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1 ORIGINAL ARTICLE ISSN , The Korean Journal of Helicobacter and Upper Gastrointestinal Research, 2014;14(1):24-30 경피내시경하위루술의합병증에대한고찰 김홍제, 이상호, 이재남, 장성필, 황철구, 김지하 지방공사부산의료원소화기내과 A Study of Complications Related to Percutaneous Endoscopic Gastrostomy Hong Jae Kim, Sang Ho Lee, Jae Nam Lee, Seong Pil Jang, Cheol Gu Hwang, Ji Ha Kim Division of Gastroentorology, Department of Internal Medicine, Busan Medical Center, Busan, Korea Background/Aims: Percutaneous endoscopic gastrostomy (PEG) is a widely used method for providing nutritional support for patients who require prolonged tubal feeding. As survival times of PEG inserted patients increase, PEG related complications are also increasing. For this reason, we decided to review complications related to PEG. Materials and Methods: A retrospective review of medical records was conducted for patients who received PEG placement between January 2004 and March 2013 in our hospital. Of the total 331 cases of PEG placement, 131 cases of PEG exchanges were excluded and a total of 200 cases were included in our review. We reviewed the baseline characteristics of all PEG inserted patients and complications related to PEG insertion. Results: Complications related to PEG developed in 45 of 200 patients (22.5%). Peristomal infection occurred in 22 patients (11.0%) and buried bumper syndrome occurred in 10 patients (5.0%). Other complications that occurred in 13 patients were hemorrhage (3.0%), leakage (1.0%), aspiration pneumonia (1.0%), ileus (0.5%), necrotizing fasciitis (0.5%) and gastro-colo-cutaneous fistula (0.5%). The characteristics according to age, gender, procedure place and underlying disease were not different between the complication group and non complication group. The onset time to complication was significantly different between the buried bumper syndrome group and the other complication groups (P=0.035). Conclusions: Peristomal infection was the most common complication of PEG in our hospital. Late peristomal infection and buried bumper syndrome occurred more often than previous studies. Buried bumper syndrome was more likely to occur in later time compared with the other complications. (Korean J Helicobacter Up Gastrointest Res 2014;14:24-30) Key Words: Gastrostomy; Adverse effects 서 론 경피내시경하위루술 (percutaneous endoscopic gastrostomy, PEG) 은경구섭취가불가능한환자에게효과적으로장기간경관영양법을시행할수있는시술로 1980년 Gauderer 등 1 에의해최초로시도되었다. 