김태현 58 dominal pain persists and prevents oral intake, debridement should be considered. This is usually accomplished surgically, but percutaneous or

Transcription

1 SESSION Ⅲ THE KOREAN JOURNAL OF PANCREAS AND BILIARY TRACT The treatment of local complication of acute pancreatitis and necrotizing pancreatitis 김태현 원광대학교의과대학내과학교실 서론 1) 급성췌장염의임상적인경과는경증에서중증까지다양하고, 췌장염의조직학적형태에따라서부종성 (edematous) 췌장염과괴사성 (necrotizing) 췌장염으로구분된다. 급성췌장염의 80-90% 를차지하는부종성췌장염은대부분보존적치료만으로도호전된다. 그러나급성췌장염의 10-20% 를차지하는괴사성췌장염은사망률이 14-25% 에이르고, 1 괴사성췌장염의 20-35% 에서감염이동반될수있어사망률이더욱증가된다. 또한췌장주위합병증들, 즉급성액체고임 (acute fluid collection), 췌장괴사 (pancreatic necrosis), 가성낭종 (pseudocyst), 췌장농양 (pancreatic abscess) 등이발생할수있다. 예후가불량한괴사성췌장염과췌장주위합병증들에대한세심한관리와치료가임상의에게는매우중요하지만국내각병원마다이질환에대한관리와치료가다양하다. 급성췌장염은우리나라의대표적인췌장질환으로진단, 치료에관한국내의료환경에맞는차별화된한국형진료가이드라인이필요한실정이다. 일본을비롯한서구에서는급성췌장염의치료에대한가이드라인발표되어임상의들에게많은도움을주고있다. 국내급성췌장염의치료근거를제시하기위한국내문헌은매우제한적이었 Correspongding author. 익산시신용동 원광대학병원소화기내과 Tel : kth@wonkwang.ac.kr 다. 따라서문헌검색을통하여외국에서제안하는가이드라인과근거문헌들을살펴보았다. 여러외국의가이드라인들은환자의인구학적차이, 선별검사의질과양적차이, 그리고표준화된치료방법의부재등유사연구간에도매우이질적인요소들이존재할수있다. 이질환의국외가이드라인들에대한질 (quality) 이 Grill, Shaneyfelt, Agree 도구들을이용하여평가되었다. 2 이보고에서최근발표된미국3, 영국4, 이탈리아5 및일본6,7의가이드라인이비교적높은점수를받았다. 따라서본고에서는이가이드라인들은바탕으로우리나라의적합한급성괴사성췌장염과국소합병증에대한치료가이드라인을도출하기위한토론의자료를제공하고자한다. 1. 무균성괴사의치료 (Treatment of Sterile Necrosis) (Japan, 2010) Conservative treatment should be performed as a rule in sterile pancreatic necrosis. (Recommendation B) (Italian, 2010) Patients with sterile pancreatic necrosis should be managed conservatively and undergo intervention only in selected cases, such as those patients with multiorgan failure who do not improve despite maximal therapy in the intensive care unit (recommendation B). (London, 2005) Patients with apparently sterile necrosis may occasionally require operation but this is relatively uncommon. (USA, 2006) Sterile necrosis is best managed medically during the first 2 3 wk. After this interval, if ab- 57

2 김태현 58 dominal pain persists and prevents oral intake, debridement should be considered. This is usually accomplished surgically, but percutaneous or endoscopic debridement is a reasonable choice in selected circumstances with the appropriate expertise. Pancreatic duct leaks and fistulas are common and may require endoscopic or surgical therapy. ( 대한췌담도학회제안 ) 무균성괴사는첫 2-3주동안에는보존적 ( 내과적 ) 치료가최우선이다 (Recommendation B) 그기간이후복통이지속되고경구음식물섭취를할수없으면괴사제거술이고려될수있다. 괴사제거는일반적으로수술적방법으로시행되고, 경피적또는내시경적괴사제거술이가능한병원에서는이방법들도선택할수있다. 괴사제거술후췌관루또는췌즙누출이발생하면수술적또는내시경적치료가필요할수있다. 무균성괴사는보존적치료가원칙으로보편적으로받아들이고있다. 4,8 무균성괴사환자의약 48% 에서장기부전이발생하며, 지난 년동안이환자들에서수술적괴사제거술이효과적이라고알려져왔다. 최근에는다음과같은몇가지이유로췌장염발생 2-3주내에는내과적치료가유지되어야한다는의견들에동의하고있다. 몇몇후향적연구들에서수술적괴사제거술을조기에시행하는것보다연기하거나수술을시행하지않았을때합병증발생률과사망률이적었다고보고하였다 무균성괴사에서수술적치료가시행되었을때감염성괴사가발생하거나추가적인수술이더필요로하게되었다. 9,12,13 무균성괴사를가진환자들에서적어도 2-3주지나면후복막에전반적인염증이호전되어괴사된췌장과췌장주위에잘싸여진구조물이형성된다. 14 이구조물이형성되는시기에도달하면장기부전도호전되고대부분의환자들의증상도소실되어추가적인치료가필요로하지않는다. 수술적치료가필요한경우에도이시기에는막으로잘싸여진구조물이형성되어있어구조물내의수액흡인과위의후벽과구조물의문합술이용이하게된다. 3 또한이구조물과위벽이잘밀착되어있어내시경초음파유도하경벽적배액술도시행될수있다. 15 이배액통로를더욱확장하여내시경을삽입한후괴사된조직들을제거할수있고강내에 내시경적비강배액관을삽입하여지속적으로생리식염수로세척을할수있다. 첫 2-3주내에수술적치료가필요한경우는드물지만다음과같다. 첫째로복압이매우증가하여복부팽만이심해지는 abdominal compartment syndrome으로즉각적인개복수술이필요하다. 둘째는췌장주위염증의확대로인하여주위의소장이나대장의천공이다. 셋째는가성동맥류로부터출혈이혈관중재술로지혈이실폐한경우이다. 2. 감염성췌장궤사 (Infected pancreatic necrosis) 1) 진단 (Italian 2010) Fine needle aspiration with a culture of the tissue obtained should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis (recommendation B). (USA, 2006) CT-guided percutaneous aspiration with Gram s stain and culture is recommended when infected necrosis is suspected. (London, 2005)All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image guided FNA to obtain material for culture 7 14 days after the onset of the pancreatitis (recommendation B). ( 한국췌담도학회제안 ) 감염성췌장염이의심되면 CT 또는초음파유도하세침흡인으로얻은검체에서 Gram s stain 과배양을하여감염여부를판단한다 (recommen- dation B). 급성궤사성췌장염에서감염성췌장궤사는췌장염이발생한후약 33% 에서발생한다. 췌장괴사의감염은 CT 나복부초음파유도하세침흡인 (fine needle aspiration, FNA) 을통하여세균을확인할수있고, 이시술의진단정확도는 % 로높다. 16,17 장천공과같은치명적인합병증없이이시술을안전하게시행하기위해서는적절한천자부위를선택하는것이중요하다. 이시술의위음성율이 20-25% 라는보고도있어, 18 이시술을시행해야할적절한시기, 회수, 적응증에대하여논란이많은상태이다. 19 미국일본영국가이드라인은모두정확한진단을위하여 CT나복부초음파유도하 FNA가필요하다고하였다.

3 The treatment of local complication of acute pancreatitis and necrotizing pancreatitis 59 특히영국가이드라인에서구체적으로췌장염발생 7-14 일후 30% 이상의췌장괴사가존재하고폐혈증의임상적소견이있으면영상유도하에세균배양을위한 FNA가필요하다고하였다. 2) 치료 (Japan, 2010) A. What is the optimal intervention for infected pancreatic necrosis? Necrosectomy is recommended as a surgical procedure for infected necrosis. (Recommendation A). Infected pancreatic necrosis is an indication for interventional therapy including surgery, interventional radiology (IVR) and endoscopic treatment (Recommendation B). However, follow-up while giving conservative treatment by means of antibiotic administration is also available in patients who are in stable general condition (Recommendation C). (Italian, 2010). What is the indication for percutaneous intervention in necrotizing pancreatitis? Answer: Even if, in the last few years, this therapeutic modality has received particular attention in clinical practice, there were no recommendations about this topic in the guidelines considered. Comment: The panel writing these guidelines suggests that the presence of well-demarcated necrosis could be treated using percutaneous drainage; in selected cases, this approach can be combined with a minimally invasive surgical approach (videoscopic assisted retroperitoneal debridement). In any case, the clinical condition of the patient should be taken into account when deciding on the therapeutic approach (USA, 2006) Treatment of choice in infected necrosis is surgical debridement. Alternative minimally invasive approaches may be used in selected circumstances. (London, 2005) Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material (recommendation grade B). The choice of surgical technique for necrosectomy, and subsequent postoperative management depends on individual features and locally available expertise (recommendation grade B). ( 한국췌담도학회제안 ) 감염성췌장과사의치료는수술적괴사제거술이다 (recommendation grade B). 환자의상태가안정된감염성췌장괴사의경우에는항생제치료와보존적치료를하면서추적관찰할수있다 (Recommendation C). 괴사된부분이 well demarcated 경우에는경피적배액술이나내시경적배액술및괴사제거술이병원실정에따라서시행될수있다 (Recommendation B). 감염성췌장괴사의치료는괴사된췌장이나췌장주위조직의제거하는것이기본적인치료방법이다것에일반적으로동의하고있다. 1990년부터 2005년까지괴사성췌장염을가진 167명에서시행된수술적괴사조직제거술 (necrosectomy) 및폐쇄충전술 (closed packing) 은감염성괴사에서 15.0% 의사망률과무균성괴사에서 4.4% 의사망률을보였다. 18 이우수한연구결과가수술적치료방식의근간이되고있다. 그러나여러수술방법에따라서수술후경과및사망률이차이가있다고보고하고있다 ( 사망률 10-30%). 19,20 괴사성췌장염에서외과의의수술적경험이수술방법에큰영향을주기때문에아직무작위전향적연구가이루어진것은없다. 감염성췌장괴사에대한치료방침에관하여많은증례보고들이있어왔다. Runzi 등의보고에의하면괴사성췌장염 88례중 28명이감염성괴사로진단되어적절한항생제가선택되어사용되었다. 21 이 28명중 12명이평균 36 일을기다리다가수술적괴사제거술을받았고사망이 2예 (16%) 에서발생하였으며, 항생제와보존적치료를받은나머지 16 명중 2명에서사망이발생하였다. 다른보고에서는감염성췌장괴사환자 24명중전신상태가불안정한 18명에서괴사제거술이시행되어사망이 5명 (28%) 에서발생하였고, 비교적안정된환자 6명은수술적치료없이모두회복되었다. 22 이등의보고에서는감염성췌장염 31 명중 23명에서경피적 (18명) 또는내시경적 (5명) 배액술을시행받았고, 이들중 5명이전신상태악화로괴사제거술을받았지만 1명사망하였으며초기치료로항생제를투여받았던 8명에서는더이상의추가치료가필요없었다. 23 결국상기보고들을보면감염성췌장괴사환자에서전신상태가안정적이면보존적치료가일차적치료가될수있음을알수있다.

4 김태현 60 최근에는개복수술에따르는높은사망률과합병증을줄이고, 대부분패혈증과다발성장기부전에의한중한상태에있는환자들에게수술로인한스트레스를최소화하기위해서다양한경로를통한최소침습시술이시행되고있고기존의개복수술보다더좋은결과들을보고하고있다 지금까지보고된괴사성췌장염에대한최소침습술식은경피적배액법, 내시경적배액법, 복강경을이용한괴사제거술등이있다. 경피적중재방사선적치료는대구경의경피도관을좌측복벽을통하여후복강내의병변부위에삽입하여적극적인세척과배액하는방법이다. 30 최근체계적인문헌검토로보고한경피적배액술을받은 381명의괴사성췌장염환자에서 17.4% 의사망률을보고하였고, 변연절제술 (debridement) 없이도경피적배액만으로치료할수있다고보고하였다. 31 필요에따라서는이통로를통하여내시경을삽입하여괴사된물질을제거할수있다. 또한급성괴사성췌장염에서감염된괴사조직과끈끈한고름이막으로잘싸여있는경우 (wall-off necrosis) 에내시경적괴사조직제거술 (necrosectomy) 이시행될수있다. 32,33 이경우에내시경적치료의성공률은 73%-92% 로보고되고있다. 34,35 최근급성괴사성감염성췌장염환자들을대상으로한내시경적치료 ( 괴사제거술및배액술 ) 와수술적치료의무작위비교연구에서내시경적치료가수술적치료에비해서사망률, 합병증발생률, 췌루형성이의미있게적었다고보고하였다. 36 경피적배액법이나내시경적배액법은성공적인배액을위해서는많은횟수의시술과시간이필요하고, 가는배액관으로고형의괴사조직파편 (debris) 들이배액되는데제한점이있어광범위한괴사를치료하는데는한계점이있다. 그러나복강경을이용한괴사제거술은작은상처를통하여광범위하게괴사부위를제거할수있는장점이있다. Connor 등은개복수술한 41명이환자들과복강경수술을한 47명의환자들의임상결과를분석한후향적연구에서수술시행횟수, 수술후중환자실체류기간, 재원기간, 사망률에서통계적으로유의하게복강경수술이우수한성적을보였다고보고하였다. 37 경피적배액이나내시경적배액술은막으로견고하게 잘싸여진병변이있을때효과적이고, 이들방법이효과적이지못할때는복강경을이용한괴사제거술을추가적으로시행할수있다. 38 최근에는한가지방법의치료법보다는처음에는경피적시술이나내시경적시술을하여최대한염증의확산을줄이고필요에따라서 2차적으로복강경이나개복에의한괴사제거술을시행하는 step-up 치료가시행되기도한다. 또한이질환에서치료방법은환자의임상적상태에따라서달라질수있다. 3. 수술적치료나중재적시술의시기 (The optimal timing for surgical intervention) (Italian, 2010) : Surgery earlier than 14 days after onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications, such as multiorgan failure, which do not improve despite maximal therapy, and in those who develop abdominal compartment syndrome (recommendation B). (Japan, 2010) Early surgery for necrotizing pancreatitis is not recommended. (Recommendation D) If surgery (necrosectomy) is performed, it should be delayed as long as possible. (Recommendation C1) ( 대한췌담도학회제안 ) 괴사성췌장염의수술적치료는조기에시행하지않는다 (Recommendation D). 