우진희외 : 비만이복강경하저위전방절제술에미치는영향 307 복강경하저위전방절제술과비만에관한연구는보고되지않고있는것으로알고있다. 이에저자들은직장암환자에서복강경하저위전방절제술시행시비만이환자의단기성적에어떠한영향을주는지확인하고자하였다. 대상및방법 2002년 9월부터 2008년 1

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1 J Korean Soc Coloproctol: Vol. 25, No. 5, , 2009 DOI: /jksc ORIGINAL ARTICLE 비만이복강경하저위전방절제술에미치는영향 우진희 박기재 최홍조 동아대학교의과대학외과학교실 The Impacts of Obesity on a Laparoscopic Low Anterior Resection Jin-Hee Woo, M.D., Ki-Jae Park, M.D., Hong-Jo Choi, M.D., F.A.C.S. Department of Surgery, Dong-A University College of Medicine, Busan, Korea Purpose: Obese patients are generally believed to be at increased risk for surgery compared to those who are not obese. It was the purpose of this study to compare the short-term outcomes of a laparoscopic low anterior resection (LAR) in obese and non-obese patients. Methods: We retrospectively reviewed 79 patients who had undergone a laparoscopic LAR for rectal cancer between September 2002 and January The degree of obesity was based on the Body Mass Index (BMI, kg/m 2 ). We divided the 79 patients into two groups: the high BMI (BMI 25) and the low BMI (BMI <25) groups. The parameters analyzed included age, gender, American Society of Anesthesiologists classification score, operative time, estimated blood loss, conversion rate, postoperative complications, hospital stay, and oncologic characteristics. Statistics included the t-test and Fisher s exact test. Statistical significance was assessed at the 5% level (P<0.05 being statistically significant). Results: There were no significant differences between the low BMI (n=55) and the high BMI (n=24) groups in age and gender. The high BMI group had significantly more conversion to an open procedure (20.8% vs. 3.6%, P=0.0244). The high BMI group and the low BMI group had no differences in blood loss, complications, hospital stay, and oncologic characteristics, but the high BMI group had a longer operative time (244.2 min vs min, P=0.0035). Conclusion: A laparoscopic LAR in obese patients had a higher conversion rate and a longer operative time, but there were no differences in postoperative complications and oncologic characteristics. A further study based on many experiences is needed to clarify the influence of the surgeon s experience on the operative time and the conversion rate, and long-term follow-up is necessary to evaluate the oncologic safety of a laparoscopic LAR in obese patients. Keywords: Laparoscopic low anterior resection, Rectal cancer, Obesity 중심단어 : 복강경저위전방절제술, 직장암, 비만 서 복강경수술은개복술에비해경미한통증, 조기장관운동회복, 재원기간의감소와미용적효과등에대한장점뿐아 Received : June 10, 2009 Accepted : October 5, 2009 Correspondence to : Ki-Jae Park, M.D. Department of Sugery, Dong-A University College of Medicine, 3-1 Dongdaeshin-dong, Seo-gu, Busan , Korea Tel : , Fax : gspark@dau.ac.kr 론 * 본논문의요지는 2008 년도대한대장항문학회학술대회에서포스터발표되었음. * 본연구는 2007 년도동아대학교학술연구비 ( 공모과제 ) 에의하여연구되었음. The Korean Society of Coloproctology 니라기술적, 종양학적안정성이인정되면서, 대장의양성및악성질환의치료에점차널리시도되고있다. 1-4 그리고많은연구들에서긍정적인평가를받고있으며, 적용술식에있어서도다양해졌고보편적인수술로인정되어가고있다. 일반적으로동반질환의가능성이높은비만환자가비만하지않은환자의경우보다수술의위험성이높은것으로알려져있고, 복강경술식을적용하는데있어서도비만이위험요소가될수있음이지적되고있다. 5,6 또한, 한국도식습관의변화로비만인구가점차증가하고있어사회적문제로받아들여지고있다. 현재까지, 국내논문중복강경하대장절제술과비만의영향에관한연구는있지만, 7 종양환자에서의 306

2 우진희외 : 비만이복강경하저위전방절제술에미치는영향 307 복강경하저위전방절제술과비만에관한연구는보고되지않고있는것으로알고있다. 이에저자들은직장암환자에서복강경하저위전방절제술시행시비만이환자의단기성적에어떠한영향을주는지확인하고자하였다. 대상및방법 2002년 9월부터 2008년 1월까지동아대학교외과학교실에서두명의수술자가종양환자에서시행한복강경하저위전방절제술 79예를대상으로후향적으로조사하였다. 이들가운데체질량지수 (kg/m 2 : Body Mass Index, BMI) 를구하여, BMI 25 이상인환자군을비만 (high BMI) 군으로정하고 BMI 25 미만인환자군을비만하지않은 (low BMI) 군으로나누어수술과관련된여러가지단기성적들을분석하였다. 임상소견은성별, 나이, 수술위험도 (ASA score), 병기및항문연에서종양까지의거리, 복부수술기왕력을비교하였다. 수술소견은수술시간, 수술중출혈량, 개복전환율을비교하였고수술후단기성적으로수술후장운동회복기간, 식이진행속도, 수술후입원기간및합병증등을비교항목으로하였다. 또한종양학적안전성을비교하기위해절제된림프절수, 종양의크기, 종양에서근위부및원위부절제연까지의길이를해부병리결과지를기준으로비교하였다. 통계는 GraphPad InStat Ver.3.06을이용하여 t-test, Fisher s exact test를하였고, P<0.05를통계적유의성이있는것으로판정하였다. 결과임상소견평균 BMI는 high BMI 군 (n=24) 이 27.2, low BMI 군 (n= 55) 이 21.6이었고, 환자의평균연령, 성비, 수술위험도에서양군간에유의한차이는없었다 (Table 1). 병기에있어서도양군간에통계적유의성은없었다 (Table 1). 복부수술기왕력은 high BMI 군이 20.8% (5예) 로 low BMI 군 16.3% (9예) 보다유의하게많았던것으로나타났다 (P<0.0001, Table 1). 이전수술의종류로는 high BMI 군에서는충수돌기절제술 (2예), 자궁전절제술 (2예), 소장부분절제술 (1예) 이있었고, low BMI 군에서는충수돌기절제술 (5예), 궤양으로인한위아전절제술 (1예), 자궁전절제술및양측난소절제술 (1예), 난관결찰술 (2예) 이있었다. 수술소견개복전환율은 high BMI 군에서 20.8% (5/24) 로 low BMI 군 3.6% (2/55) 보다통계적으로유의하게빈발한것으로나타났다 (P=0.0244; Table 1). High BMI 군에서개복으로전환하게된원인으로는큰종양및상대적으로좁은골반강 (3예), 간경화가있는환자에서전천골출혈 (1예), 그리고불충분한원위부절제연 (1예) 들이있었다. Low BMI 군에서는선형봉합기의오작동과전천골출혈로개복술로전환을하였다. 복부수술기왕력이없는환자만을대상으로한개복전환율비교에서도 high BMI 군 (n=19) 에서 21.0% (4/19) 로 low BMI 군 (n=46) 의 4.3% (2/46) 보다통계적으로유의하게빈발한것으로나타났다 (P=0.0101; Table 1). High BMI 군 (n=24) 과 low BMI 군 (n=55) 간의수술단기성적에관한비교분석에서출혈량은 high BMI 군에서 95.0 ml, low BMI 군에서 ml로 low BMI 군에서약간많았으나통계학적차이는보이지않았다 (Table 2). 평균수술시간은 low BMI 군 (n=55) 이 212.0분인데반해 high BMI 군 (n=24) 이 244.2분으로비만군에서수술시간이유의하게긴것으로조사되었다 (P=0.0035; Table 2). 그리고, 전체환자중복부수술기왕력이없는환자만을대상으로하여수술시간을비교한결과에서도 low BMI 군 (n=46) 이평균 212.9분, Table 1. Clinical characteristics and conversion rate in each groups Non-obese (n=55) Obese (n=24) Age (mean, range) 62.5 (43-81) 63.5 (40-75) NS Sex NS M F ASA NS I, II 41 (74.5%) 13 (54.2%) III 14 (24.5%) 11 (45.8%) Tumor location (cm)* (4.5-20) 9.95 (6-15) NS Stage (AJCC) (7.3%) 1 (4.2%) I 16 (29.1%) 8 (33.3%) II 18 (32.7%) 3 (12.5%) III 16 (29.1%) 10 (41.7%) IV 1 (1.8%) 2 (8.3%) Previous Op. 9 (16.3%) 5 (20.8%) < BMI (mean, range) 21.6 ( ) 27.2 ( ) < Conversion 2 (3.6%) 5 (20.8%) EPO 2 (4.3%) 4 (21.0%) *Distance from anal verge; Previous abdominal operation history; Except previous abdominal operation history: none-obese (n=46), obese (n=19). ASA=American Society of Anesthesiologists; NS=not significant. P

3 308 Jin-Hee Woo, et al. : The Impacts of Obesity on a Laparoscopic Low Anterior Resection Table 2. Comparison of short term outcomes Table 3. Comparison of pathologic outcomes Non-obese (n=55) Obese (n=24) P Non-obese (n=55) Obese (n=24) P Bleeding (ml) (20-300) 95.0 (30-300) NS Op. time (min) ( ) ( ) EPO* ( ) (175-30) Bowel recovery (day) NS Flatus 3.0 (1-5) 3.3 (1-5) Liquid diet 3.3 (3-7) 3.3 (3-9) Hospital stay 8.9 (5-22) 10.6 (5-35) Complication 11 (20.8%) 3 (15.8%) NS Post-op bleeding 5 0 Wound seroma 2 0 Ileus 2 0 Atelectasis 1 0 Chyle ascites 1 1 Rectovaginal fistula 1 0 Voiding difficulty 0 1 Air leakage 0 1 *Except previous abdominal operation history: none-obese (n=46), obese (n=19); One patient had two complications (post-op bleeding & atelectasis); Intraoperative air leakage in the leakage test after anastomosis. NS=not significant. high BMI 군 (n=19) 이평균 243.9분으로 high BMI 군에서통계적으로유의하게수술시간이길었다 (P=0.0099; Table 2). 수술후단기성적최초가스배출일은 high BMI 군에서평균 3.3일, low BMI 군에서평균 3.0일로유의한차이가없었으며, 유동식개시일도각각평균 3.3일로유의한차이가없는것으로나타났다 (Table 2). 수술후재원기간은 high BMI 군에서평균 10.6 일, low BMI 군에서평균 8.9일로차이를보였지만통계적유의성은없었다 (Table 2). 합병증은 high BMI 군에서 3명으로 15.8%, low BMI 군에서 11명으로 20.8% 였으며유의한차이는없는것으로나타났다 (Table 2). 수술후출혈이 5예로가장많은빈도를나타냈는데모두 low BMI 군에서발생하였고, 그중 1예는지혈을위해개복술을시행하였다. 창상합병증이 2예, 수술후장마비 2예로나타났다. 병리학적성적양군간의적출된림프절수 (low BMI 군 : high BMI 군 = 17.8개 : 16.6개 ) 는차이가없었고, 종양크기 (low BMI 군 : high BMI 군 =3.99 cm:4.32 cm) 도유의한차이가없는것으로나타났다 (Table 3). 또한, 종양의근위부절제연의평균길이 (low BMI 군 :high BMI 군 =10.5 cm:11.0 cm) 와, 원위부절제연의평균길이 (low BMI 군 :high BMI 군 =4.2 cm:3.6 cm) Harvested lymph node 17.8 (0-55) 16.6 (3-34) NS Tumor size (cm) 3.99 ( ) 4.32 (1-7.8) NS Margin (cm) Proximal 10.5 (3-21) 11.0 (4-25) NS Distal 4.2 ( ) 3.6 (0.5-8) NS NS=not significant. 모두통계적유의한차이를보이지않았다 (Table 3). 고 복강경수술이가지는고유한장점들로인해그대상영역의범위가빠른속도로확대되고있으며, 양성질환을비롯하여대장암, 위암등의악성종양에서도그시도가점차확장되고있다. 복강경결장절제술은암의근치적수술로부족함이없음을여러논문에서보고하고있다. 1-4 결장암과는달리종양학적인관점에서직장암의복강경수술에대한대규모전향적무작위연구의결과는아직결론적이지않기때문에더많은연구가진행되어야하는것으로받아들여지고있지만, 8 최근에는직장병변에대한단기성적및종양학적장기성적에서복강경수술이개복술에비해나쁘지않다는연구들이보고되고있다. 9,10 비만환자는당뇨와같은대사장애질환이나심혈관질환등의동반질환의가능성이높아수술위험도가증가하는것으로알려져있다. 또한수술중에도과다한지방조직으로인하여출혈을많게하고, 수술부위의시야확보를방해함으로써수술시간을연장시키며수술중과수술후의합병증발생을증가시키는것으로알려져있다. 5 초기복강경하담낭절제술을적용함에있어비만이개복술로전환하는위험인자가되었으나, 11,12 술식의발달및장비의발달로인해비만환자에있어서도복강경하담낭절제술이표준술식이되고있음에비해, 비뇨기과적복강경술식에있어서는아직도합병증의빈도가비만환자군에서더높게보고되고있다. 13,14 비만도의측정에서 BMI는실제체지방을잘반영하면서도신장과체중으로간단하게구할수있어비만에관한역학조사에서널리사용되고있다. 15,16 대부분의외국논문에서는 BMI 30을기준으로하여비만군과그렇지않은군으로나누고있다. 그러나본논문에서제시하고있는비만판정기준은 2000년세계보건기구의아시아태평양지역지침 17,18 을기준으로 BMI 찰

4 우진희외 : 비만이복강경하저위전방절제술에미치는영향 이상을과체중, 25 이상을비만으로정의하였다. 19 최근우리나라환자의비만은서양에비해아직그정도가심하지않지만식생활습관및환경요인으로인하여점차심각해지고있고, 이에따라비만환자에서복강경저위전방절제술의시행빈도가점점증가할것으로판단된다. 복강경하저위전방절제술의경우비만한환자는두꺼운직장간막과상대적으로좁은골반강으로수술시야가좁게되고이에따른수술기구의조작이용이하지않기때문에수술과정의어려움으로합병증, 수술시간, 출혈량등의단기성적요소들이비만하지않은환자에서보다나쁠가능성이있음을예상할수있다. Leroy 등 20 은복강경하대장절제술을시행한환자에있어서 BMI 30을기준으로후향적으로연구하였으며, 비만군과대조군에서평균수술시간에차이가없는것으로보고하였다. Schwandner 등 21 과 Pikarsky 등 22 도마찬가지로수술시간에있어서는비만군과대조군에서유의한차이가없었다고하였다. 그러나본연구에서는비만환자군에서평균수술시간이긴것으로나타났다. 종양뿐아니라양성대장질환을포함해서복강경수술과비만과의영향을비교조사한위보고들과는달리본연구에서는종양환자만을대상으로단일수술법에있어비만의영향을조사하였기때문에수술시간에대한결과를이전의논문들과단순비교하기에는무리가있을것으로판단된다. Senagore 등 23 은본연구처럼비만군에있어서평균수술시간이더긴것으로보고하였고, Dostalik 등 24 은통계적으로유의하지는않지만평균수술시간이비만환자군에서더긴것으로보고하였다. 각각의논문에서수술시간에대한서로상이한결과가도출되었고, 수술자의숙련도에따라수술시간이달라질수있는가능성을고려해볼수있는데수술자의경험에대한명확한언급이없어본연구의결과와단순한비교가곤란할것으로보이므로, 비만으로인한수술시간의연장여부에대한더정확한평가가필요할것으로생각된다. Feliciotti 등 25 은복강경하대장절제술에서개복전환의이유가비만이나염증성유착으로인한해부학적구조의확인이어려운경우라고보고하고있는데, 다른많은논문에서도비만환자군에서복강경하대장절제술을시행할경우개복전환율이더높은것으로보고하고있다. 26,27 본연구결과에서도대조군의개복전환율 (3.6%) 에비해비만군의개복전환율 (20.8%) 이현저히높은것으로조사되었는데, 비만한환자에게서골반강이좁아수술시야확보가어렵거나수술기구의원활한활동반경이제한되어수술진행이곤란하였기때 문인것으로생각된다. 본연구에서는양군에서합병증발생률이통계학적유의한차이를보이지않았으며 Tuech 등 28 과 Delaney 등 29 도합병증발생률에있어차이가없는것으로나타났다. 반면 Pikarsky 22 는비만군에서수술후장마비소견이 32.2%, 대조군에서 7.6% 로발생하는것으로보고하였고, 병원재원일수에서도비만군에서 9.5일로대조군 6.9일로유의하게긴것으로보고하면서, 장마비가비만군의재원일수를증가시키는중요한원인으로보았다. 또한창상감염도비만군에서 12.9%, 대조군에서 3.1% 로발생하는것으로보고하였다. 복강경수술이아닌통상의개복술에서도비만환자군에서창상감염발생률이높은것으로인식되고있는것과유사한결과를보여주었다. 창상감염이비만군에서빈발하는이유는비만자체의위험요소뿐아니라, 비만환자에서동반가능한대사적, 내분비적및심혈관계문제등에기인한것으로생각된다. 21 또한, Senagore 등 23 도비만군에서더높은합병증발생률 (22% vs. 13%) 을보고하였는데, 특히문합부누출이비만군에서 5.1% 로대조군의 1.2% 보다더높은것으로나타났다. 본연구에서는종양학적안전성의척도로절제연과적출된림프절의수는양군간에유의한차이를보이지않았고안전한범위로확인되었다. 그러나, 직장암의또다른종양학적주요요소인환상절제연과정확한근막박리여부에대한검체분석이대상군들의대부분에서시행되지않았기때문에종양학적안전성을결론지을수없을것으로판단된다. 또한, 연구대상군이작고, 후향적인연구라는제한점을가지기때문에복강경하저위전방절제술에있어비만의영향을결론적으로언급하기는한계가있다. 본연구는전체대상군이 79예에불과하고, 두명의수술자의경험이라는점을감안하면각수술자의경험이풍부하지않은단계의결과로, 숙련된수술자의입장이아닌경우비만환자에서의복강경하저위전방절제술은개복전환의가능성이높고수술시간이많이소요될수있다는것을확인할수있었다. 다양하고많은복강경대장수술의경험이축적된수술자가아닌초심자의경우는복막반전부하방박리경험이많지않고기술적노하우축적이부족할수밖에없다. 더구나비만환자의경우라면적절한시야확보기술이나경험부족으로초심자의경우종양학적으로매우중요한직장간막절제술시의정확한근막박리연확보가어려울수있고, 이에따라수술진행이매끄럽지않게됨으로불필요한수술시간의연장이발생하고, 종양학적불확실성이나술기상의한계점으로개복전환이빈발할수있을것으로생각된다.

5 310 Jin-Hee Woo, et al. : The Impacts of Obesity on a Laparoscopic Low Anterior Resection 결론복강경하저위전방절제술시비만한환자는그렇지않은환자들보다개복전환율이높고, 수술시간이상대적으로길게소요되었지만, 병리종양학적결과와합병증에있어서는나쁘지않은것으로확인되었다. 그러나, 비만에관한보다정확한결론을위해서는경험축적후와초기경험과의단기성적을비교분석하는연구와종양학적안전성확인을위해장기추적이필요할것으로생각된다. REFERENCES 1. Lacy AM, Garcia-Valdeciasas JC, Delgado S, Castells A, Taura P, Pique JM, et al. Laparoscopy-assisted colectyomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial. Lancet 2002;359: Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350: Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW Jr, et al. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data form the COST study group trial. Ann Surg 2007; 246: Lacy AM, Delgado S, Castells A, Prins HA, Arroyo V, Ibarzabal A, et al. The long-term results of a randomized clinical trial of laparoscopyassisted versus open surgery for colon cancer. Ann Surg 2008;248: Abdel-Moneim RI. The hazards of surgery in the obese. Int Surg 1985; 70: Choi SM, Kim MC, Lee JH, Kim KH, Choi HJ, Kim YH, et al. The effects of obesity for laparoscopy-assisted distal gastrectomy in patient with early gastric cancer. J Korean Surg Soc 2005;69: Joh YG, Kim SH, Yoon JS, Chung CS, Lee DK. Impact of Body Mass Index on surgical outcomes of laparoscopic colorectal cancer resection. J Korean Soc Coloproctol 2003;19: Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer J. Long-term outcome of laparoscopic surgery for colorectal cancer: a cochrane systematic review of randomized controlled trials. Cancer Treat Rev 2008; 34: Park KJ, Lee MR, Choi HJ. Early experiences with laparoscopic-assisted colectomy: retrospective comparison with open colectomy (case-control study). J Korean Soc Coloproctol 2007;23: Ng KH, Ng DC, Cheung HY, Wong JC, Yau KK, Chung CC, et al. Laparoscopic resection for rectal cancers: lessons learned from 579 cases. Ann Surg 2009;249: Hutchinson CH, Traverso LW, Lee FT. Laparoscopic cholecystectomy: Do preoperative factors predict the need to convert to open? Surg Endosc 1994;8: Rosen M, Brody F, Ponsky J. Predictive factors for conversion of laparoscopic cholecystectomy. Am J Surg 2002;184: Mendoza D, Newman RC, Albala D, Cohen MS, Tewari A, Lingeman J, et al. Laparoscopic complications in markedly obese urologic patients (a multi-institutional review). Urology 1996;48: Feder MT, Patel MB, Melman A, Ghavamian R, Hoenig DM. Comparison of open and laparoscopic nephrectomy in obese and nonobese patients: outcomes stratified by body mass index. J Urol 2008;180: Chirinos JA, Franklin SS, Townsend RR, Raij L. Body mass index and hypertension hemodynamic subtypes in the adult US population. Arch Intern Med 2009;169: Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, JAMA 2006;295: World health organization western pacific region. The asia pacific perspective; redefining obesity and its treatment; Australia The Examination Committee of Criteria for Obesity Disease in Japan. Japan Society for the study of Obesity. New Criteria for obesity disease in Japan. Circ J 2002;66: Tsujinaka S, Konishi F, Kawamura YJ, Saito M, Tajima N, Tanaka O, et al. Visceral obesity predicts surgical outcomes after laparoscopic colectomy for sigmoid colon cancer. Dis Colon Rectum 2008;51: Leroy J, Ananian P, Rubino F, Claudon B, Mutter D, Marescaux J. The impact of obesity on technical feasibility and postoperative outcomes of laparoscopic left colectomy. Ann Surg 2005;241: Schwandner O, Farke S, Schiedectk TH, Bruch HP. Laparoscopic colorectal surgery in obese and nonobese patients: do differences in body mass indices lead to different outcomes? Surg Endosc 2004;18: Pikarsky AJ, Saida Y, Yamaguchi T, Martinez S, Chen W, Weiss EG, et al. Is obesity a high-risk factor for laparoscopic colorectal surgery? Surg Endosc 2002;16: Senagore AJ, Delaney CP, Madboulay K, Brady KM, Fazio VW. Laparoscopic colectomy in obese and nonobese patients. J Gastointest Surg 2003;7: Dostalik J, Martinek L, Vavra P, Andel P, Gunka I, Gunkova P. Lapa-

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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