내시경을이용하여국소마취하에시행할수있고수술적위루술에비해간편하고시술에따른합병증이적으며위루관의제거와재삽입이용이하다는장점이있어전세계적으로널리이용되고있다. PEG 의효용성과안전성에대한국외연구들이진행되면서시술부위감염, 위장관출혈, 누출, 흡인성폐렴, 장마비, buried bumper 증후군, 괴사성근막염, 위결장누공등의합병증이보고되었고, 발생 Received: August 5, 2013 Accepted: September 11, 2013 Corresponding author: Sang Ho Lee Division of Gastroenterology, Department of Internal Medicine, Busan Medical Center, 359, World cup-daero, Yeonje-gu, Busan , Korea Tel: , Fax: , skylsh1@hanmail.net 빈도는 16 70% 까지다양하게나타나고있다. 2-5 국내에서도 PEG 관련합병증에대한보고가있으나, 6-8 최근 10년간단일기관에서시행한 200예이상의대규모연구는찾아보기어려우며 buried bumper 증후군에대한연구도증례중심으로만보고되고있다. 9 이에저자들은본원소화기내과에서 PEG 를시행한환자들을대상으로합병증의종류와빈도, 발생시기, 기저질환의연관성, buried bumper 증후군의임상양상에대하여알아보고자하였다. 대상및방법 1. 연구대상 2004년 1월부터 2013년 3월까지본원에서다양한기저질환에의해장기적경관영양법으로 PEG 를시행한 331 예의환자중에서자가제거로인한재삽입, 위루관의위생불량으로교환시술을한 131예를제외한 200명의환자를대상으로진료기록을후향적으로조사하였다. 위장관기능은정상이나뇌혈관질 Copyright 2014 Korean College of Helicobacter and Upper Gastrointestinal Research The Korean Journal of Helicobacter and Upper Gastrointestinal Research is an Open-Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Hong Jae Kim, et al: A Study of Complications Related to Percutaneous Endoscopic Gastrostomy Table 1. Baseline Characteristics of the 200 Patients and Underlying Indications for Percutaneous Endoscopic Gastrostomy Characteristic Value Gender Male 122 (61.0) Female 78 (39.0) Age (yr) 66.8±14.5 < (62.5) (37.5) Procedure place Inpatient 161 (80.5) Outpatient 39 (19.5) Communication Possible 26 (13.0) Impossible 174 (87.0) Diabetes mellitus (+) 40 (20.0) ( ) 160 (80.0) Underlying indication Central nervous system disease Stroke 159 (79.5) Dementia 12 (6.0) Hypoxic brain damage 6 (3.0) Parkisonism 6 (3.0) Brain tumor 3 (1.5) Meningitis 2 (1.0) Spinal injury 2 (1.0) Head and neck cancer 7 (3.5) Esophageal cancer 2 (1.0) Wilson disease 1 (0.5) Values are presented as n (%) or mean±sd. 환, 치매, 두부손상, 파킨슨병등의중추신경계질환으로인해연하곤란이발생한경우, 두경부종양, 식도종양, 윌슨병의진행으로연하곤란이있는경우를 PEG 의적응증으로하였으며, 악성복막염, 복수, 구강의구조적문제가있는경우, 교정되지않는응고질환, 인두및식도의폐쇄가있는경우등금기증을가진환자에서는시행하지않았다. 환자의평균나이는 66.8 세 ( 범위 세 ) 였으며남자 122명, 여자는 78명이었다 (Table 1). 2. 연구방법 1) PEG 시술과정 PEG 시술은입원환자나외래환자들을대상으로소화기내시경전문의들이 24 French 직경의위루관 (Flow-24-pull PEG system; Wilson-Cook Medical, Winston-Salem, NC, USA) 과상부위장관용내시경 (GIF 240 and GIF Q260; Olympus Optical, Tokyo, Japan) 을이용하여, 구강과식도를통해위강내로위루관을밀어넣고복벽바깥으로잡아당겨고정하는 pull technique 으로시행하였다. 시술전날자정부터시술후 24시간동안금식을유지하였고합병증이없는경우위루관을통해 물부터시작하여식이를주입하였다. 예방적항생제는시술직전이나직후에 1세대 cephalosporin 을투여하였으며환자의상태에따라 1 3 일간추가사용하였다. 시술전금기증이없는환자에게전처치및의식하진정을위해 cimetropium bromide (5 mg), midazolam (5 mg) 을각각정맥투여하였다. 시술후다음날아침부터상처부위를소독하였고, 식이공급할때의환자의자세및공급방법등에대해간병인에게교육하도록하였다. 2) 합병증의분류, 위험인자, 치료방법합병증의종류는시술부위감염, 위장관출혈, 누출, 흡인성폐렴, 장마비, buried bumper 증후군, 괴사성근막염, 위결장누공으로구분하였다. 시술부위감염은고름이나삼출물이있으면서 38 o C 이상의발열등의전신증상을동반한경우를감염이있는것으로간주하였으며, 시술직후의일시적인압통이나미열, 단순발적등은제외하였다. 합병증의발생시기는시술후 4주이내에발생한경우는초기합병증, 4주이후에발생한경우는후기합병증으로구분하였고, 한환자에서두가지이상의합병증이동시에나타난경우는일차적원인이되거나더중한합병증으로단일화하였다. 합병증발생의위험인자를알아보기위해성별, 연령, 시술장소, 당뇨병유무, 기저질환, 의사소통가능유무등에대해진료기록을후향적으로조사하였다. 시술장소는외래및입원환자로구분하였다. 의사소통가능여부는시술후위루관을손상시키거나자가제거할가능성을고려하여조사항목에포함하였으며, 언어장애가있더라도비언어적의사소통으로대화내용의감지및반응이가능하여시술에협조가가능한경우를포함하였다. 합병증의치료방법은내과적치료와수술적치료로구분하였고, 내과적치료는항생제, 프로톤펌프억제제등의약물치료와수혈, 내시경적시술등으로치료한경우로정의하였다. 3) 통계분석연령, 합병증의발생시기는평균, 표준편차로기술하였고그이외의자료는환자의수 ( 퍼센트 ) 로기술하였다. Chi-square test, Fisher s exact test 를이용하여환자의특성을분석하고각군을비교하였다. P 값 0.05 이하를통계적으로유의하다고정의하였으며, 통계분석은 IBM SPSS Statistics 21.0 (IBM Co., Armonk, NY, USA) 을이용하였다. 결 과 1. 합병증의발생빈도, 발생시기에따른분류, 치료및예후 합병증은 200 명중 45 명 (22.5%) 에서발생하였다 (Table 2). 25

3 Korean J Helicobacter Up Gastrointest Res: Vol 14, No 1, March 2014 Table 2. Incidence of Complications Related to Percutaneous Endoscopic Gastrostomy and Its Onset Time Parameter Occurrence within 1 month Occurrence after 1 month Total (%) Occurrence time (wk) P value Peristomal infection (49.0) Buried bumper syndrome (22.3) Hemorrhage (13.3) Leakage (4.4) Aspiration pneumonia (4.4) Ileus (2.2) Necrotizing fasciitis (2.2) Gastro-colo-cutaneous fistula (2.2) Total (100) 11.0 Table 3. Comparison of Baseline Characteristics between Complication Group and Non-complication Group (n=200) Characteristic Complication group (n=45) Non-complication group (n=155) P value Gender Male Female Age (yr) 68.4± ± < Procedure place Inpatient Outpatient 4 35 Communication Possible 4 23 Impossible Diabetes mellitus (+) 9 31 ( ) Underlying indication Central nervous system disease Other disease day-mortality Values are presented as n or mean±sd. 시술중에발생한합병증은없었고, 시술후에발생한합병증은시술부위감염이 22명으로전체 PEG 시술환자중 11.0% 를차지하였고가장많았다. 그다음으로 buried bumper 증후군이 10명 (5.0%) 에서발생하였고, 위장관출혈 6명, 누출 2명, 흡인성폐렴 2명, 장마비와괴사성근막염, 위결장누공이각각 1 명에서발견되었다 (Table 2). 합병증의발생시기는평균 11.0 주였으며, PEG 시술후 4주이내에발생한경우는 27명 (60.0%), 4주이후에발생한경우는 18명 (40.0%) 이었다. 