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1 D-IV. 췌담도질환에서내시경치료의근거중심전략적접근 Room D 악성담도협착에서최선의수술전담도배액술 이우진 우상명 국립암센터췌담도암클리닉 Best Preoperative Biliary Drainage: Endoscopic or Percutaneous Approach Woo Jin Lee, Sang Myung Woo Pancreatobiliary Cancer Clinic, National Cancer Center, Goyang, Korea 서론 폐쇄성황달은담도폐쇄로인해고빌리루빈혈증이특징으로간기능이상, 지방과지용성비타민소화흡수이상, 면역결핍, 담도감염, 내독소혈증 (endotoxemia), 또는신질환을야기하며결국간부전과간-신 (hepatorenal) 증후군에이르게된다. 하지만췌십이지장절제술또는간절제술이예정된폐쇄성황달이있는환자에서절제수술이전에담도배액술로폐쇄성황달을호전시키는것이이러한합병증을감소시켜수술이환율이나사망률을감소시키는지는아직논란이있는실정이다. 1-6 본론 1. 췌십이지장절제술이예정되어있는폐쇄성황달환자에서수술전담도배액술의역할 최근수술술기발달및수술전후의환자처치발달로췌십이지장절제술의수술사망률은 1-2% 까지낮아졌다. 팽대부주위암에서수술전담도배액술의역할에대해서는여러연구들이다양한결과를보고하고있다. 초기후향적 7-9 또는무작위대조연구 10 에서수술전담도배액술로수술이환율이나사망률을감소시켰다는보고가있는반면에다른무작위대조연구 또는최근의관찰연구 나최근의대규모전향적연구 에서는수술전담도배액술이의미있는이익이없다는보고가우세하며수술부위감염이나심지어는사망률을증가시켰다는보고도있다. 17 최근의메타분석에서비록더많은무작위대조연구가필요하지만수술전담도배액술이의미있는이익이없어통상적으 로시행하지는말것을권고하였다 이후의가장최근의연구들에서도부정적인결과들이더우세하였다 간절제술이예정되어있는폐쇄성황달환자에서수술전담도배액술의역할 췌십이지장절제술이예정되어있는폐쇄성황달환자와달리간절제술을하여야하는간문부담도암의경우수술후간부전으로인한사망률이상대적으로더높다. 간문부담도암의경우미상엽 (caudate lobe) 과간외담도절제및경우에따라확대간절제술, 혈관절제를요하여수술전에향후잔존간 (future liver remnant, FLR) 의용적과간기능의정확한평가가중요하다. 더욱이일부에서는잔존간의용적을키우기위해간문맥색전술 (portal vein embolization) 을요한다. 29,30 이러한환자들에서수술전담도배액술은결과가다양하여아직논란이있다. 22 하지만경험적으로특히급성담도염이있거나간문맥색전술을요하는경우에는시행할것을권장한다. 1) 수술전배액찬성폐쇄성황달환자에서수술전배액없이간절제술을시행하는경우출혈, 감염, 담즙누출로입한농양, 패혈증및간부전등으로수술이환율이나사망률이증가한다는보고가있어 많은병원특히적극적으로확대절제술을시행하는아시아에서통상적으로수술전담도배액이선호된다 이론적인근거로는담즙울체성 (cholestatic) 간은허혈 / 재관류간손상을잘받고염증반응이증가한다는실험적인연구가있으며 48,49 또한비타민 K의존응고인자합성의장애에도불구하고응고증강상태라는임상적연구가있다. 50 제 49 회대한소화기내시경학회세미나 269

2 악성담도협착에서최선의수술전담도배액술 이우진 우상명 2) 수술전배액반대수술전배액술이담도의세균오염을야기하며복벽감염이나복강내감염을증가시켜수술이환율이나사망률을높인다는보고가있고시술자체의부가적인비용증가와입원기간의연장등의단점이있다. 또한많은연구에서시술합병증으로재발성황달, 담도염, 췌장염, 출혈및누공등을보고하고있다. 따라서임상적이점을보이지못하므로일괄적으로시행하지는말아야한다는주장이있다. 22,35,51-57 배액술로인한합병증이이익을상쇄할수있기때문이다. 따라서서양에서는주로영양이상이심하거나, 담도염이있거나황달이오래된경우, 잔존간이 30-40% 이하인경우에만수술전담도배액술을하는경향이있다. 3. 내시경또는경피경간담도배액술 (Tables 1, 2) 수술전담도배액술은크게경피경간담도배액술 (percutaneous transhepatic biliary drainage, PTBD) 과내시경적담도배액술 (endoscopic biliary drainage, EBD) 로나누고, 내시경적담도배액술은다시내시경적경비담도배액술 (endoscopic nasogastric biliary drainage, ENBD) 과내시경적역행성담도배액술 (endoscopic retrograde biliary drainage, ERBD) 로구분할수있다. ERBD는가장덜침습적이고환자에게편하며내부배액으로생리적인장-간순환이회복하여내독소혈증감소, 면역기능이상의정상화, 체액및전해질의손실방지가가능하고시술과동시에조직검사가가능하다는장점이있으나상행담도염, 췌장염, 십이지장천공, 출혈, 도관폐쇄등의단점이있다. 시술후조영술이불가능하나최근에는 MRCP의발전으로수술전평가가보다정확해졌다. 배액관주변의담도주위, 간십이지장인대 (hepatoduodenal ligament) 의염증과섬유화반응을초래하여외과의가절개시어려움을증가시키고담도크기의감소는담도-장문합술을더어렵게한다. 또한근위부담도폐쇄시특히간내담도가각각종양으로인해분리되어있을시에는주입한조영제가배액되지않는경우담도염을조장할수있어오히려수술을저해할수있어몹시조심하여야한다. 따라서근위부담도폐쇄시의수술전배액술로는점차사용이제한되는추세이다. Table 1. Advantages and Disadvantages of Each Biliary Drainage Method Advantages Disadvantages PTBD Entire liver can be drained by multiple catheter placement Invasive Post-drainage cholangiography is possible Risk of seeding cancer in the tract External drainage ENBD Less invasive than PTBD Discomfort of nasal tube Post-drainage cholangiography is possible Draining both lobes is difficult External drainage ERBD Internal drainage method Post-drainage cholangiography is difficult Even less invasive than ENBD Risk of cholangitis PTBD, percutaneous transhepatic biliary drainage; ENBD, endoscopic nasobiliary drainage; ERBD, endoscopic retrograde biliary drainage. Table 2. Data from Studies Concerning Endoscopic Nasobiliary Drainage or Comparison among Different Types of Biliary Drainage for Proximal Obstruction Author Type of study Type of Drainage related Minor Drainage related Major drainage Complications (%) Complications (%) Conclusions Arakura Retrospective ENBD 13 ENBD had low morbidity rate and no risk of cancer seeding Kloek Retrospective ERBD 48 (p < 0.05) PTBD outperformed ERBD PTBD 9 Hirano Retrospective ENBD 5 ENBD first choice for biliary decompression for FRL. Drain only FRL Lee Retrospective ENBD ENBD for decompression of Bismuth-Corlette I and II tumor Kawakami Retrospective PTBD ENBD ERBD PTBD ENBD is highly recommended 270 Korean Society of Gastrointestinal Endoscopy

3 이우진 우상명 악성담도협착에서최선의수술전담도배액술 ENBD는 PTBD보다덜침습적이고수술전담도조영이가능하다는장점이있다. 또한지속적인세척이가능하여담도염이 ERBD보다상대적으로적다. 환자가다소불편하고외부배액으로인한체액및전해질손실등의단점이있다. PTBD의가장큰장점은근위부담도폐쇄시특히각간내담도가각각종양으로인해분리되어있을시에여러도관의삽입이가능하여성공률이더높고담도염가능성이상대적으로적으며수술 1-2일전에조영술을통해병변부를확인, 수술전평가에도움이되나환자가불편하고침습성이가장강해출혈, 담즙누출및복막염, 삽입부동통, 도관폐쇄및이탈로인한담도염등의합병증이있고외부배액으로인한체액및전해질손실등의단점이있다. 특히 PTBD의경우장기적으로배액관경로를따라종양파종 (seeding) 이 5-10% 에서보고되고있다. 38,58-61 따라서간문부담도암의경우최근동양에서는점차 ENBD 방법이많이사용되어지는추세이다 근위부담도폐쇄시경우에따라 2개이상의도관삽입이시도되고있다. 4. 내부배액또는외부배액 전술한바와같이내부배액은생리적으로여러장점이있으나상행담도염을초래하여오히려수술을저해할수있다. PTBD로내부배액도가능한데종양을통과해서건드려야한다는단점이있다. 도관끝을십이지장까지빼지말고폐쇄원위부의총담도에위치시키면오디괄약근의기능을보존하여상행담도염의위험성을줄일수있다. 외부배액의경우일부일본에서는간의재생능력을높이고장기능을유지해세균의전위 (translocation) 을예방할목적으로배액된담즙을다시경구또는비위관으로주입하기도하나논란이있다. 62,63 5. 간절제술이예정되어있는폐쇄성황달환자에서수술전편측또는양측담도배액 우선적으로는수술후남는잔존간을배액하는것이추천된다. 38,40 수술전간절제술종류가불확실할때는일단좌엽을배액할것을추천하기도한다. 양측배액을하여야하는경우는수술전간절제술종류를결정하기어려울때, 편측배액으로담도염이해소되지않는경우, 황달의감소가더딜때등이다. 수술종류, 간기능정도, 분절성담도염 (segmental cholangitis) 유무등이중요한결정요소이다. 1,39 6. 수술전담도배액술의적응증 여러연구보고에서수술전담도배액술이크게이익이없는 이론적근거로는배액기간과의관계가제시되고있다. 배액후고빌리루빈혈증의정상화는 2/3에서만이루어지며간세포미토콘드리아기능의정상화나조직병리학적으로완전회복에는 6-8주가소요된다 여러연구에서수술전배액기간은 10-32일, 평균 2주로 67 이기간동안평균빌리루빈수치는최초의 1/4정도로감소하였는데췌십이지장절제술에는큰문제가없으나간절제술의경우에는 2-3 mg/dl까지감소하거나간기능의완전회복에이르기에는시간이모자라다. 절대적적응증으로는담도염이있을때해소를위해서, 심한영양이상이나저알부민혈증, 폐쇄성황달로인한간부전또는신부전의호전을위해서, 그리고선행보조 (neoadjuvant) 치료를하거나간문맥색전술을요하는경우이다. 또한수술이지연되거나전원시심한황달의악화를예방하기위해시행할수있다. 7. 요약 1) 췌십이지장절제술이예정되어있는폐쇄성황달환자에서수술전담도배액술수술전담도배액술이의미있는이익이없어통상적으로시행하지는말것을권하는추세이다. 4주이상의오래된황달, 담도염, 신부전, 영양이상, 선행보조치료예정등특수한경우에선택적으로시행하는데 EBD가 PTBD보다추천된다. 이경우금속배액관과플라스틱배액관에대한비교연구는아직거의없다. 68 PTBD는 EBD가실패시시행한다. 2) 간절제술이예정되어있는폐쇄성황달환자에서수술전담도배액술아직논란이있는실정으로적응증이되는경우에만시행할것을주장하기도하나보통아시아에서는주요간절제술이예정되어있는경우통상적으로시행하는추세로보다많은대규모의여러병원이참여한무작위연구가필요하나쉽지않은실정이다. 최근 ENBD 가합병증이적어많이이용되는추세이나 Bismuth 3형이나 4형같은경우나여러분절의배액을요할때는 ENBD방법으로 2-3개의도관을삽입할수도있으나담도염의위험성이높아주의를요하며이런경우 PTBD가보다안전하게이용될수있다. 수술후남는잔존간을배액하는것으로대개충분하나개개인의증례에따라다를수있으며수술종류, 간기능정도, 분절성담도염유무등이중요한고려인자이다. 결론수술전정확한평가와여러과가다학적팀으로참여해충 제 49 회대한소화기내시경학회세미나 271

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노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding