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Endoscopic bariatric therapy 이항락한양대학교의과대학내과학교실 Hang Lak Lee Department of Internal Medicine, Hanyang University Hospital, Seoul, Korea 서론 비만은과도한지방이축적되어있는복잡한대사성질환이며다양한질환과연관되어있다.

1 Endoscopic bariatric therapy 이항락한양대학교의과대학내과학교실 Hang Lak Lee Department of Internal Medicine, Hanyang University Hospital, Seoul, Korea 서론 비만은과도한지방이축적되어있는복잡한대사성질환이며다양한질환과연관되어있다. 기존의비만치료는생활습관교정, 식사조절, 운동과몇개의약물치료에의존했으나이러한방법은체중감량효과가떨어지는경우가많고체중감량효과가있더라고그지속성에문제가있었다. 따라서좀더적극적인치료방법이필요하게되었다. 고도비만환자에게복강경을이용한비만수술이소개되고시행되고있지만수술에따른 morbidity, mortality 등을무시할수없고장내구조가비가역적으로변한다는문제를가지고있다. 따라서비만치료로덜침습적인다양한내시경적비만치료방법이소개되고있으며본고에서는그방법들에대해소개하고장점과한계점에대해알아보고자한다. 본론 비만의내시경적치료는크게위용적을인위적으로작게만드는 restrictive 방법과영양분을흡수를 줄이는 bypass devices 방법으로구분할수있다. I. Restrictive methods 1. Intragastric balloon (Figure 1) 위내풍선을삽입해풍선을부풀려서경구음식섭취량을줄이려는방법이며, 가장먼저시작된내시경치료방법이다. 처음에여러풍선이개발되었으나여러가지합병증으로시장에서퇴출이되었으며현재가장많이연구가진행된풍선은 BioEnteric intragastric Balloon (BIB) (Allergan, Irvine, California, 38 대한간학회 The Korean Association for study of the Liver

이항락 Endoscopic bariatric therapy Figure 1. Intragastric balloon. USA) 이다. 이풍선은구형의실리콘으로제작된풍선으로 6개월정도위산분해에견딜수있다고되어있다. 1 시술방법은내시경을통해위로삽입후에 400 cc에서 700 cc가량의생리식염수와메틸렌블루가혼합된액체를풍선안으로주입해풍선을부풀리게하는방법이다.

2 이항락 Endoscopic bariatric therapy Figure 1. Intragastric balloon. USA) 이다. 이풍선은구형의실리콘으로제작된풍선으로 6개월정도위산분해에견딜수있다고되어있다. 1 시술방법은내시경을통해위로삽입후에 400 cc에서 700 cc가량의생리식염수와메틸렌블루가혼합된액체를풍선안으로주입해풍선을부풀리게하는방법이다. 메틸렌블루를혼합하는이유는만약에풍선이터지는경우에소변색깔을변하게만들어조기진단이가능하게하기위해서이다. Imaz 등 2 에의한 3,698명의환자를대상으로한 meta분석결과를소개하면시술 6개월후에평균 14.7 kg의체중감소, 체질량지수는 5.7 kg/m 2 가감소되었다. 4.2% 의환자에서심한오심과구토로인해조기에풍선을제거했다. 드물지만 0.8% 에서장폐색이, 0.1 % 에서위천공이발생했다. Forlano 등 3 은풍선삽입에의한대사변화에대해연구했다. 평균체질량지수가 43.1 ± 8 kg/m 2 인총 130명의환자를대상으로한전향적인연구에서 10명의환자가복통및구토로조기에풍선을제거했으며 6개월간관찰시평균체중이 kg에서 kg으로통계적으로의미있게감소했다. 고도비만환자비율도 23% 에서 8% 로감소했으며동시에체질량지수 30 kg/m 2 환자도 0% 에서 19% 로증가했다. 혈당수치, 중성지방수치, ALT 수치등도의미있는변화를보였다. 평균 22개월간추적관찰시 50% 환자에서체중이다시증가했으며 39% 환자는체중유지가가능했으며 11% 의환자에서는추가적인체중감소가있었다. 따라서풍선제거후체중증가가문제이며 Dastis 등은풍선제거후 4.8 년기간을추적한결과단지 25% 에서체중이그대로유지되는것으로보고했다. 따라서이러한문제를해결하고자 Dumonceau 등 4 은반복적인풍선삽입에대해연구했으며그결과는두번째풍선삽입은좀더적은체중감량효과가있었으며좀더많은합병증발생비율을보였다. 2. Transoral gastroplasty (Figure 2) Transoral gastroplasty (TOGa; Satiety, Palo Alto, California, USA) 는 full-thickness plication device를이용해위소만부를결찰해주어위내강을좁게만들어서비만치료에이용하는방법이다. 흡인기를통 39

2016 대한간학회추계 Single Topic Symposium Figure 2. Transoral gastroplasty (TOGA) sleeve stapler. A, The gastroscope is positioned in retroflexion to visualize the stapler at the gastroesophageal junction.

3 2016 대한간학회추계 Single Topic Symposium Figure 2. Transoral gastroplasty (TOGA) sleeve stapler. A, The gastroscope is positioned in retroflexion to visualize the stapler at the gastroesophageal junction. The retraction wire (arrow) helps to align the greater curvature optimally. B, Endoscopic view demonstrates that the stapler has been opened and is ready for tissue acquisition by using vacuum pods. C, With suctioning, the stomach is collapsed, and tissue from the opposing walls is acquired in the vacuum pods. D, The stapler is closed and fired, creating a full-thickness placation, as shown in E. 해위의전벽과후벽을만나게하고 stapler를사용해서반복적으로위주름을이용해서후벽과전벽을만나게하는시술이다. 처음으로나온사람을대상으로한연구에서는 6개월간 percentage excess weight loss 가 24.4% 에서 46% 로조사되었고, stapler 사이가벌어지는일이발생할수있는데 1 세대기구인경우 6개월추적기간동안 76% 의환자에서발생했으나 2세대기구에서는 36% 로향상된결과를보여주고있다. 5 평균시술시간은 2시간이었으며시술에따른중요합병증은없었다. 유럽에서시행한 67명을환자를대상으로한다기관연구 6 에서 1년동안 percentage of excess weight loss가평균 38.7 ± 17.1% 였다. 3. Endoluminal vertical gastroplasty (EVG) (Figure 3, 4) EVG는 Bard EndoCinch device (C.R. Bard, Murray Hill, NJ) 을통해시술이된다. 7 시술방법은진단내시경선단부에금속캡슐을부착시킨후, 위벽에이캡슐을부착시킨후 T-tag suture 사용해서 suture를시행한다. 반복적으로시행하면서위공간을좁게만드는방법이다. 64명의환자를대상으로한연구 8 에서 12개월동안 percentage of excess weight loss가 58.1 ± 19.9 % 였다. 12개월후추적내시경검사에서 72% 의환자에서 suture가부분적으로또는완전히분리되었다. 따라서시술후이장치의지속 40 대한간학회 The Korean Association for study of the Liver

이항락 Endoscopic bariatric therapy 적인유지에대한문제점이대두되고있다. II.

Roux-en-Y에의한소장우회술의대사질환개선및체중감소효과가있는점을감안해서고안된방법이다.

Endobarrier gastrointestinal liner (GI Dynamics Inc.

이기구는 60 cm 길이의프라스틱물질로된자가확장형구조물이다. 내시경및 X Figure 3.

(EndoCinch). A, Aspirate tissue just below the Z-line.

4 이항락 Endoscopic bariatric therapy 적인유지에대한문제점이대두되고있다. II. Endoscopic gastrointestinal bypass devices 이방법은 Roux-en-Y에의한소장우회술의대사질환개선및체중감소효과가있는점을감안해서고안된방법이다. 소장점막과음식물이만나지못하게인위적으로그물스탠트같은긴구조물을소장에삽입하는방법이다. 이방법은체중감량효과와함께당대사에좋은역할을하는것으로알려져있다. EndoBarrier gastrointestinal liner (Figure 5). Endobarrier gastrointestinal liner (GI Dynamics Inc., Lexington, MA, USA) 가가장처음으로사람에게시행된십이지장공장우회기구이다. 이기구는 60 cm 길이의프라스틱물질로된자가확장형구조물이다. 내시경및 X Figure 3. Endoluminal suturing using endoluminal vertical gastroplasty (EndoCinch). A, Aspirate tissue just below the Z-line. B, Needle with preloaded suture advanced. C, Cinching/deployment device advanced. D, Final appearance of placation in cardia. Figure 4. Endoscopic suturing for vertical gastroplasty. 41

2016 대한간학회추계 Single Topic Symposium Figure 5.

B, The GI Dynamics DJBS (duodenojejunal bypass sleeve).

mucosa of the duodenum and proximal jejunum.

D, With the sleeve in place, the retaining device is then fully deployed in the duodenal bulb to anchor the device.

5 2016 대한간학회추계 Single Topic Symposium Figure 5. A, A depiction of the GI Dynamics sleeve in place preventing ingested contents from contacting the mucosa of the duodenum and proximal jejunum. B, The GI Dynamics DJBS (duodenojejunal bypass sleeve). It consists of a nitinol retaining device and a 60-cm plastic sleeve that preventscontact of food with bile and pancreatic secretions and the mucosa of the duodenum and proximal jejunum. C, The sleeve system is passed over a guidewire and then, under direct visualization, the sleeve is deployed over a deeply placed guidewire. D, With the sleeve in place, the retaining device is then fully deployed in the duodenal bulb to anchor the device. The endoscope is used to visualize placement of the retaining device. E, For retrieval of the sleeve, a cap is placed at the tip of the upper endoscope. The nitinol retaining device is then grasped with a forceps and brought into the cap. The entire apparatus is then removed through the mouth. 선투시하에서시행하며근위부공장에서부터십이지장까지걸쳐서위치시키며원위부로의이동을방지하기위해십이지장에고정을시켜야한다 년도 12명의환자를대상으로한연구 9 에서시술은모두성공적으로이루어졌으며 10명은연구목표기간인 12주까지유지되었으나 2명에서심한복통으로 42 대한간학회 The Korean Association for study of the Liver

6 이항락 Endoscopic bariatric therapy 중도에제거했다. 중요한합병증은없었으며 percentage of excess weight loss 23.6 이었다. 최근 21명을대상으로한연구 10 에서 38% 의환자에서중도에기구를제거했다. 기구를제거한주요원인은치유되지않은심한복통, 출혈, 고정구이탈, 소장폐색등이었다. 결국이기구는비교적높은비율로나타나는중도제거율이문제로되어있으며향후이에대한보완이필요하다. 11,12 결론 현재소개되고있는비만에대한내시경적치료방법은비록체중감소의효과가있다고해도여러문 제점이제시되고있다. 단기간에는효과가있다고할수있으나지속적인체중유지면에서는미흡한점 이많으며어떤환자는대상으로시술을해야하는지에논의가필요하다고생각한다. REFERENCES 1. Imaz I, Martínez-Cervell C, García-Alvarez EE, Sendra-Gutiérrez JM, González-Enríquez J. Safety and effectiveness of the intragastric balloon for obesity. A meta-analysis. Obes Surg 2008;7: Kumar N, Thompson CC. Endoscopic solutions for weight loss. Curr Opin Gastroenterol 2011;27: Forlano R, Ippolito AM, Iacobellis A, Merla A, Valvano MR, Niro G, et al. Effect of the BioEnterics intragastric balloon on weight, insulin resistance, and liver steatosis in obese patients. Gastrointest Endosc 2010; 71: Dumonceau JM, François E, Hittelet A, Mehdi AI, Barea M, Deviere J. Single vs repeated treatment with the intragastric balloon: a 5-year weight loss study. Obes Surg 2010;20: Moreno C, Closset J, Dugardeyn S, Baréa M, Mehdi A, Collignon L, et al. Transoral gastroplasty is safe, feasible, and induces significant weight loss in morbidly obese patients: results of the second human pilot study. Endoscopy 2008;40: Familiari P, Costamagna G, Bléro D, Le Moine O, Perri V, Boskoski I, et al. Transoral gastroplasty for morbid obesity: a multicenter trial with a 1-year outcome. Gastrointest Endosc 2011;74: Ryou M, Ryan MB, Thompson CC. Current status of endoluminal bariatric procedures for primary and revision indications. Gastrointest Endosc Clin N Am 2011;21: Fogel R, De Fogel J, Bonilla Y, De La Fuente R. Clinical experience of transoral suturing for an endoluminal vertical gastroplasty: 1-year follow-up in 64 patients. Gastrointest Endosc 2008;68: Rodriguez-Grunert L, Galvao Neto MP, Alamo M, Ramos AC, Baez PB, Tarnoff M. First human experience with endoscopically delivered and retrieved duodenal-jejunal bypass sleeve. Surg Obes Relat Dis 2008;4: Gersin KS, Rothstein RI, Rosenthal RJ, Stefanidis D, Deal SE, Kuwada TS, et al. Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates. Gastrointest Endosc 2010; 71: Majumder S, Birk J. A review of the current status of endoluminal therapy as a primary approach to obesity management. Surg Endosc 2013;27: Coté GA, Edmundowicz SA. Emerging technology: endoluminal treatment of obesity. Gastrointest Endosc 2009;70:

02 What's hot-5.hwp

02 What's hot-5.hwp 대한내과학회지 : 제 94 권제 1 호 2019 https://doi.org/10.3904/kjm.2019.94.1.5 What s hot? 비만의내시경치료 한양대학교의과대학내과학교실 윤재훈ㆍ이항락 Current Status of Bariatric Endoscopy in Obesity Control Jai Hoon Yoon and Hang Lak Lee Department