시술부위감염은 22명중 10명이시술 4 주이후에발생하였고, buried bumper 증후군은 10명중 8명이발생해서다른합병증군에비해서시술 4주이후에발생하는비율이통계적으로유의하게높았다 (P =0.035). PEG 관련합병증이발생한 45명중위결장누공이발생하였던사례를포함하여 43명은내과적치료로호전되었고, 괴사성근막염이발생하였던 1명과 PEG 시술다음날심한위장관출혈이발생되었던 1명은수술과내과적치료를병행하여호전되었다. 전체 PEG 시술환자중 4주이내에사망한환자가 7명이었으나모두시술과무관하게기저질환의악화로사망하였다. 2. 합병증발생의위험인자합병증이발생한군과합병증이발생하지않은군으로나눠서대상환자들의성별, 연령, 시술장소, 당뇨병유무, 기저질환, 의사소통가능유무등에대하여분석하였으나연관성은발견되지않았다. 시술 30일내사망한환자는합병증이발생한 45명중 2명이었고, 발생하지않은 155명중에서는 5명이었으나통계적유의성은없었다 (Table 3). 3. 시술부위감염의원인균시술부위감염이발생한 22명의환자에서분비물과혈액을배양하여원인균을조사하였다. 총 17명에서원인균이동정되었으며 methicillin-resistant Staphylococcus aureus 와 Pseudomonas aeruginosa 가각각 4명 (23.5%) 에서발견되어가장많았고, Escherichia coli 3명, Klebsiella pneumoniae 2명에서발견되었으며, 그밖에도여러가지균주가동정되었다 (Table 4). 4. Buried bumper 증후군의특징과임상양상 Buried bumper 증후군은총 200명중 10명 (5%) 에서발생하였고, 평균연령은 68.2 세, PEG 시술후발생시기는평균 18.6 주였다. 다른합병증이발생한군과비교했을때성별, 연령, 시술장소, 당뇨병유무, 기저질환, 의사소통가능여부와 30 26

4 Hong Jae Kim, et al: A Study of Complications Related to Percutaneous Endoscopic Gastrostomy Table 4. Microorganisms Isolated from Peristomal Infection Patients Species n (%) Methicillin-resistant Staphylococcus aureus 4 (23.5) Pseudomonas aeruginosa 4 (23.5) Escherichia coli 3 (17.6) Klebsiella pneumonia 2 (11.8) Candida tropicalis 1 (5.9) Acinetobacter baumanii 1 (5.9) Enterobacter cloacae 1 (5.9) Enterobacter aerogenes 1 (5.9) Total 17 (100) 일내사망여부에서유의한차이는발견되지않았다 (Table 5). Buried bumper 증후군의진단당시임상양상은위루관의기능부전으로발견된경우 (4명 ), 발열과복통, 구토등의위장관증상이동반된경우 (3명 ), 압통을동반한복부종괴 (2명 ), 위루관을통한출혈 (1명 ) 등의증상으로나타났다. 10명모두내시경으로위내부를확인하였으며, 내시경소견에서위강내에내부완충기가관찰되지않고상피조직으로완전히덮여서주변부발적과부종을동반된경우가 7명, 내부완충기가부분적으로관찰되나위벽이함몰되어궤양형성및출혈이관찰된경우가 3명이었다. 내부완충기가보이지않았던 7명은외부로위루관을견인하여제거후항생제등의보존적치료를시행하였으며, 이중삽입부통과가쉽고변형이나염증이심하지않은 4명은즉시같은자리에위루관을재삽입, 삽입부변형과염증이심한 3명은 2 4 주이상보존적치료후다른자리에재삽입하였다. 반면, 내부완충기가부분적으로관찰되나위벽의함몰이있었던 3명은위루관을제거하지않고위강내로밀어넣어위치를조절한후완전비경구영양법과항생제, 고용량프로톤펌프억제제를투여하여치료하였다. 고 찰 PEG 는비위관을통한영양공급에비해서는침습적인방법이나, 장기간경관영양법이필요한환자에서안정적으로영양공급을할수있고시술에대한사망률과이환율이낮은것으로알려져있어성인뿐만아니라소아에서도널리적용되는시술이다. 1,2,10 적응증은뇌혈관질환, 치매, 두부손상, 파킨슨병과같은중추신경계질환이나두경부종양, 식도종양, 다른전신적인질환에의해위장관기능은정상이나연하곤란이있어경구영양공급이불충분한환자가해당되며, 이중중추신경계질환이있는환자들이적응증의대부분을차지하였다. 1,2 본연구에포함된 200명의환자중에서도중추신경계질환을가진 Table 5. Comparison of Baseline Characteristics between Buried Bumper Syndrome Group and Other Complication Group (n=45) Characteristic Buried bumper syndrome (n=10) Other complications (n=35) P value Gender Male 6 21 Female 4 14 Age (yr) 68.2± ± < Procedure place Inpatient 9 32 Outpatient 1 3 Communication Possible 2 3 Impossible 8 32 Diabetes mellitus (+) 3 6 ( ) 7 29 Underlying indication Central nervous 9 35 system disease Other disease day-mortality Occurrence of complications, weeks from insertion 18.6± ±13.3 Values are presented as n or mean±sd. 환자가 190명 (95.0%) 이었다. 술기가발달함에따라시술의안정성및효용성을인정받고있으나, PEG 관련합병증으로시술부위감염, 위장관출혈, 누출, 흡인성폐렴, 장마비, buried bumper 증후군, 괴사성근막염, 위결장누공등이있고발생빈도는각연구마다 16 70% 까지다양하게보고되며그중에서도시술부위감염이가장흔한합병증으로알려져있다. 2-5 본연구에서는 PEG 를시행한 200 명의환자중 45명 (22.5%) 에서합병증이발생하였고, 그중시술부위감염이 22명 (11.0%) 으로가장많이발생하였다. 그다음으로 buried bumper 증후군이 10명 (5%) 에서발생하였고, 위장관출혈 6명, 누출 2명, 흡인성폐렴 2명, 장마비와괴사성근막염, 위결장누공이각각 1명에서발생하였다. PEG 관련합병증이발생한 45명중 43명은내과적치료로호전되었으나 2명은수술적치료를병행하였다. 위장관출혈이발생한 6명중 5명은내시경소견에서다른합병증이없었고위루관삽입부의반대편에생긴궤양에서의출혈또는위루관삽입으로인한주변모세혈관의출혈로생각되어내부완충기의위치를조절하고프로톤펌프억제제주입및금식을시행한후호전되었고, 1명은시술다음날대량토혈과위루관으로 27

5 Korean J Helicobacter Up Gastrointest Res: Vol 14, No 1, March 2014 의출혈이동반되어내시경적지혈이불가능하여응급수술을시행하고내과적치료를병행하여호전되었다. 괴사성근막염이발생한환자는복벽외부로완충기가거의돌출되어있었고내시경과복부 CT에서위내벽과주위복벽근육및점막층의괴사가의심되어외과에의뢰하여응급수술을통해괴사된부위를제거하고보존적치료를지속하면서호전되었다. 위결장누공이발생한환자는통상적으로수술을시행하며최근에는내시경적봉합술로성공적으로치료한증례도보고되지만, 11 본증례에서는전반적인전신상태와대장의누공의크기가크지않은점등을고려하여내시경으로위루관을제거하고장기간완전비경구영양법, 항생제치료및중환자실집중치료를시행한후자발적폐쇄가이루어졌다. PEG 관련합병증의발생시기와위험인자에대해서는각합병증의종류에따라보고된바가있다. PEG 시술후통로가성숙되기까지 2 4 주가걸리는것으로알려져있으므로, 12,13 본연구에서도 4주를기준으로하여통로가성숙되기전에시술과정의문제로발생하는초기합병증과통로가성숙된이후위루관및상처관리의문제로발생하는후기합병증으로분류하였다. 가장흔한합병증인시술부위감염은다양한시기에나타날수있으나주로시술 2 4 주이내에발생하며, 위험인자로내시경시술자또는기구에의한감염, 예방적항생제미사용및환자의코인두굴상재균, 피부균에의한감염, 당뇨병과불량한영양상태, 숙주의면역저하로상처치유가늦어지는경우등이보고되었다 본연구에서도합병증간의위험인자를비교하기위해성별, 연령, 시술장소, 당뇨병유무, 기저질환, 의사소통가능유무등에대하여조사하였으나유의한차이점은발견되지않았다. 시술부위감염이발생한 22명중 17명에서원인균이동정되었는데, 그중 methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa 가가장많이발견되었다. 그러나시술부위감염이발생한 22명중 10명이시술 4주이후에발생해서기존보고보다발생시기가늦은경우가많았다. 이는주로 PEG 시술과정에서발생하는초기감염보다는불량한영양상태, 면역기능저하가동반된환자에서위루관의부주의한조작및소홀한상처관리로인한후기감염이늘어난결과로생각된다. Buried bumper 증후군은위루관의내부완충기가위벽이나복벽으로탈출하는경우로전체 PEG 관련합병증중 % 를차지하는드문합병증으로발생시기는대부분 3개월이후로시술후발생까지 15일에서 1년이상까지다양하게보고되고있다. 4,17,18 위험인자로는내부및외부완충기에과도한장력이가해지는경우, 영양상태가불량한경우, 상처치유가불량한경우, 성공적인장관영양으로인해유의한체중증가가있는경우가제시되었다. 2,12,13 또한 Sacks-Vine 위루관을사용 할경우 buried bumper 증후군이더많이발생한다는보고가있었으나최근에는다양한종류의위루관이관련있다고보고되어, 위루관의종류는 buried bumper 증후군발생에영향을끼치지않는것으로생각된다. 17,19 본연구에서는 PEG 시술후발생까지평균 18.6 주 ( 범위 2 48 주 ) 가걸렸고다른합병증에비해시술 4주이후에발생하는비율이유의하게높았으며 (P =0.035) 이는기존보고들과일치하고있다. 14,17,20 그러나전체 PEG 를시행한 200명의환자중 10명 (5%) 에서 buried bumper 증후군이발생해서이전의보고에비해발생빈도가높게측정되었다. 4,17,18 이는 PEG 시술이후에위루관의조작및상처소독과정에서과도한장력이가해진것이가장큰원인으로생각된다. PEG 시술후 2 4 주동안은통로가성숙되는시기이므로위루관이지나치게당겨지지않도록유의해야하고, 12,13 상처소독시에는복벽과외부완충기사이의공간을 5 mm 이상으로유지하는것이필요하다. 21 Buried bumper 증후군은대개위루관주위로의누출, 감염, 위루관의부동성및기능부전, 발열, 복통, 복부종괴등의증상으로발견되며, 17,20 buried bumper 증후군이의심될경우반드시내시경을통해확인해야한다. 본연구에서는위루관의기능부전으로발견된경우가가장많았고, 내시경소견에서내부완충기가상피조직으로완전히덮여서관찰되지않는경우가대부분이었다. 그러나내부완충기가관찰되지않아도통로가남아있는경우가있고위루관으로주입한물이잘통과하더라도내부완충기가정상적인위치에있는것이아니기때문에일단위루관을내강으로조심스럽게밀어서확인해보는것이중요하며, 만약위루관이움직이지않는다면반드시제거해야한다. 20 문제가발생한위루관을제거하는방법으로는국소마취만시행하여내벽의절개등없이경피적으로위루관을외부로수동적으로견인하여제거하는방법, 내시경적으로 needle knife 등을이용하여함몰된위벽을약간절개하고제거하는방법, 수술로제거하는방법, 위루관의제거없이위치만교정하는방법등이있다. 17,22-28 본연구에서경피적견인법을시도한 7명모두성공적으로위루관을제거하였고합병증도발견되지않았으므로비교적안전하게시도할수있는방법이라생각된다. 그러나무리한힘으로견인할경우복막염이나고름집, 괴사성근막염등이동반될가능성이있으므로내시경또는경피적견인법으로위루관이제거되지않을경우, 수술적치료를통한위루관의제거가필요할것이다. 결론적으로, 장기간경관영양법이필요한환자들에서 PEG 는안전하고효과적인방법으로인정받고있으나, 최근의료기술의발달로 PEG 를시행한환자들의생존기간이늘어나면서합병증의예방과관리에대한중요성이더욱강조되고있다. 이에저자들은본원에서 PEG 를시행한 200명의환자들을대상으 28

6 Hong Jae Kim, et al: A Study of Complications Related to Percutaneous Endoscopic Gastrostomy 로 PEG 관련합병증의빈도와특징에대해알아보고자하였고, 시술부위감염과 buried bumper 증후군이가장많은빈도로발생하는것으로밝혀졌다. 다른연구에비해서시술 4주이후에발생한시술부위감염과 buried bumper 증후군의빈도가높게나타났으며, 이는 PEG 시술과정의문제로발생하는초기합병증보다는 PEG 관리과정에서발생하는후기합병증이늘어난결과로생각된다. 그러나본원을포함한대부분의 1차, 2 차의료기관에서는간병인또는보호자들에의해경관영양공급과환자의체위변경이이루어지는것이현실이며, 이로인한부주의한위루관조작및소홀한상처관리가문제로지적되고있다. 이에대한대책으로본원에서는직접경관영양을시행하는간병인과보호자를대상으로위루관관리법에대한교육을월 1회정기적으로시행하고있으며, 상처소독은반드시수련의이상의료진이시행하도록규정하고있다. 또한위루관이과도하게당겨지는것을예방하기위해반드시 PEG 시술후위루관의고정길이를기록하고위루관외부에도고정선을표시하여복벽과외부완충기사이에 5 mm 이상의충분한공간을유지할수있도록하고있다. 그리고합병증의종류에상관없이증상이동반되면반드시복부단순촬영과내시경을시행하여완충기의위치와출혈, 천공여부를확인하여위루관의유지또는제거를결정해야하고, 복막염이나괴사성근막염등의진행이의심될경우에는복부 CT를추가로시행하여수술적치료여부를조기에결정해야할것이다. 앞으로 PEG 관련합병증에대하여더많은환자수와장기간추적관찰을토대로한전향적연구가필요할것이라생각되며, 이러한후속연구가지속되어장기간경관영양법이필요한환자에게 PEG 가더욱안전하고효과적인시술이될수있기를기원한다. REFERENCES 1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15: Sheehan JJ, Hill AD, Fanning NP, et al. Percutaneous endoscopic gastrostomy: 5 years of clinical experience on 238 patients. Ir Med J 2003;96: Grant DG, Bradley PT, Pothier DD, et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clin Otolaryngol 2009;34: Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987;93: Taylor CA, Larson DE, Ballard DJ, et al. Predictors of outcome after percutaneous endoscopic gastrostomy: a community- based study. Mayo Clin Proc 1992;67: Choi KW, Rhee JC, Jang JK, et al. Complications of percutaneous endoscopic gastrostomy and predictors of wound infection. Korean J Gastroenterol 2001;38: Nah YH, Kim DW, Yim CI, et al. Clinical review of percutaneous endoscopic gastrostomy. Korean J Intern Med 1992;42: Lee HH, Shim KN, Kwon JM, Jung SA, Yoo K. Complications of percutaneous endoscopic gastrostomy and risk factors of peristomal wound infection. Korean J Med 2004;67: Kim YS, Oh YL, Shon YW, et al. A case of buried bumper syndrome in a patient with a balloon-tipped percutaneous endoscopic gastrostomy tube. Endoscopy 2006;38(Suppl 2):E41- E van der Merwe WG, Brown RA, Ireland JD, Goddard E. Percutaneous endoscopic gastrostomy in children--a 5-year experience. S Afr Med J 2003;93: Hwang JH, Kim HW, Kang DH, et al. A case of endoscopic treatment for gastrocolocutaneous fistula as a complication of percutaneous endoscopic gastrostomy. Clin Endosc 2012;45: McClave SA, Chang WK. Complications of enteral access. Gastrointest Endosc 2003;58: Oh HJ, Shim KN, Choi HJ, et al. Contribution of nasal methicillin-resistant Staphylococcus aureus colonization to percutaneous endoscopic gastrostomy site infection and risk factors of wound infection. Korean J Gastroenterol 2007;49: Horiuchi A, Nakayama Y, Kajiyama M, Fujii H, Tanaka N. Nasopharyngeal decolonization of methicillin-resistant Staphylococcus aureus can reduce PEG peristomal wound infection. Am J Gastroenterol 2006;101: Chaudhary KA, Smith OJ, Cuddy PG, Clarkston WK. PEG site infections: the emergence of methicillin resistant Staphylococcus aureus as a major pathogen. Am J Gastroenterol 2002;97: Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis 2007;16: Lee TH, Lin JT. Clinical manifestations and management of buried bumper syndrome in patients with percutaneous endoscopic gastrostomy. Gastrointest Endosc 2008;68: Venu RP, Brown RD, Pastika BJ, Erikson LW Jr. The buried bumper syndrome: a simple management approach in two patients. Gastrointest Endosc 2002;56: Hogan RB, DeMarco DC, Hamilton JK, Walker CO, Polter DE. Percutaneous endoscopic gastrostomy--to push or pull. A prospective randomized trial. Gastrointest Endosc 1986;32: Horbach T, Teske V, Hohenberger W, Siassi M. Endoscopic therapy of the buried bumper syndrome: a clinical algorithm. Surg Endosc 2007;21: Löser C, Aschl G, Hébuterne X, et al. ESPEN guidelines on artificial enteral nutrition--percutaneous endoscopic gastrostomy (PEG). Clin Nutr 2005;24:

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar