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1 The Korean Journal of Gastrointestinal Endoscopy Review 경피내시경하위루술의삽입과관리 임윤정ㆍ양창헌 동국대학교의과대학내과학교실 Technique, Management and Complications of Percutaneous Endoscopic Gastrostomy Yun Jeong Lim, M.D. and Chang Heon Yang, M.D. Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea Percutaneous endoscopic gastrostomy (PEG) is a widely used method for introducing a gastrostomy tube endoscopically to enable enteral feeding in patients who are unable to eat but have a normally functioning gut. The endsopist trained in the techniques for enteral access should be equally acquired the knowledge for monitoring patients and managing the complications arising from the initial gastrostomy procedure. Optimal endoscopic technique, proper monitor, early recognition of impending complication and quick management are important because most of these patients are elderly, debilitated, and chronically ill. In this review, general information about insertion and management of PEG was described based on the our experience of PEG and review of literatures. (Korean J Gastrointest Endosc 2009;39: ) Key Words: Enteral feeding, Percutaneous endoscopic gastrostomy, Complication 교신저자. 양창헌동국대학교의과대학내과학교실 ( ), 경북경주시석장동 707 번지전화 : 팩스 : 이메일 : chhyang@dongguk.ac.kr 접수 년 8 월 23 일승인 년 9 월 24 일 서론 로협착, 신경근장애등으로경구섭취가불가능할때등이다 (Table 1) 비위관 (Levin tube) 을이용한영양공급은비침습 경피내시경하위루술 (percutaneous endoscopic gastrostomy, PEG) 은내시경을이용하여위에관을삽입하여이를통해경장영양을할수있는방법으로시술이간편하고안전하여널리쓰이고있는방법이다. 1,2 PEG는 1980년 Gauderer와 Ponsky 등 3,4 이내시경을이용하여국소마취하에서비수술적으로위루술을시행한것을최초보고한이후우리나라에도활발히시술되고일반화가되어있다. 본종설은저자의경험과문헌고찰, 외국가이드라인을참고하여 PEG의길잡이를제시하고자 PEG에대한삽입뿐아니라 PEG 관리및합병증에대해기술하였다. 본론 1. PEG 의적응증과금기 PEG는연하곤란으로경구섭취가불가능한환자에서경장영양을할목적으로이용될수있다. 5-7 PEG의적응증은의식저하로연하곤란이발생한경우 ( 뇌졸중, 외상에의한뇌손상, 뇌종양등 ), 안면손상, 식도천공, 인후두와식도의악성종양으 Table 1. Indication and Contraindication of Percutaneous Endoscopic Gastrostomy Indication Dysphagia Neoplasm of pharynx and esophagus Neurologic disorder including cerebrovascular attack Facial injury Contraindication Absolute No passage of gastrofiberscope into the stomach Incorrectable coagulapathy Peritonitis Intestinal obstruction Relative Massive ascites Large gastric varix Extensive laparotomy Severe obesity Neoplasm of stomach Vol. 39, No. 3 September, 2009 ( ) 119

적이어서많이이용하고있으나흡인성폐렴, 역류성식도염, 기계적자극에따른식도궤양및미란, 부비동염등합병증이있고한달에한번교환해야하므로한달이상의장기간의영양공급이필요할때는 PEG를권고하고있다. 5,6 PEG의영양관이경비위관보다굵어집에서만든보통음식, 섬유질이풍부한과일과야채를갈아서공급할수있는영양학적인장점이있다.

PEG의삽입의금기증은식도와인두의완전폐쇄로내시경적접근이불가능한경우, 간경변증등으로인한복수에의한복막염, 교정되지않는응고장애, 위아전절제술을받은경우, 위정맥류, 위암의위치가유문부를막고있는경우등이다.

15-19 2. PEG 의삽입과전후관리 PEG 시행전에반드시함께복용하고있는약중에서아스피린, 혈소판응집억제제, 와파린등출혈성경향이있는약을복용하고있는지점검하고아스피린, 혈소판응집억제제는일주일전에, 와파린은 3 5일전에끊고시술해야한다.

그러나, PPI와히스타민수용체차단제는 PEG후출혈이관찰되거나, 위루관의내부완충기 (internal bump) 에의한허혈과조직궤사에궤양이발생될때, 위루관의통로를통한위산등위분비액누출을감소시킬목적으로사용할수있다.

2 적이어서많이이용하고있으나흡인성폐렴, 역류성식도염, 기계적자극에따른식도궤양및미란, 부비동염등합병증이있고한달에한번교환해야하므로한달이상의장기간의영양공급이필요할때는 PEG를권고하고있다. 5,6 PEG의영양관이경비위관보다굵어집에서만든보통음식, 섬유질이풍부한과일과야채를갈아서공급할수있는영양학적인장점이있다. 장기간경장영양을해야하는경우는 PEG가비위관보다더좋을수있으나, 재활치료를통해음식물의섭취가가능할것으로예상되는환자에서는 PEG보다는덜침습적인경비위관의삽입이나을것으로생각한다. PEG의삽입의금기증은식도와인두의완전폐쇄로내시경적접근이불가능한경우, 간경변증등으로인한복수에의한복막염, 교정되지않는응고장애, 위아전절제술을받은경우, 위정맥류, 위암의위치가유문부를막고있는경우등이다. 5,14 복부수술로인한유착으로위의위치가변한경우, 심한복부비만의경우내시경적빛의투과가안되고위전벽을손가락으로눌러도함몰이잘안타나기술적으로어려운점이있어시술에신중을기해야한다 (Table 1). 환자가급성질환을앓고있거나중환자실에있을때, 다른부위의감염으로열이있을때는 PEG 후감염등합병증의위험이증가하므로일반적으로 PEG는환자의상태가최대한안정화되었을때삽입할것을권고한다 PEG 의삽입과전후관리 PEG 시행전에반드시함께복용하고있는약중에서아스피린, 혈소판응집억제제, 와파린등출혈성경향이있는약을복용하고있는지점검하고아스피린, 혈소판응집억제제는일주일전에, 와파린은 3 5일전에끊고시술해야한다. 1,5 산분비를억제하는프로톤펌프억제제 (Proton pump inhibitor, PPI), 히스타민수용체차단제 (H 2 blocker) 등은위내의산도를높여위내세균증식이증가되어 PEG 후창상감염을증가시키므로시술하기전에끊는게좋다. 그러나, PPI와히스타민수용체차단제는 PEG후출혈이관찰되거나, 위루관의내부완충기 (internal bump) 에의한허혈과조직궤사에궤양이발생될때, 위루관의통로를통한위산등위분비액누출을감소시킬목적으로사용할수있다. 창상감염은주로구강내세균에의한내부완충기의오염이나피부절개를통해생기는것으로생각되며예방적항생제는주로 PEG 시행 30분전 1회분량의광범위항생제 ( 주로 1세대 cephalosporine 계열 ) 를주는것이시술후국소및전신감염을예방하는것으로보고하고있다 PEG는현재다양한 Kit로개발되어시판되고있으며당김형 (push type, Ponsky-Gauderer술기 ), 삽입기형 (introducer type, Russell술기 ), 밀기형 (pull type, Sacks-Vine 술기 ) 등이있으나최근에는밀기형을보편적으로이용하고있다. 5,23 밀기형은대 Figure 1. Techniques of percutaneous endoscopic gastrostomy (pull type). (A) Digital indentation is seen in the insufflated stomach. (B) Needle is passed through the nearest site of abdominal wall. (C) Guidewire is being grasped with snare. (D) Internal bolster of PEG is fixated in the stomach. 120 The Korean Journal of Gastrointestinal Endoscopy

3 개배꼽과좌측연골연연결선중간부위가천자부위가되나내시경을위내로삽입하여송기한후불빛을이용하거나복벽을손가락으로눌러위전벽중복벽에가장가까운근접부위를천자부위로선정하여표시한다. 이부위를 povidone iodine과알코올로소독하고국소마취후천자침을찔러천자침이위내강에삽입되는것을내시경화면을보고확인한다. 천자침안의 catheter를통해유도선 (guidewire) 을삽입하고영양관이통과될정도의적절한길이만큼피부절개를한다. 위내강의유도선을생검겸자또는올가미로잡아서체외로배출한다. 유도선과영양관을묶어복벽의천공부위유도선를입에서부터위내로잡아당기면서영양관을식도를거쳐위내로삽입하고영양관끝에부착된내부완충기에의해위벽에고정시킨다. 복벽을통해체외로배출된영양관의고정은외부완충기에의해고정시키면시술이끝난다 (Fig. 1). 5,23 당김형은밀기형과비슷하나입으로낸유도선을따라영양관을위에서복벽으로밀어내는방법이다. 설치의최종단계까지유도선이유치되어있기때문에중도에튜브파손등에의한대처가쉬운장점이있고밀기형과단점은거의같다. 삽입기형은일본에서개발된간편한방법으로복벽으로넣은트로커를매개로직접위루튜브를삽입한다. 내시경의삽입이 1회로끝나고감염의위험이적으며 kit가싸다는등의장점이있는한편, 첫회설치튜브가세경으로막히기쉽다는것, 풍선파손에의한튜브일탈등의단점이있다. PEG의삽입은기도가확보된상태에서시행하며 인공호흡기 (ventilator) 나인공호흡 (ambu bagging) 을하면서도시술할수있다. PEG 후영양공급시기는시행기관마다다소다르며대개 24시간후공급하나최근 3시간지나공급해도안전하다는보고가있다. 23 저자는환자에따라조금씩다른데피부절개가과도하게된경우, 위내출혈이관찰되는경우등에서는영양공급을늦게시작하고별다른문제가없는경우, 오후에시술하였으면다음날아침부터영양공급을시작할수있다. 경장영양시작전에물을먼저주어본후특별한문제가없으면경장영양을시작하도록한다. 경장영양을하는동안상체를약간세워공급하고경장영양이끝나고 30분이상눕히지않도록교육시킨다. 경장영양은 intermittent feeding, continuous feeding, bolus feeding 3가지방법이있다. 24,25 Intermittent feeding은하루에 3 6회로나누어한번에 30 60분에걸쳐서서히중력을이용해공급하고 continuous feeding은 12 24시간동안중단없이지속적으로준다. Bolus feeding은주사위를이용해 15 30분동안주는방법으로간편하나설사, 위식도역류, 흡인성폐렴의위험이있어잘쓰이고있지않다. 경장영양의주입속도는 120 ml/hr 속도를넘기지않는것이바람직하다. 18 영양공급후물을주사기를통해 flushing하여영양관이막히지않도록주의한다. 경관급식이끝나고 2시간후자주위내잔류량을조사해서잔류량이 200 ml 이상일때흡인폐렴의위험성이증가하므로 PEG를통한경장영양을중단할것을권고 Table 2. Prevention and Complication of Percutaneous Endoscopic Gastrostomy Complication Prevention Treatment PEG site infection IV antibiotic before PEG 1 IV antibiotic 2 Incision & Drainage, if pus is accumulated 3 Removal of PEG, if it is intractable Excessive leakage Proper skin incision during PEG 1 NPO & IV PPI 2 Consider completely removal of PEG or, naso-gastric tube feeding, conversion to PEG-jejunostomy, if it is intractable Aspiration pneumonia Avoid rapid infusion rate of enteral 1 IV antibiotic feeding, semifowler position for 2 Convert to PEG-jejunostomy if recurrent 30 minutes after feeding, periodic aspiration pneumonia occurs check-up of gastric residual volume PEG tube displacement Suspect tube displacement if infusion of 1 Promptly manual correction of tube feeding is interrupted displacement 2 Re-insertion of new feeding tube Buried bumper syndrome Avoid excessive tension of fixation of tube Surgical removal of bump Peritonitis IV antibiotics, surgery Necrotizing fascitis Surgical approach Enterocutaneous fistula Laparotomy Pneumoperitoneum Observation GI bleeding PPI, endoscopic treatment Vol. 39, No. 3 September, 2009 ( ) 121

4 한다. 18 일반적으로위배출기능이정상일경우경관급식은주로액체형태의음식을공급하기때문에급식이끝나고 2시간이지나면위안에액체음식이거의남아있지않다. Intermittent feeding의경우 4 5시간간격으로경관급식을시작하자마자 ( 액체음식을 50 ml 주기전 ) 위내잔류량을조사해서잔류량이 200 ml 이상이고경관급식을적응하지못하는증상이나징후가보이면바로경관급식을중단하는것보다영양관의끝을위치를 Treitz 인대이하로할것을권고한다 PEG 합병증과대처방안 PEG의합병증은창상감염이가장흔하며보고자에따라 5 40% 까지다양하게보고하고있다. 5 그외위장출혈, 기복증 (pneumoperitoneum), 영양관이탈, 흡인성폐렴, 장천공, buried bumper syndrome, 복막염, 괴사성근막염등이있다 (Table 2) 영양관의통로는삽입후약 2 4주후에성숙되게된다. 창상감염은대개영양관의통로가성숙되기전에발생하며특히, 영양관의통로가성숙되기전에영양관를잡아뽑는경우피부절개와영양관통로부위가느슨해지면서벌어져서출혈및창상감염의증가, 복막염등이발생할수있으므로세심한주의를요한다. 저자는 PEG 삽입후통로가성숙되기전환자가잡아빼면위내강내내부완충기가피부밖으로통과하는과정에서피부와위벽의출혈이되고통로가넓어지면서위내용물이피부밖으로새서창상감염의치료가어려운경험이있어영양관삽입후환자가잡아빼지않도록주의를주고복대를하거나특히, 의사소통이안되면서손을움직이는환자에서는통로가성숙될때까지손을묶어두는방법도좋은방법이라고생각한다. 영양관을심하게당겨지게고정하면물리적으로내부완충기에의해가해지는압력으로허혈, 조직궤사, 창상감염등합병증이증가하므로고정을조금느슨하게해주는것이좋다. 저자는 PEG 후외부완충기에의한지속적인피부과민반응과지속적인위분비액유출로심한피부발적이있고, 항생제, 단기간의급식중단으로도창상감염이조절되지않아 PEG를제거한예를경험하였다. PEG 주변으로피부의육아조직이자라나오면육아조직으로출혈이지속되고분비물로인한감염이생길수있어육아조직을제거하는것이좋다. PEG후창상감염은기저질환의중증도가높을수록잘생기는것으로보고하고있고영양상태악화, 조절되지않는당뇨병, 다른부위의전신적인감염이동반된경우등에서빈도가증가하는것으로알려져있다. 5 저자의경험으로 PEG 시술할때적절한피부절개도중요한데과도한피부절개가되면창상감염의빈도가증가한다. 예방적항생제의사용은논란은있으나일반적으로예방적으로항생제를사용한경우가사용하지않은경우보다 17.5% 정도시술부위감염을감소시킬수있었다고보고하고있다. 20 창상감염은주로금식과항생제투여로호전되 는경우가많으나심한감염의경우복부 CT를통해복벽의조영증가, 농양의여부를확인하는것이안전하다. 항생제치료로호전이되지않는경우대부분절개, 배농, 영양관의제거로해결되는경우가많으나드물게개복술이필요한경우도있다. 5 괴사성근막염은가장심각한합병증으로사망률이 30 50% 으로창상부위의국소염증이연부조직으로파급되어발생한다. 31 일단괴사성근막염이의심이되면복부 CT 또는초음파를해서확인하고개복하여괴사된조직을제거하고결손된위벽을봉합한다. 항생제는배양검사가나오기전에는적극적으로그람음성균, 혐기성균을포함하는광범위항생제를투여하고배양결과가나오면그결과에따른적절한항생제를투여하며명확한기간은정할수없지만염증이소실될때까지충분한기간동안투여한다. 31 시술후위장출혈은대부분위벽의고정부에서출혈이되므로고정부위를느슨하게하여출혈부위를확인한후내시경적지혈치료와위산분비억제제의투여로대부분지혈이되며출혈이심하지않으면고정부위를더세게당겨주는것만으로출혈이멈추어진다. 기복증은 PEG 후 40 56% 정도생기는것으로보고하고있고임상적으로크게문제가되지않는경우가대부분이며 1주일정도지나면소실된다. 35 천자침으로위천공을할때복벽과위사이에대장, 주로횡행결장이끼이면서결장-위누공이발생할수있어주의를요하며이때는개복술을해야한다. 36 저자는 PEG의삽입은성공적으로이루어졌으나전해질불균형등다른원인없이장마비 (ileus) 가발생하여금식등보존적치료에도전혀호전되지않아 PEG를제거하였던증례를경험하였다. 경장영양공급할때음식이잘들어가지않고밖으로새면일단영양관의위치가이탈되지않았는지점검을해야하며이는환자의체위변경, 드레싱, 경장영양공급할때부주의한관의조작으로생기는경우가많다. 영양관위치의이탈을빨리발견하는것이중요하며영양관을위내강으로많이밀어넣은후다시내부완충기에의해복벽에고정될때까지조심스레밖으로잡아당기면해결되는경우가많다. 만약, 영양관이안으로밀어넣어도들어가지않는다면즉시내시경을시행하여영양관을제거하고새로 PEG 삽입을권고한다 부적절하게도관이지나치게당겨내부완충기가위점막에지나치게밀착되면국소조직손상과이차적으로재생상피가내부완충기를덮어서발생하는 buried bump synsdrome은도관폐색이되어음식물주입이더이상안되는것으로내시경적제거가어렵고수술적제거를해야하는경우가많다. 32 흡인성폐렴은경장영양의가장중요한합병증중에하나이다. 27 PEG 시술하는동안자주 suction을통해침, 분비액등이기도로흡인되지않도록한다. 또, 경관급식하는동안주입속도가너무빠르지않도록주의하고경관급식이끝나고 30분이상 semi-fowler position을유지한다. 25 경관급식이끝나고 The Korean Journal of Gastrointestinal Endoscopy

5 시간후위내잔류량을조사해서잔류량이 200 ml 이상일때흡인폐렴의위험성이증가하므로경장영양을중단할것을권고한다. 29 흡인성폐렴의발생을줄이기위해위장관운동촉진제등을쓰는것은논란이많으나아직까지그효과가미미한것으로보고하고있다. 15 경장영양하는동안설사는흔하게나타날수있는데경관급식의속도가너무빠르지않은지, 경관의끝의위치가유문부아래소장에위치에있지않은지, 주입하는음식물에섬유소가너무적게포함되거나세균에오염되지않았는지먼저점검하고복용하는약물중에설사를일으킬만한약이있다면끊도록한다. 4. PEG 교환영양관의교환은대개 6개월간격을권장하나 4시간간격으로영양관을 ml 정도따뜻한물로씻어음식물찌꺼기, 약제등이관에끼지않도록잘관리해관의손상만없다면 1년이상사용할수있다. 39 신체활동이높은환자에는버튼형의 PEG로교환하는것도고려해볼만하다. 시술후영양관교체의가장흔한이유는환자가무의식적으로제거한경우와체위변경등으로관이잡아당겨지는경우이다. 사고로영양관이제거되면통로를막히지않게하기위해서 24시간내새로삽입할것을권하나시술이즉각적으로용이하지않아영양관삽입이늦어질때는 foley catheter 를삽입하여위내강에 balloon 으로고정하면통로가막히는것을막을수있다. PEG를제거하면통로는 1 2주안에저절로막히는경우가대부분이나저자는영양관을제거후한달이지나도통로가막히지않고그통로를통해계속적으로위분비액이나와치료가어려웠던몇예를경험하였다. 결론 PEG 삽입은비교적안전하고효과적인시술이나 PEG를삽입하는환자는대개영양상태가불량한기저질환과고령인경우가많아작은합병증도자칫심각한결과로이어질수있어세심한주의를요한다. 또, 무엇보다도 PEG 삽입후지속적인관리가중요하며 PEG 합병증에대한정확한지식의숙지와빠른대처가 PEG 삽입만큼중요하다고할수있다. 요약경피내시경하위루술 (percutaneous endoscopic gastrostomy, PEG) 은연하곤란으로경구섭취가불가능한환자에서경장영양을할목적으로내시경을이용하여위에관을삽입하는방법으로시술이간편하고안전하여널리쓰이고있는방법이다. PEG를삽입하는환자는대개영양상태가불량한기저질환과고령인경우가많아 PEG 삽입후지속적인관리가중요하며 PEG 합병증에대한정확한지식의숙지와빠른대처가 PEG 삽입만큼중요하다. 본종설에서는저자의경험과문헌고찰, 외국가이드라인을참고하여 PEG에대한삽입, 관리및합병증에대한 PEG의길잡이를제시하고자한다. 색인단어 : 경피내시경하위루술, 경장영양, 합병증 참고문헌 1. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr 2002;26(suppl):33S-35S. 2. Lo ser C, Aschl G, He buterne X, et al. ESPEN guidelines on artificial enteral nutrition--percutaneous endoscopic gastrostomy (PEG). Clin Nutr 2005;24: Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15: Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27: American Gastroenterological Association. Technical Review on Tube Feeding for Enteral Nutrition. Gastroenterology 1995; 108: Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy: Indications, success, complications and mortality in 314 consecutive patients. Gastroenterology 1987;93: ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr 2002;26(Suppl):1S-138S. 8. Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987;93: Sangster W, Cuddington GD, Bachulis BL. Percutaneous endoscopic gastrostomy. Am J Surg 1988;155: DeLegge MH. Percutaneous endoscopic gastrostomy. Am J Gastroenterol 2007;102: Gencosmanoglu R. Percutaneous endoscopic gastrostomy: a safe and effective bridge for enteral nutrition in neurological or non-neurological conditions. Neurocrit Care 2004;1: Colasanto JM, Prasad P, Nash MA, Decker RH, Wilson LD. Nutritional support of patients undergoing radiation therapy for head and neck cancer. Oncology 2005;19: Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal, percutaneous endosopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad Med J 2002;78: Pennington C. To PEG or not to PEG. Clin Med 2002;2: Yavagal DR, Karnad DR, Oak JL. Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: a randomized controlled trial. Crit Care Med 2000; Vol. 39, No. 3 September, 2009 ( ) 123

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untitled ORIGINAL ARTICLE ISSN 1738-3331, http://dx.doi.org/10.7704/kjhugr.2014.14.1.24 The Korean Journal of Helicobacter and Upper Gastrointestinal Research, 2014;14(1):24-30 경피내시경하위루술의합병증에대한고찰 김홍제, 이상호, 이재남,