지 : 제 86 권제 6 호통권제 646 호 2014 - Figure 4. (A) Bronchoscopy shows near total obstruction with thickened mucosa and a small amount of bleeding at the right bronchus intermedius.

응급실로내원하여 9분간의심폐소생술후심기능회복되어중환자실로입원하였다. 과거력및사회력 : 자궁경부암외에특이병력없었다. 검사소견 : 백혈구 7,690/μL, 혈색소 10.5 g/dl, 혈소판 258,000/μL 이었으나 2시간후시행한추적검사상혈색소는 7.7 g/dl로감소되었다. 일반생화학검사상 AST 54 IU/L, ALT 77 IU/L, BUN 14.

방사선학적소견 : 단순흉부방사선사진에서는우중엽및우하엽의무기폐로의심되는음영증가소견과함께우상엽의경화소견이관찰되었고 (Fig. 3A), 흉부전산화단층촬영상우중간기관지의협착및우중엽및하엽의무기폐와우측에소량의흉수가관찰되었다 (Fig. 3B). 치료및임상경과 : 환자는기계환기및저체온요법을시행하였고항생제와지혈제를투여하였다.

4 - 대한내과학회지 : 제 86 권제 6 호통권제 646 호 Figure 4. (A) Bronchoscopy shows near total obstruction with thickened mucosa and a small amount of bleeding at the right bronchus intermedius. (B, C) Bronchoscopy shows serially recanalized right bronchus intermedius after tissue removal with the insulation-tipped diathermic knife-2 at hospital days 12 and 19, respectively. 응급실로내원하여 9분간의심폐소생술후심기능회복되어중환자실로입원하였다. 과거력및사회력 : 자궁경부암외에특이병력없었다. 검사소견 : 백혈구 7,690/μL, 혈색소 10.5 g/dl, 혈소판 258,000/μL 이었으나 2시간후시행한추적검사상혈색소는 7.7 g/dl로감소되었다. 일반생화학검사상 AST 54 IU/L, ALT 77 IU/L, BUN 14.1 mg/dl, Cr 1.2 mg/dl였다. 용적조절환기모드, 1회호흡량 350 ml, 산소분압 0.5 호흡수 16회 / 분에서시행한동맥혈가스분석에서 ph 7.31, PaCO mmhg, PaO mmhg, - HCO mmol/l, SaO % 였다. 방사선학적소견 : 단순흉부방사선사진에서는우중엽및우하엽의무기폐로의심되는음영증가소견과함께우상엽의경화소견이관찰되었고 (Fig. 3A), 흉부전산화단층촬영상우중간기관지의협착및우중엽및하엽의무기폐와우측에소량의흉수가관찰되었다 (Fig. 3B). 치료및임상경과 : 환자는기계환기및저체온요법을시행하였고항생제와지혈제를투여하였다. 중환자실치료중객혈은점차호전되었고입원 5일째의식이회복되었다. 기계환기중생체징후는안정적이었고입원 7일째발관후일반병실로전실하였으나우폐야에서천명음이지속적으로청진되었으며추적흉부방사선사진상우측무기폐가지속되었다. 입원 11일째기관지경을시행하였으며기관및좌측기관지에전이로의심되는다발성소결절이관찰되었고우중간기관지에는육아조직으로비후된점막으로인해겸자만통과가능할정도의심한협착과함께원위부에서약간의 출혈이관찰되었다 (Fig. 4A). 자궁경부암의다발성폐 / 기관지내전이에의한객혈과방사선치료후의기관지협착으로최종진단후다음날소화기내과세부전문의의감독하에증례 1과같은방법으로우중간기관지의협착부위를 IT knife-2를사용하여절개하여넓혀주었고 (Fig. 4B) 입원 19 일째추적기관지경을시행하여남아있는협착부위를추가적으로절개하였다 (Fig. 4C). 통전강도및고주파모드는 20W, swift coagulation mode를사용하였으며시술시간은각각약 10분이었다. 2번째시술후 1일째추적단순흉부방사선사진상무기폐의호전을보였다 (Fig. 3C). 고찰중심성기도폐쇄는다양한악성또는양성질환에의해발생하며폐암의증가및기관내삽관과같은기도시술의증가로인해유병률이늘어나고있는추세이다 [2]. 악성종양중가장흔한형태는원발성폐암의직접적인기도침범이며폐암에의한중심성기도폐쇄는전체폐암환자중 20-30% 에서발생하고폐암으로인한사망의 40% 에서연관이있다 [5]. 이러한중심성기도폐쇄는다양한정도의호흡곤란, 객혈, 무기폐, 폐쇄성폐렴등을동반하며수술적치료가불가능한경우가많아삶의질을저하시키는주요한원인이다 [6]. 양성질환에의한기도폐쇄는매우다양한원인으로발생하며기관내삽관, 기관지내결핵그리고방사선치료의합병증등대부분섬유화병변에의해발생한다 [2]

- 고규한외 6 인. 기도폐쇄에서 IT knife-2 의유용성 - 최근내시경적중재술의발달로이러한병변들을치료함으로써증상의극적인완화및삶의질향상을가져오는것으로알려져있지만많은경우시술법이고가의장비를필요로하고상당수에서전신마취가필요한경직성내시경이필요하다는제한점이있다 [7].

5 - 고규한외 6 인. 기도폐쇄에서 IT knife-2 의유용성 - 최근내시경적중재술의발달로이러한병변들을치료함으로써증상의극적인완화및삶의질향상을가져오는것으로알려져있지만많은경우시술법이고가의장비를필요로하고상당수에서전신마취가필요한경직성내시경이필요하다는제한점이있다 [7]. 시술방법의선택에대한명확한가이드라인은현재까지없으나병변의위치와성격, 환자의상태등의내적요인과장비의구비유무, 의료진의숙련도등외적요인을고려하여선택하여야한다 [2]. 전기소작술, 아르곤플라즈마응고요법, 스텐트삽입술은냉동치료, 근접치료, 광역동치료와달리즉각적으로기도폐쇄를완화시킬수있다는장점이있다. 전기소작술은가장오래된방법으로기도폐쇄의주요병변을제거할수있으나출혈, 기도천공, 기관지경손상등의부작용위험이있다. 아르곤플라즈마응고요법및레이저는출혈및천공위험이낮고지혈효과가우수하다는장점이있으나고비용과장비의부재로상급의료기관외에는시행에어려움이있다 [2]. 비교적최근에도입된광역동치료나냉동요법의경우효과가나타날때까지일정한시간이소요되므로즉각적인내경확보가필요한상황에서는사용하기어렵다는한계가있다 [7]. IT knife는 1994년일본에서소화기종양의내시경적점막하박리술을위해개발된장비로서길이 4 mm 얇은통전선의끝에직경 2.2 mm의세라믹절연체를부착하여선단에의한천공의위험성을줄인절개도의일종이다. 최근에는절 Figure 5. Photograph of the insulation-tipped diathermic knife-2. 연체안쪽에세갈래의날을추가하여조직의뒷면에도통전이가능하게하여절개가용이하도록개량된 IT knife-2가널리사용되고있다 (Fig. 5). IT knife-2는내시경적점막하박리술에서천공이나출혈의위험은 3% 가량으로적고측면절개가용이하며기존의 IT-knife 에비해시술시간을단축시켰다는장점이있다 [8]. 점막하박리술이외에도역류성식도염환자에서발생한식도의그물양협착 (weblike stenosis) 을 IT knife-2를이용하여성공적으로치료하였다는보고가있다 [9]. 호흡기영역에서 IT knife의사용은그보고가거의없는데최근 Sasada 등 [10] 은흉막조직검사시 IT-knife를사용하였을때겸자를이용한조직검사로는불가능한비후되고딱딱한흉막의조직검사가가능하였고충분한양의조직을안전하게얻을수있다고보고하였다. 현재까지 IT knife-2를기도폐쇄환자에서기관지경을이용한중재적치료에이용하였다는보고는없다. 본증례는기도폐쇄를치료할수있는특별한장비가없는국내 2차의료기관에서소화기영역에서널리사용되고있는 IT knife-2 를사용하여중심성기도폐쇄를가진환자를효과적으로치료할수있음을보여주었다. 위에서언급된장점이외에기관지경적중재술에있어서의 IT knife-2가가지는장점으로는 1) 양성뿐만아니라악성질환에의한기도폐쇄를치료할수있고, 2) 기도내병변뿐아니라외부압박에의한병변도치료할수있으며, 3) 전신마취없이의식하진정하에굴곡성기관지경을이용하여시술가능하며, 4) 복잡한술기를요구하지않고시술시간이짧으며, 5) 국내의료기관의소화기내과에보편적으로존재하는장비를공유함으로써기구의구매비용을줄일수있으며시술비가저렴하다는것을들수있겠다. 본증례에서처럼증상을호소하는중심성기도폐쇄의치료에있어 IT knife-2는기존의시술법들과함께고려될수있는하나의유용한시술이될수있을것으로판단되며향후본시술에대한장기적인안정성과합병증에대한연구가수반되어야하겠다. 또한이러한다양한시술법은궁극적인치료가아닌대부분증상완화가목적이므로원인질환에대한근본적인치료가필요함을인지함과동시에각시술법의장단점및환자의상태와예후등을고려하여환자개개인에맞는시술법을올바로선택하는것이무엇보다중요하겠다

6 - The Korean Journal of Medicine: Vol. 86, No. 6, 요 중심성기도폐쇄는양성혹은악성질환과동반되어나타날수있으며현재다양한기관지경적치료법이사용되고있다. IT knife-2는소화기내시경적시술을위해고안된장비로서그안정성과효용성이입증되어국내의료기관에서내시경적점막하박리술에널리사용되고있다. 저자들은굴곡성기관지경과 IT knife-2를이용하여진행성폐암과방사선치료후발생한중심성기도폐쇄를가진두환자를성공적으로치료하였다. 합병증과예후에대한추가적인연구가필수적이지만 IT knife-2는향후기도폐쇄의내시경적중재적시술법중하나로고려될수있을것이다. 약 중심단어 : 기관지경 ; 중심성기도폐쇄 ; 폐암 REFERENCES 1. Wood DE, Liu YH, Vallières E, Karmy-Jones R, Mulligan MS. Airway stenting for malignant and benign tracheobronchial stenosis. Ann Thorac Surg 2003;76: Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004;169: Chhajed PN, Somandin S, Baty F, et al. Therapeutic bronchoscopy for malignant airway stenoses: choice of modality and survival. J Cancer Res Ther 2010;6: Morris ML, Tucker RD, Baron TH, Song LM. Electrosurgery in gastrointestinal endoscopy: principles to practice. Am J Gastroenterol 2009;104: Noppen M, Meysman M, D'Haese J, Schlesser M, Vincken W. Interventional bronchoscopy: 5-year experience at the Academic Hospital of the Vrije Universiteit Brussel (AZ-VUB). Acta Clin Belg 1997;52: Smith EL, Hann DM, Ahles TA, et al. Dyspnea, anxiety, body consciousness, and quality of life in patients with lung cancer. J Pain Symptom Manage 2001;21: Amjadi K, Voduc N, Cruysberghs Y, et al. Impact of interventional bronchoscopy on quality of life in malignant airway obstruction. Respiration 2008;76: Ono H, Hasuike N, Inui T, et al. Usefulness of a novel electrosurgical knife, the insulation-tipped diathermic knife-2, for endoscopic submucosal dissection of early gastric cancer. Gastric Cancer 2008;11: Hyun JJ, Chun HJ, Keum B, et al. Weblike stenosis due to gastroesophageal reflux disease, treated with an insulationtipped diathermic knife-2 (IT-2). Endoscopy 2010;42(Suppl 2):E Sasada S, Kawahara K, Kusunoki Y, et al. A new electrocautery pleural biopsy technique using an insulated-tip diathermic knife during semirigid pleuroscopy. Surg Endosc 2009;23:

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