수술적괴사제거술이필요하다면가능한지연하는것을권장한다 (Recommendation C). 중증급성췌장염에서장기부전이조기에발생하므로과거에는수술적치료가조기에시행되었다. 그러나조기에시행하는수술적치료는합병증발생이높았고사망률이65% 에이르러이치료의효과에의문을가지게되었다. 18,23,39-41 한후향적연구에서급성괴사성췌장염환자중지연수술군에비하여조기수술군에서사망률 (12% vs 39%) 이통계학적으로의미있게높았다. 11 이연구결과는가능한수술을지연하는것이환자의사망률을감소시킬수있음을강조하고있다. 조기수술과지연수술군을무작위비교한연구에따르면조기수술군사망률이56%, 지연수술군사망률은 27% 로의미있는차이를보여주지는못했다. 그러나이연구는조기수술을받은환자에서사망률이너무높아연구가중단되었다. 40 급성췌장염으로수술

5 The treatment of local complication of acute pancreatitis and necrotizing pancreatitis 61 적치료를받은환자들의예후에영향을주는요소들을후향적연구에서는 56명의환자중 22명이조기수술 ( 췌장염발생 12일내 ) 을받았고, 34명이지연수술 ( 췌장염발생 12 일이후 ) 을받았는데, 조기수술군의사망률이 54.5% 였고지연수술군의사망률이 29.4% 였다 (p=0.06). 42 괴사성췌장염으로수술을받은 53명을대상으로한수술시기에관한연구에서발병 14일안에수술을받은군의사망률은 75%, 일사이에수술을받은수술군의사망률은 45%, 30일이후수술군의사망률은 8% 였다 (p=0.001). 11개의논문에포함된 1,136명을대상으로한체계적분석에서발병후조기에수술하면할수록사망률이높았다. 39 상기의여러가지문헌들을토대로하면가능한췌장염발병후괴사제거술을가능한지연해야하는것이지배적이다. 발병후시간이지남에따라서정상췌장과괴사된췌장의경계가분명해지고, 수술중출혈을최소할수있고불필요한정상췌장조직의제거를피할수있다. 4. Long-term follow-up of after necrosectomy (Japan, 2010) Following necrosectomy, a long- term follow-up paying attention to endocrine and exocrine pancreatic function and complication including the stricture of the bile duct and the stenosis of the pancreatic duct is necessary. (Recommenda- tion A) ( 대한췌담도학회제안 ) 췌장괴사제거술후에는담도협착, 췌관협착, 췌장의내분비와외분비기능장애에대한장기간동안추적검사가필요하다. 63명의환자에서장기간 ( 평균추적기간 : 28.9 개월 ) 예후에관한연구에서췌장기능이상을제외한합병증이 39 명 (62%) 에서발생하였다. 합병증으로는췌장루 8예, 담도협착 4예, 가성낭종 5예, 췌장의외분비기능장애 25% 당뇨 33% 에서발생하였다. 췌장궤사제거술을받은 98명을대상으로한다른연구에서는주췌관의협착으로 14.3% 에서재발성췌장염이발생하여수술적치료가필요하였다. 중증의담석성괴사성췌장염으로치료받은 39명을괴사제거술을받은군 (12명) 과그렇지않는군 (15명) 으로구분하여전향적코호트연구를시행하였다. 43 이보고에서지방변과인슐린대체치료가괴사제거술군에서만각가 25% 와 33.3% 에서발생하였다. 상기연구들을토대로보면괴사제거술을받은환자들은췌관협착, 담도협착, 그리고외분비및내분비췌장기능에대한장기간추적이필요함을알수있다. 5. 췌장가성낭종 (Pancreatic pseudocysts) 1) 췌장가성낭종배액술의적응증 (Indication for drainage treatment in pancreatic pseucocysts) (Italian, 2010) What are the indications for drainage treatment in pancreatic pseudocysts? Pancreatic pseudocysts which give rise to symptoms and complications or in which the diameter increases require drainage treatment (recommendation B). (Japan, 2010) What are the indications for intervention in pancreatic pseudocysts?interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts (Recommendation A). (London, 2005) Local complications of pancreatic necrosis, such as pseudocyst and pancreatic abscess, often require surgical, endoscopic, or radiological intervention. It is difficult to give precise guidance in this area because of the variations in patients, anatomical disturbance, and local expertise. ( 대한췌담도학회제안 ) 가성낭종으로인한임상적증상이발생하거나낭종의크기가커지는경우, 가성낭종의합병증이발생한경우에배액술을고려할수있다. 급성췌장염에서내시경적배액술이필요한경우는대부분가성낭종이다. 급성췌장염후발생하는가성낭종은보통최소 4주이후형성된다. 발생기전은급성췌장염발생후췌관에서췌장액이누출되어췌장실질이나췌장주위지방이괴사된부위가액화되면서발생할수있다. 44 과거에는가성낭종의크기가 6주이상지속되면모두배액이필요하다는진료지침이있었다. 45 최근장기간가성낭종의추적관찰한연구에서 86% 에서자발적소실이있었고합병증발생율은 3-9% 이므로장기간관찰이안전하고효과적이다고보고하였다. 46 또한전통적으로가성낭종의크기가 6cm 이상이면자발적소실확률이적으므로배액의적응증으로인식되어왔다. 47 그러나최근연구에서는낭종의크기가가성낭의합병증발생에중대한영향을주지

6 김태현 62 않는다고보고하였다. 46,48 따라서가성낭으로인해복통이발생하는경우, 가성낭의크기가점점커질때, 감염성가성낭, 가성낭내출혈, 가성낭에의한장이나총담관의폐쇄가있을때내시경적배액술이필요하다. 배액술을결정하기전고려해야할사항은낭종성종양과감별이다. 따라서췌장염의병력이명확하지않거나영상소견에서가성낭종의가능성이낮다면 EUS-FNA 을통한낭종의수액분석이필요할수있다. 2) 췌장가성낭종의중재적치료 (Interventional treatment selected for pancreatic pseudocysts) (Japan, 2010) Percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases including the communication with the pancreatic duct and the positional relationship between the digestive tract walls. (Recommendation A) (Italian, 2010) A. what is the indication for surgical intervention in pancreatic pseudocysts: Hemorrhagic pseudocysts or pseudocysts which do not tend to improve in response to percutaneous or endoscopic drainage should be managed surgically (recommendation C). B. what is the indication for endoscopic intervention in pancreatic pseudocysts? This indication was not present in the guidelines evaluated even if there are many suggestions for the treatment of pseudocysts using an interventional nonsurgical approach. Comment: The endoscopic approach can be performed in the case of favorable anatomical contiguity of the wall with the adjacent viscera (stomach, duodenum) and a minimum diameter of 5 6 cm. The authors of the present guidelines suggest that EUS- guided drainage may be safer than conventional endoscopic drainage. ( 대한췌담도학회제안 ) 췌장가성낭종의치료는내시경적배액술, 경피적배액술, 수술적배액술이이용될수있다. 각치료법의선택은낭종의위치, 낭종과췌관의연결유무, 낭종과위장관과해부학적위치관계, 병원의시설에따라서결정될수있다. 췌장가성낭종의치료방법은경피적배액술, 내시경적배액술, 수술적배액술이있다. 경피적배액술은 % 로높은치료성공률을보이고있어수술적치료를대체할수있다. 경피적배액술은간단하고비침습적인시술이지만재발율은 7%, 합병증발생율은 18%, 피부-췌루형성빈도가 11-39% 로다양하고, 가성낭종의완치율은수술적치료가경피적치료에비하여높다는보고도있다 (level 3b). 52,53 가성낭종에대한경피적치료와수술적치료를비교한한전향적연구 (level 2b) 에서일단계치유율은각각77% (20/26), 73% (18/26) 였고, 치료방법에따른재발율과완치율은차이가없었다. 54 배액의효과가있었던경피적배액관의평균유치기간은 일이었다 (level 2c-3b). 55,56 따라서이기간이지나도가성낭종이지속되면수술적치료가고려되어야한다. 경피적치료와내시경적치료로가성낭종을효과적으로배액하기위해서는췌관이정상이거나췌관협착이존재하지만낭종과췌관의교통이없어야한다. 57 반면에경유두적배액술은췌관과낭종이연결이되어있을때이용될수있다. 가성낭종에대한내시경배액방법은위벽을통한방법 (endoscopic cystogastrostomy), 십이지장벽을통한방법 (endoscopic cystoduodenostomy), 그리고유두를통한방법 (transpapillary drainage) 이있다. 내시경배액방법의성공률은 %, 합병증발생률은 4-33%, 재발률은 4-30% 로보고되었다. 15,58-60 이시술은경피적치료에비하여피부-췌누공을피할수있다는장점이있지만, 내시경치료의성적이시술자의숙련도에따라다를수있다는단점이있다. 61 후향적연구이기는하지만수술적치료내시경치료를비교한한보고에서는내시경배액방법의성공률과합병증발생률은수술방법과비슷하였다. 62 최근에는내시경초음파가치료내시경에이용되면서가성낭종의내시경치료가증가하고있다. 위나십이지장에서가장융기된 (bulging) 부위를내시경초음파없이맹목천자 (blind puncture) 하여배액하는방법에비하여내시경초음파로천자부위의주위구조물과목표부위를실시간으로관찰하면서천자를하면목표물과위장사이에존재하는혈관과장기를확인할수있다. 15,63 경유두적배액술은낭종과췌관이서로연결되어있는경우에이용될수있다.

7 The treatment of local complication of acute pancreatitis and necrotizing pancreatitis 63 수술적치료의적응증은보존적치료, 내시경적배액술, 경피적배액술에효과적이지못하거나낭종의감염또는출혈이동반되는경우이다. 수술적치료는낭종과장관사이에누공을만드는방법 (cystogastrostomy, cystojejunostomy) 과낭종절제술으로구분된다. 복강경수술이최근에보고되고있지만 64 더많은연구가필요하다. 가성낭종의배액방법은경피적, 내시경적, 그리고수술적치료방법이있는데치료방법선택은가성낭의특성과시술자숙련도및시술병원의시설에따라결정해야한다. 6. 췌장농양 (pancreatic abscess) (Japan, 2010) How should pancreatic abscess be drained? Drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess. (Recommendation B). (Italian, 2010) What is the indication for surgical drainage in pancreatic abscess? If the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed immediately. (Recommendation B) ( 대한췌담도학회제안 ) 췌장농양의치료는내시경적배액술, 경피적배액술, 수술적배액술이이용될수있다. 각치료법의선택은농양의위치, 농양과위장관과해부학적위치관계, 병원의시설에따라서결정될수있다. 췌장농양도가성낭종과비슷한특징을가지고있어가성낭종의치료법과큰차이가없어각치료법들의장단점은비슷하다. 또한췌장농양의발생빈도수가많지않아가성낭종에포함되어보고된경우가많고순수하게췌장농양만보고한문헌은많지않다. 췌장농양의대부분은액화된상태가대부분이고, 경피적배액술은 78-86% 의 치료성적을보고하고있다. Venu 등의보고에의하면췌장농양에대한내시경배액술의조기치료성공률은 94% 였고추적기간동안 74% 였다 명을대상으로한다른보고에서는치료성공률은 80% 였고 7명에서수술적치료가추가되었다. 68 대부분이소수의환자들을대상으로한연구들이어서많은증례를축적한장기간추적연구가필요하다. 췌장농양에대한경피적또는내시경적치료에서좋은결과를발표한보고들은후향적증례연구들이다. 이들방벙의치료성적이 80% 내외의좋은치료성적을보고하고있지만 ranson score 가 5점이상인중증이나다발성농양의경우에경피적치료의조기치료율은 30-47% 로낮다. 54,69 농양의경피적또는내시경적배액에도불구하고감염의임상적증후가지속되면수술적배액술을시행해야한다. 또한경피적배액술에더하여경파경위배액술이나내시경적배액술이추가적으로시도될수있다. 그러나이들치료방법들의효과를입증하기위해서는더많은증례를통한연구가필요하다. 참고문헌 1. Sekimoto M, Shikata S, Takada T, et al. Changes in management of acute pancreatitis before and after the publication of evidence-based practice guidelines in J Hepatobiliary Pancreat Sci 2010;17: Loveday BP, Srinivasa S, Vather R, et al. High quantity and variable quality of guidelines for acute pancreatitis: a systematic review. Am J Gastroenterol 2010;105: Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101: UK guidelines for the management of acute pancreatitis. Gut 2005;54 Suppl 3:iii Pezzilli R, Zerbi A, Di Carlo V, Bassi C, Delle Fave GF. Practical guidelines for acute pancreatitis. Pancreatology 2010;10: Takeda K, Yokoe M, Takada T, et al. Assessment of severity of acute pancreatitis according to new prognostic factors and CT grading. J Hepatobiliary Pancreat Sci 2010;17: Hirota M, Takada T, Kawarada Y, et al. JPN Guidelines for the management of acute pancreatitis: severity assessment of acute pancreatitis. J Hepatobiliary Pancreat Surg 2006;13: Uhl W, Warshaw A, Imrie C, et al. IAP Guidelines for the Surgical Management of Acute Pancreatitis. Pancreatology 2002;2: Connor S, Ghaneh P, Raraty M, et al. Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy. Br J Surg 2003;90: Hungness ES, Robb BW, Seeskin C, Hasselgren PO, Luchette FA. Early debridement for necrotizing pancreatitis: is it worthwhile? J Am Coll Surg 2002;194:

8 김태현 ; discussion Hartwig W, Maksan SM, Foitzik T, Schmidt J, Herfarth C, Klar E. Reduction in mortality with delayed surgical therapy of severe pancreatitis. J Gastrointest Surg 2002;6: Gotzinger P, Wamser P, Barlan M, Sautner T, Jakesz R, Fugger R. Candida infection of local necrosis in severe acute pancreatitis is associated with increased mortality. Shock 2000;14: ; discussion Gotzinger P, Wamser P, Exner R, et al. Surgical treatment of severe acute pancreatitis: timing of operation is crucial for survival. Surg Infect (Larchmt) 2003;4: Baron TH, Harewood GC, Morgan DE, Yates MR. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002;56: Sriram PV, Kaffes AJ, Rao GV, Reddy DN. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels. Endoscopy 2005;37: Banks PA, Gerzof SG, Langevin RE, Silverman SG, Sica GT, Hughes MD. CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome. Int J Pancreatol 1995;18: Rau B, Pralle U, Mayer JM, Beger HG. Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis. Br J Surg 1998;85: Rodriguez JR, Razo AO, Targarona J, et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008;247: Buchler MW, Gloor B, Muller CA, Friess H, Seiler CA, Uhl W. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000;232: Fernandez-del Castillo C, Rattner DW, Makary MA, Mostafavi A, McGrath D, Warshaw AL. Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 1998;228: Runzi M, Niebel W, Goebell H, Gerken G, Layer P. Severe acute pancreatitis: nonsurgical treatment of infected necroses. Pancreas 2005;30: Sivasankar A, Kannan DG, Ravichandran P, Jeswanth S, Balachandar TG, Surendran R. Outcome of severe acute pancreatitis: is there a role for conservative management of infected pancreatic necrosis? Hepatobiliary Pancreat Dis Int 2006;5: Lee JK, Kwak KK, Park JK, et al. The efficacy of nonsurgical treatment of infected pancreatic necrosis. Pancreas 2007;34: Morise Z, Yamafuji K, Asami A, et al. Direct retroperitoneal open drainage via a long posterior oblique incision for infected necrotizing pancreatitis: report of three cases. Surg Today 2003;33: Carter R. Management of infected necrosis secondary to acute pancreatitis: a balanced role for minimal access techniques. Pancreatology 2003;3: Pamoukian VN, Gagner M. Laparoscopic necrosectomy for acute necrotizing pancreatitis. J Hepatobiliary Pancreat Surg 2001;8: Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc 2005;62: Bucher P, Pugin F, Morel P. Minimally invasive necrosectomy for infected necrotizing pancreatitis. Pancreas 2008;36: Werner J, Feuerbach S, Uhl W, Buchler MW. Management of acute pancreatitis: from surgery to interventional intensive care. Gut 2005;54: Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 2000;232: van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 2011;98: Coelho D, Ardengh JC, Eulalio JM, Manso JE, Monkemuller K, Coelho JF. Management of infected and sterile pancreatic necrosis by programmed endoscopic necrosectomy. Dig Dis 2008;26: Seewald S, Ang TL, Teng KC, Soehendra N. EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis. Dig Endosc 2009;21 Suppl 1:S Seewald S, Ang TL, Teng KY, et al. Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis. Endoscopy 2009;41: Seifert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009;58: Bakker OJ, van Santvoort HC, van Brunschot S, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA

9 The treatment of local complication of acute pancreatitis and necrotizing pancreatitis ;307: Connor S, Raraty MG, Howes N, et al. Surgery in the treatment of acute pancreatitis--minimal access pancreatic necrosectomy. Scand J Surg 2005;94: van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362: Besselink MG, Verwer TJ, Schoenmaeckers EJ, et al. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 2007;142: Mier J, Leon EL, Castillo A, Robledo F, Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997;173: Nathens AB, Curtis JR, Beale RJ, et al. Management of the critically ill patient with severe acute pancreatitis. Crit Care Med 2004;32: De Waele JJ, Hoste E, Blot SI, et al. Perioperative factors determine outcome after surgery for severe acute pancreatitis. Crit Care 2004;8:R Sabater L, Pareja E, Aparisi L, et al. Pancreatic function after severe acute biliary pancreatitis: the role of necrosectomy. Pancreas 2004;28: Segal D, Mortele KJ, Banks PA, Silverman SG. Acute necrotizing pancreatitis: role of CT-guided percutaneous catheter drainage. Abdom Imaging 2007;32: Bradley EL, Clements JL, Jr., Gonzalez AC. The natural history of pancreatic pseudocysts: a unified concept of management. Am J Surg 1979;137: Cheruvu CV, Clarke MG, Prentice M, Eyre-Brook IA. Conservative treatment as an option in the management of pancreatic pseudocyst. Ann R Coll Surg Engl 2003;85: Bergman S, Melvin WS. Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am 2007;87: , ix. 48. Nguyen BL, Thompson JS, Edney JA, Bragg LE, Rikkers LF. Influence of the etiology of pancreatitis on the natural history of pancreatic pseudocysts. Am J Surg 1991;162: ; discussion Pitchumoni CS, Agarwal N. Pancreatic pseudocysts. When and how should drainage be performed? Gastroenterol Clin North Am 1999;28: Zerem E, Pavlovic-Calic N, Susic A, Haracic B. Percutaneous management of pancreatic abscesses: long term results in a single center. Eur J Intern Med 2011;22:e Freeny PC, Hauptmann E, Althaus SJ, Traverso LW, Sinanan M. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am J Roentgenol 1998;170: Heider R, Meyer AA, Galanko JA, Behrns KE. Percutaneous drainage of pancreatic pseudocysts is associated with a higher failure rate than surgical treatment in unselected patients. Ann Surg 1999;229: ; discussion Soliani P, Franzini C, Ziegler S, et al. Pancreatic pseudocysts following acute pancreatitis: risk factors influencing therapeutic outcomes. JOP 2004;5: Lang EK, Paolini RM, Pottmeyer A. The efficacy of palliative and definitive percutaneous versus surgical drainage of pancreatic abscesses and pseudocysts: a prospective study of 85 patients. South Med J 1991;84: D'Egidio A, Schein M. Percutaneous drainage of pancreatic pseudocysts: a prospective study. World J Surg 1992;16: ; discussion Adams DB, Anderson MC. Changing concepts in the surgical management of pancreatic pseudocysts. Am Surg 1992;58: Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 2002;235: Baron TH. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis. Gastrointest Endosc Clin N Am 2003;13: Weckman L, Kylanpaa ML, Puolakkainen P, Halttunen J. Endoscopic treatment of pancreatic pseudocysts. Surg Endosc 2006;20: Gumaste VV, Aron J. Pseudocyst management: endoscopic drainage and other emerging techniques. J Clin Gastroenterol 2010;44: Harewood GC, Wright CA, Baron TH. Impact on patient outcomes of experience in the performance of endoscopic pancreatic fluid collection drainage. Gastrointest Endosc 2003;58: Johnson MD, Walsh RM, Henderson JM, et al. Surgical versus nonsurgical management of pancreatic pseudocysts. J Clin Gastroenterol 2009;43: Varadarajulu S, Christein JD, Tamhane A, Drelichman ER, Wilcox CM. Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc 2008;68: Palanivelu C, Senthilkumar K, Madhankumar MV, et al. Management of pancreatic pseudocyst in the era of laparoscopic surgery-experience from a tertiary centre. Surg Endosc 2007;21:

10 김태현 vansonnenberg E, Wittich GR, Goodacre BW, Casola G, D Agostino HB. Percutaneous abscess drainage: update. World J Surg 2001;25: ; discussion Baril NB, Ralls PW, Wren SM, et al. Does an infected peripancreatic fluid collection or abscess mandate operation? Ann Surg 2000;231: Venu RP, Brown RD, Marrero JA, Pastika BJ, Frakes JT. Endoscopic transpapillary drainage of pancreatic abscess: technique and results. Gastrointest Endosc 2000;51: Vitale GC, Davis BR, Vitale M, Tran TC, Clemons R. Natural orifice translumenal endoscopic drainage for pancreatic abscesses. Surg Endosc 2009;23: Lee MJ, Rattner DW, Legemate DA, et al. Acute complicated pancreatitis: redefining the role of interventional radiology. Radiology 1992;183: