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1 대흉외지 2009;42:34-40 임상연구 복부대동맥류치료의임상적고찰 ; 후복막접근법과경복막접근법의비교 손봉수 * ㆍ정성운 * ㆍ이상권 * Clinical Study of the Treatments for Abdominal Aortic Aneurysm; Comparison between the Retroperitoneal and Transperitoneal Approaches Bong Soo Son, M.D.*, Sung Woon Chung, M.D.*, Sang Kwon Lee, M.D.* Background: The principal surgical technique for treating an abdominal aortic aneurysm since the 1960s has been the transperitoneal approach, yet there have been some recent studies that have reported improved surgical results with using the retroperitoneal approach. However, there are only limited clinical Korean studies that have, compared between the transperitoneal and retroperitoneal approaches. Material and Method: This study included 36 patients who had been diagnosed as having an aneurysm of the abdominal aorta and they were surgically treated between January 2001 and July The patients were subdivided into the retroperitoneal approach group (n=17) and the transperitoneal approach group (n=19), and they were compared in terms of the preoperative risk factors, the postoperative complications and the operative mortality. The risk factors of operative mortality risk and long-term survival for the 36 patients were assessed by the Kaplan-Meier method. Result: There were no significant differences between the groups in terms of gender, age, the underlying disease, a history of smoking, rupture of aneurysm, the preoperative symptoms, the operation time and the incidence of postoperative complications. However, the duration of postoperative fasting, the number of days of having an indwelling nasogastric tube and the length of the stay in the intensive care unit were significantly short for the retroperitoneal approach group (p<0.05). There was a 16.7% rate of operative mortality (6/36) and five of the deaths were attributed to preoperative ruptured aneurysm. On univariate analysis, a higher preoperative serum creatinine level (SCr 1.8 mg/dl, p=0.016) and ruptured aneurysm (p<0.001) were the significant risk factors of operative mortality. As assessed by the Kaplan-Meier method, the long-term survival was comparable between the groups and the five-year survival rate of all the patients was 57.5%. Conclusion: In the present study, a retroperitoneal approach has several advantages such as a shorter intensive care unit stay, a shorter duration of postoperative fasting and a shorter duration of an indwelling nasogastric tube. Therefore, unless there is any contraindication for a retroperitoneal approach, it could be considered as a primary surgical access for repairing an abdominal aortic aneurysm. Key words: 1. Aorta 2. Aneurysm 3. Retroperitoneal approach (Korean J Thorac Cardiovasc Surg 2009;42:34-40) * 부산대학교의학전문대학원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University 본연구는 2007 년도부산대학교병원임상연구비지원으로이루어졌음. 이논문은 2007 년도대한흉부외과학회제 39 차추계학술대회에서구연발표되었음. 논문접수일 :2008 년 7 월 25 일, 심사통과일 :2008 년 11 월 14 일책임저자 : 정성운 ( ) 부산시서구아미동 1 가 10, 부산대학교병원흉부외과 (Tel) , (Fax) , chungsungwoon@hanmail.net 본논문의저작권및전자매체의지적소유권은대한흉부외과학회에있다. 34

2 손봉수외 Comparison between Retroperitoneal and Transperitoneal Approach Table 1. Operative procedures Unruptured group Ruptured group Total (n=27) (n=9) (%) Retroperitoneal approach (n=17) Aorto-biiliac bypass (41.8) Aorto-bifemoral bypass (47.1) Straight graft replacement (11.8) Transperitoneal approach (n=19) Aorto-biiliac bypass (26.3) Aorto-bifemoral bypass (52.6) Straight graft replacement (15.8) 서론동맥류란동맥의정상직경보다 1.5배이상커진상태가동맥에국소적으로일어나는것으로정의되며동맥류는유전, 단백분화, 죽상동맥경화증등여러가지소인의복합적인상호작용에의한결과로형성된다. 그중에서도복부대동맥류가가장흔하며 1951년, Charles Dubost[1] 에의해인간흉부대동맥이식편을이용한복부대동맥류치환술을성공적으로시행한이래로 1960년대동종이식편에서인조혈관으로대체되면서현재까지인공혈관을이용한복부대동맥류치환술이보편적으로사용되고있다. 이러한수술적치료에서일반적인접근방법으로경복막접근법 (transperitoneal approach) 과후복막접근법 (retroperitoneal approach) 이있다. 그중후복막접근법은 1980년 Ricotta 등 [2] 이신장주위와신장상부의대동맥의수술에좋은시야를확보할수있다고보고한후많은사람들에의해선택적으로사용되고있으며술후회복및합병증발생에있어후복막접근법이더우수하다는많은보고가있다. 그러나국내에서는두수술접근법사이의비교가제한적인실정이다. 이에저자들은복부대동맥류로진단된환자중외과적치료를받은환자를대상으로접근방법에따른비교및치료결과를보고하고자한다. 대상및방법 1) 대상환자 2001년 1월부터 2007년 7월까지복부대동맥류교정술을시행받은 42명의환자중중재적혈관내대동맥류복구술을시행한 6명을제외한총 36명의수술적교정술을시행받은환자를연구대상으로하였다. 환자의평균연령은 65.3±10.2세였으며남녀비는 31:5였다. 대동맥류의진단은대부분전산화단층촬영을이용하였으며급성신 부전으로혈관내조영제투여가힘든 1명의환자에서 MRI를시행하였고 2명의환자에서초음파검사를병행하였다. 2) 수술방법후복막접근법은 17명에서시행되었으며, 수술은전신마취상태에서환자를 45도정도우측반측와위로좌측 11번, 12번째늑골연에서배꼽과치골결합부위를연결하는선상의중간지점까지피부절개를시행하였다. 피하조직및근육층을절개한후후복막지방층을박리하여복부대동맥까지접근하여요관을확인한후앞쪽으로젖혀대동맥류주위및장골동맥을노출시키고정맥내헤파린 (100 U/kg) 주사후대동맥류의근위부와원위부를각각겸자를이용하여잡고대동맥류절개를시행하였다. 절개시하장간막동맥은일반적으로결찰하였다. 대동맥내죽종을제거하고척추동맥기시부를결찰한후근위부대동맥의크기에알맞은인공혈관을이용하여근위부문합을시행하고이후원위부에문합하였다. 경복막접근법의경우 19명의환자에서시행되었으며, 전신마취상태에서환자를바로눕힌후정중개복술을시행하고장을젖혀후복막을절개하여동맥류주위를노출시킨다음후복막접근법과같은방법으로문합을시행하였다. 총 36명의환자에서원위부문합부는장골동맥류의유무에따라그위치를달리하였는데총 18명의환자 (50%, 18/36) 에서장골동맥류가있거나폐쇄및협착, 석회화로문합이어려워대동맥-양측대퇴동맥우회술을시행하였다. 13명의환자 (36.1%, 13/36) 는대동맥류가복부대동맥말단부까지진행되어대동맥-양측장골동맥우회술을시행하였으며그외일자인공혈관 (straight graft) 을이용한복부대동맥치환술을시행한환자가 5명 (13.9%, 5/36) 이었다 (Table 1). 35

3 대흉외지 2009;42:34-40 Table 2. Preoperative characteristics of patients Retroperitoneal Transperitoneal approach approach p-value (n=17) (n=19) Male gender 88.2% (15) 78.9% (15) >0.1 Mean age (years) 65.8± ±12.5 >0.1 Underlying disease >0.1 Hypertension 70.6% (12) 52.6% (11) >0.1 DM 17.6% (3) 21.1% (4) >0.1 IHD 29.4% (5) 21.1% (4) >0.1 CHF 0% (0) 5.3% (1) >0.1 PAOD 5.9% (1) 10.6% (2) >0.1 Preoperative SCr 11.8% (2) 21.1% (4) > mg/dl Pulmonary disease 29.4% (5) 21.1% (4) >0.1 Old CVA 11.8% (2) 10.6% (2) >0.1 Marfan syndrome 0% (0) 5.3% (1) >0.1 Smoking 58.8% (10) 68.4% (13) >0.1 Diameter of aneurysm 6.7± ±2.1 >0.1 (cm) Ruptured aneurysm 17.6% (3) 31.6% (6) >0.1 Preoperative symptoms >0.1 Incidental 23.5% (4) 10.6% (2) >0.1 Pulsating mass 35.3% (6) 42.1% (8) >0.1 Abdominal pain, 41.2% (7) 47.4% (9) >0.1 back pain Leg pain with skin 0% (0) 5.3% (1) >0.1 color change DM=Diabetes mellitus; IHD=Ischemic heart disease; CHF= Congestive heart failure; PAOD=Peripheral artery occlusive disease; SCr=Serum creatinine; CVA=Cerebral vascular accident. Table 3. Operative results Retroperitoneal Transperitoneal approach approach p-value (n=17) (n=19) Admission period (day) 16.6± ±30.9 >0.1 ICU stay (day) 3.5± ± Operative time (min) 341.2± ±111.9 >0.1 Fasting time (day) 2.3± ± L-tube keeping time (day) 1.9± ± P-RBC transfusion (pint) 5.2± ±4.6 >0.1 Intraoperative fluid 6,189.7±4, ,452±2,973.1 >0.1 infusion (ml) ICU=Intensive care unit; L-tube=Levin tube; P-RBC=Packed RBC. Table 4. Post operative complication & mortality Mortality Retroperitoneal approach (n=17) Transperitoneal approach (n=19) 5.9% (1) 26.3% (5) ARF 1 1 DIC 1 1 Leg ischemia 1 2 Pneumonia 1 0 Sepsis 1 1 CVA 0 2 Wound infection 0 1 Colon ischemia 0 1 ARF=Acute renal failure; DIC=Disseminated intravascular coagulopathy; CVA=Cerebral vascular accident. 3) 두군간비교본연구에서는총 36명의환자들을각각후복막접근법으로수술한군 (n=17) 과경복막접근법으로수술한군 (n=19) 으로나누어두군의성별, 나이, 술전동반질환유무, 파열유무, 술전복부대동맥류의최대직경, 입원기간, 중환자실재실기간, 술후금식기간, 비위관거치기간, 술중수액투여용량, 술중수혈량, 술후합병증, 수술사망률을비교분석하였다. 전체환자에서수술사망의위험인자를분석하였고, 전화설문및정기적인외래관찰을통해환자의생존여부를조사한후 Kaplan-Meier 생존분석을이용하여장기생존율을조사하였다. 모든연구자료는의무기록을이용한후향적분석을이용하였다. 4) 통계분석본연구의통계학적분석은 SPSS 10.0 (SPSS Inc., Chicago, IL, USA) 을이용하였다. 양군간의연속변수자료는평균값 ± 표준편차로표시하였고, 독립표본 T-검정 (independent T-test) 으로비교하였으며, 범주형변수의비교를위하여 Chi-Square 혹은 Fisher의정확한검정을이용하였다. 유의수준이 0.05 이하일때통계학적으로유의한차이가있는것으로하였다. 결과두군간연령, 나이, 술전동반질환의유무, 흡연력, 술 36

4 손봉수외 Comparison between Retroperitoneal and Transperitoneal Approach Fig. 1. (A) Kaplan-Meier survival analysis, comparison between retroperitoneal and trans-peritoneal approach group ( =retroperitoneal approach group I; =trans-peritoeneal approach group). (B) Kaplan-Meier survival analysis of total patients. 전컴퓨터단층촬영으로측정한대동맥류의최대직경, 파열유무, 술전증상등은차이가없었다. 술전증상에서두군모두우연히발견된경우와박동성종물등특별한증상이없었던경우가많았으며복통및허리통증이그다음을차지하였다 (Table 2). 후복막접근법군과경복막접근법군간의대동맥재건술식에서대동맥-양측장골동맥우회술이각각 7명, 10명이었으며대동맥-양측대퇴동맥우회술이 8명, 10명, 단순대동맥치환술이 2명, 3명으로역시두군간의차이는없었다 (Table 1). 수술결과에서중환자실재실기간, 금식기간, 비위관삽입기간에서두군간에통계적으로유의한차이를보였으나술중수혈및수액투여양은유의한차이를보이지않았다 (Table 3). 술후조기사망은총 6명 (16.7%) 이었으며파열전에수술을시행하였던환자 27명중사망이 1명 (3.7%) 이었던것에비해대동맥류가파열되어응급수술을시행한환자총 9명중에서 5명 (55.6%) 이사망하였다. 술후합병증에서는두군간에차이가없었다 (Table 4). 전체 36명의환자에서수술사망의위험인자로서성별, 연령, 당뇨, 고혈압, 허혈성심질환, 혈중크레아티닌 (> 1.8 mg/dl), 폐질환, 파열유무등을단변량분석하였으며이중술전혈중크레아티닌이 1.8 mg/dl 이상일때 (p=0.016) 와파열된대동맥류 (p<0.001) 가유의한위험인자로밝혀졌다. 장기생존율을분석한 Kaplan-Meier 생존율조사에서후복막접근법군과경복막접근법군간의유의한차이는 없었으며 (p>0.1) 전체환자의 5년생존율은 57.5% 로나타났다 (Fig. 1). 고찰 1952년, Charles Dubost[1] 에의해인간흉부대동맥이식편을이용한복부대동맥류치환술을성공적으로시행한이래로현재까지수술수기및환자관리가발달하였고복부대동맥류수술은지속적인증가추세에있다. 국내에서도 1963년이한길등 [3] 에의해처음으로복부대동맥류환자의수술적치험례가보고된후이질환의수술에대한보고가점차증가하고있으며무증상의복부대동맥류도건강검진등의증가로앞으로도더많이발견될것으로전망된다. 복부대동맥류는 60세이상의나이에서주로발생하고남녀의발생비율은 6:1로남자에게서많이발생하는것으로알려져있다. 복부대동맥류의발병기전으로는여러가지복합적인요인이있는데그하나가대동맥벽결체조직의단백분해를들수있다. 대식세포와평활근세포에서 matrix metalloproteinases (MMPS) 와그외의여러가지단백분해효소들을분비하며이것들이대동맥류를발생하는것으로알려져있다 [4]. 또다른요인은생화학적인특성과장력인데복부대동맥류의호발부위인신장동맥직하부는대동맥구조, 생화학적특성, 대동맥에작용하는장력이다른곳과다르다. 실제로신동맥하방의대동맥에는대동맥궁이나하행대동맥보다엘라스틴-콜라겐비율이감소되어있고, 엘라 37

5 대흉외지 2009;42:34-40 스틴의감소는대동맥이늘어나는것과연관성이있다고한다 [5]. 복부대동맥류의수술방법으로는주로정중복부절개에의한경복막접근법이시행되었는데 1980년 Ricotta 등 [2] 이신장주위와신장상부복부대동맥의수술에좋은시야를확보할수있다고보고한후많은사람들이후복막접근법을사용하고있다. 경복막접근법은수술중신장하부동맥의노출에용이하고하장간막동맥의결찰시대장의혈류공급장애에의한괴사를육안으로확인할수있으며원활한시야확보의장점이있는것으로알려져있다. 그러나경복막접근법은심장질환및폐질환등을가진위험도가높은환자에서발생할수있는합병증의발생을증가시킬수있어 Sicard 등 [6] 은일반적인복부대동맥류환자에서도후복막접근법에의한수술을권유하였으며 Lacroix 등 [7] 은신동맥상부뿐만아니라신동맥하부대동맥재건술에도충분히적용할수있다고주장하였다. Johnson 등 [8] 은대동맥과장골동맥폐쇄질환의 459명의환자를대상으로한연구에서수술시간및술후장폐쇄등의합병증들이후복막접근법에의한경우에서적었고신장하부대동맥재건술에도충분히사용가능하다고주장하였다. 또한 Cina 등 [9] 은후복막접근법의경우가환자들에게혈관내수액의투여가적고중환자실재원기간및기계환기사용기간등을단축시킬수있으며통증이작아술후진통제사용을줄일수있다고보고하였으며경복막접근법에비해장마비, 제3강유출 (third-space fluid loss) 증가등의합병증을줄일수있다고한연구도있다 [10]. 따라서후복막접근법은경험이축적되면수술중충분한시야를확보할수있고회복이빠르며술후합병증의발생이적은장점이있다. 본연구의결과에서도비교적적은수의환자군을대상으로한연구임에도불구하고, 술후중환자실재원기간및장기능회복시간이통계적으로유의하게짧았다. 본연구의수행후, 최근저자들은환자의수술후조기회복의장점이있는후복막접근법을복부대동맥류수술의일차적접근방법으로사용하고있다. 수술전사망과관련되는위험인자로 Steyerberg 등 [11] 은 meta-analysis를통하여술전신기능부전 ( 혈중크레아티닌 >1.8 mg/dl), 울혈성심부전, 심전도상허혈소견, 폐질환, 연령, 성별등을위험인자로보았다. 본연구에서는성별, 연령, 당뇨, 고혈압, 허혈성심질환, 혈중크레아티닌 1.8 mg/dl 이상, 폐질환, 파열유무등을조사하였으 며이중혈중크레아티닌이 1.8 mg/dl 이상일때 (p= 0.016) 와파열유무 (p<0.001) 가통계적으로유의한것으로나타났다. 복부대동맥류파열의발생은과거에비해아직증가하고있는추세이며복부대동맥류가있는환자의약 1/3이그들이살아있는동안파열을경험한다 [12]. 또한, 복부대동맥류가있는환자들의약 40% 가처음으로겪는증상이파열일만큼파열전에는증상이없는경우가많다고한다 [13]. 파열복부대동맥류는수술술기가지난 50여년간꾸준히발전하였음에도불구하고수술사망률은여전히높아약 50% 정도로보고되고있으며종합적인사망률은이보다더높을것으로생각된다. 한보고에따르면술전심정지, 80세이상의고령, 여성, 대량의출혈등이있는경우술후사망률은 90% 가넘는다고보고하였다 [14]. 본연구에서도술전파열되어응급수술의시행한환자의사망률이 55.6% 에달하여파열되지않았던환자군과비교하였을때유의한차이를보이고있다 (p<0.001). 따라서파열되기전에조속한치료가환자의예후를결정하는중요한인자가된다는것을시사한다. Scott 등 [15] 이 6 cm 미만크기의복부대동맥류환자에서초음파검사를통해 7년간추적관찰을한결과직경 cm 크기의작은복부대동맥류의파열가능성은연 2.1% 이라고보고하였다. 다른연구에따르면직경 5 cm 크기의동맥류가파열될가능성은연 5% 로여러병원에서파열되지않은대동맥류의수술사망률은 5% 정도가일반적이기때문에직경 5 cm 이상의크기를수술적응으로보고있지만한편에서는수술위험도가적은환자에서는크기가 4 cm 이상이면수술의적응이된다고보는견해도있다 [16]. 따라서일반적으로는대동맥류가 5 cm 이상인환자는비록무증상이라하더라도적극적인치료가필요할것으로생각된다. 복부대동맥류로치료받은환자에있어서장기생존율은 5년생존율이평균약 70% (61 82%) 정도로보고되고있으며 [17] 본연구에서는 Kaplan-Meier 생존율조사에서 57.5% 로조사되었으나추적관찰기간이짧고환자수가적어앞으로더연구가필요할것이다. 본연구의제한점으로는첫째, 적은수의환자의의무기록을대상으로한후향적연구이므로환자선택에대한오류를피할수없었다. 이에대해서는향후더많은환자를대상으로한전향적인연구를계획중이다. 둘째, 비교적짧은추적관찰기간으로인하여장기생존율의비교를위한대상환자의수가부족하였으나, 이는추후추가적인 38

6 손봉수외 Comparison between Retroperitoneal and Transperitoneal Approach 연구를통하여수정보완하고자한다. 결 이상의연구결과에의하면후복막접근법이경복막접근법에비하여중환자실재실기간, 금식기간및비위관삽입기간이짧은경향이있어후복막접근법에대한특별한금기가없다면수술적치료를요하는환자의경우후복막접근법을선택할만하다고생각된다. 또한술후사망과관련된인자로혈중크레아티닌수치 (<1.8 mg/dl)(p=0.016) 와파열 (p<0.001) 등이있었으며파열이되었을때에는파열되지않았을때의 3.7% 의사망률에비해 55.6% 의높은사망률을보인다. 이는파열되기전에조기발견하여치료의적응증이되는경우에는조속한수술이필요하며작은크기의복부대동맥일지라도주의깊은경과관찰이중요함을말해준다. 론 참고문헌 1. Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with results after five months. Arch Surg 1952;64: Ricotta JJ, Williams GM. Endarterectomy of the upper abdominal aorta and visceral arteries through an extra-peritoneal approach. Ann Surg 1980;192: Lee HK, Lee YK. Abdominal aortic aneurysm. J Korean Surgical Society 1963;5: Davies MJ. Aortic aneurysm formation: lessons from human studies and experimental models. Circulation 1998;98: Ailawadi G, Eliason JL, Upchurch GR Jr. Current concepts in the pathogenesis of abdominal aortic aneurysm. J Vasc Surg 2003;38: Sicard GA, Allen BT, Munn JS, Anderson CB. Retroperitoneal versus transperitoneal approach for repair of abdominal aortic aneurysm. Surg Clin North Am 1989;69: Lacroix H, Van Hemelrijk J, Nevelsteen A, Suy R. Transperitoneal versus extraperitoneal approach for routine vascular reconstruction of the abdominal aorta. Atca Chir Belg 1994;94: Johnson JN, McLoughlin GA, Wake PN, Helsy CR. Comparison of extraperitoneal and transperitoneal methods of aorto-iliac reconstruction. Twenty years experience. J Cardiovasc Surg (Torino) 1986;27: Cina B, Goksel O, Kut S, et al. Abdominal aortic aneurysm surgery: retroperitoneal or transperitoneal approach? J Cardiovasc Surg (Torino) 2006;47: Sicard GA, Freeman MB, Vanderwoude JC, Anderson CB. Comparison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. J Vasc Surg 1987;5: Steyerberg EW, Kievit J, de Mol Van Otterloo JC, van Bockel JH, Eijkemans MJ, Habbema JD. Perioperative mortality of elective abdominal aortic aneurysm surgery: a clinical prediction rule based on literature and individual patient data. Arch Intern Med 1995;155: Treska V, Certik B, Cechura M, Novak M. Ruptured abdominal aortic aneurysms - university center experience. Interact Cardiovasc Thorac Surg 2006;5: Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993;328: Johansen K, Kohler TR, Nicholls SC, Zierler RE, Clowes AW, Kazmers A. Ruptured abdominal aortic aneurysm: the harborview experience. J Vasc Surg 1991;13: Scott RA, Tisi PV, Ashton HA, Allen DR. A 7-year follow-up of the entire abdominal aortic aneurysm population detected by screening. J Vasc Surg 1998;28: Katz DA, Littenberg B, Cronenwtt JL. Manangement of small abdominal aortic aneurysms: early surgery vs watchful waiting. JAMA 1992;268: Norman PE, Semmens JB, Lawrence-Brown MM. Long-term relative survival following surgery for abdominal aortic aneurysm: a review. Cardiovasc Surg 2001;9:

7 대흉외지 2009;42:34-40 = 국문초록 = 배경 : 1960 년대이래로복부대동맥류의주된수술적접근방법은경복막접근법이나, 최근에는후복막접근법을이용한향상된수술성적들이보고되고있다. 하지만후복막접근법과경복막접근법의비교에대한국내연구는제한적이다. 대상및방법 : 2001 년 1 월부터 2007 년 7 월까지복부대동맥류로진단받고수술적대동맥치환술을받은 36 명중후복막접근법을이용한 17 명과경복막접근법을이용한 19 명의수술전위험인자, 술후합병증, 수술사망률을비교분석하였다. 전체 36 명의환자에서수술사망의위험인자를조사하고 Kaplan-Meier 생존분석을이용한술후장기생존율조사하였다. 결과 : 대상환자중두군간에성별, 연령, 동반질환의유무, 흡연력, 파열유무, 술전증상간의유의한차이는없었으며, 대동맥재건술식, 수술시간및술후합병증의발생빈도에서도유의한차이가없었다. 그러나후복막접근법군에서술후금식기간및비위관제거기간이짧았으며 (p <0.05), 중환자실재실기간에서도경복막접근법군에비하여유의하게짧았다 (p<0.05), 수술사망은총 6 명 (16.7%) 이었으며그중 5 명이술전파열된경우로, 단변량분석에서수술전 1.8 mg/dl 이상의혈중크레아티닌수치를보이는경우 (p=0.016) 및파열된복부대동맥류 (p<0.001) 가유의한수술사망의위험인자로조사되었다. Kaplan-Meier 생존율조사에서는두군간의장기생존율의차이는없었으며전체환자의 5 년생존율은 57.5% 였다. 결론 : 본연구결과후복막접근법이경복막접근법에비하여중환자실재실기간이짧고술후금식기간및비위간거치기간이짧은장점이있었다. 따라서후복막접근법에대한특별한금기가없다면후복막접근법을일차적으로고려하는것이좋을것으로사료된다. 중심단어 :1. 대동맥 2. 동맥류 3. 후복막접근 40

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic