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1 대한내시경복강경외과학회지 Vol. 14. No. 1, 2011 급성합병성담낭염의치료에서 PTGBD 의유용성 원저 을지대학교병원외과 김정혁ㆍ박혜원ㆍ이문수ㆍ이민구ㆍ조병선ㆍ박주승 Impact of PTGBD on Patients with Acute Complicated Cholecystitis: Consecutive 4,000 Cases of Laparoscopic Cholecystectomy Jung Hyuk Kim, M.D., Hye Won Park, M.D., Mun Su Lee, M.D., Min Koo Lee, M.D., Byung Sun Cho, M.D., Joo Seung Park, M.D. Department of Surgery, Eulji University Hospital, Daejeon, Korea Purpose: The aim of this study was to determine the advantage of adequate PTGBD in acute complicated cholecystitis patients. Methods: We performed a retrospective review of a collected database from September 2001 to July Acute cholecystitis with gangrene or perforation was defined as acute complicated cholecystitis. A PTGBD was performed for these patients immediately after the diagnosis using US or CT and then a tubogram was performed after 5 7 days. After evaluating the gallbladder (GB) and common bile duct (CBD) with a tubogram, we removed the drainage tube and the patients underwent a LC after readmission. Results: Three hundred seventy four of the 893 patients who were diagnosed with acute cholecystitis underwent PTGBD. While 19 (3.2%) of the total acute cholecystitis patients were converted to open cholecystectomy due to severe inflammation, 14 (3.7%) of the acute complicated patients were converted to open cholecystectomy. In 79 patients, the pre-operative tubogram showed the presence of CBD stone and so ERCP was performed. There were no post-operative deaths. Conclusion: PTBGD in acute complicated cholecystitis patients allows the early relief of acute cholecystitis symptoms. This allows sufficient evaluation and treatment for CBD during the PTGBD state. Furthermore, this decreases the mortality and morbidity in the high-risk patients due to sufficient evaluation and management of the underlying critical disease, which allows elective cholecystectomy when the patients is in better condition for surgery. Therefore, PTGBD can be useful for acute complicated cholecystitis. Key words: Laparoscopic cholecystectomy, Complicated acute cholecystitis, Percutaneous transhepatic gallbladder drainage (PTGBD) 중심단어 : 복강경담낭절제술, 급성합병성담낭염, 경피간담낭배액술 서 담낭염환자에서복강경담낭절제술 (laparoscopic cholecystectomy: LC) 은표준치료로써지난십여년간시행되어오고있다. 복강경담낭절제술이담낭염의표준술식으로인정받은이후로급성합병성담낭염환자에서도진단즉시가능한빠른시기에복강경또는개복담낭절제술을시행하는것이표준술식으로그동안많은병원의외과의들에의해시행되어왔으나급성합병성담낭염환자의경우담낭주변의심한염증반응으로인한수술의어려움으로개복술로의높은전환율과수술전후의높은합병증발생등의문제가여전히남아있다. 그래서최근급성합병성담낭 론 통신저자 : 박주승, 대전시서구둔산동우편번호 : 을지대학교병원외과 Tel: , Fax: jspark@eulji.ac.kr 염환자에서급성염증기에경피간담낭배액술 (percutaneous transhepatic gallbladder drainage: PTGBD) 을이용한치료의유용성이점차제기되어왔다. 1-4 그러나아직도 PTGBD 의정확한대상및시행후적절한제거시기와수술시기에대해서는표준술식이없이각임상의들의경험에의지해시행되고있다. 이에우리는본원에서단일외과의에의한장기간의많은환자들에게서시행된 PTGBD 후의복강경담낭절제술의결과를통해 PTGBD를이용한치료방침과유용성에대해보고하고자한다. 대상및방법본원외과에서 1992년 1월부터 2009년 3월까지시행된복강경담낭절제술환자 4,700명중기록이가능했던 2001 년 9월부터 2008년 6월까지의 2,067명의환자를대상으로후향적인분석을시행하였다. 상기기간중담낭염으로수술을시행했던환자들은환자의연령, 수술기왕력, 타질병기왕력등에관계없이모두일차적으로복강경담낭절제술 12

2 김정혁외 5 인 : 급성합병성담낭염의치료에서 PTGBD 의유용성 13 Table 1. General feature of patients Biliary colic Hx. Previous abdominal op. Hx. Past medical Hx. DM Acute cholecystitis Biliary scan PTGBD ERCP Open cholecystectomy Yes (n, %) No (n, %) 1,316 (63.7) 672 (32.5) 812 (39.3) 238 (11.5) 893 (43.2) 106 (5.1) 374 (18.1) 427 (20.7) 67 (3.2) 751 (36.3) 1,395 (67.5) 1,255 (60.7) 1,829 (88.5) 1,174 (56.8) 1,956 (94.9) 1,693 (81.9) 1,640 (79.3) 2,000 (96.8) DM = diabetes mellitus; PTGBD = percutaneous transhepatic gallbladder drainage; ERCP = endoscopic retrograde cholangiopancreatography. 이시도되었고단일외과의에의해집도되었다. 담낭용종및종양으로수술한환자는제외하였다. 급성담낭염의진단은이학적검사상심한우상복부통증과압통을동반한 Murphy sign 양성, 초음파및복부컴퓨터단층촬영 (CT) 상담낭벽의과도한비후및팽창, 담낭점막의조영증강, 담낭주위의수액저류, 담낭내또는담낭벽의가스형성, 담낭주위의농양형성, 간담도스캔 (DISIDA scan) 상양성소견등으로진단하였고초음파나복부컴퓨터단층촬영상천공성담낭염이나괴사성담낭염으로진단된경우나의심되는경우를급성합병성담낭염으로정의하였다. 급성담낭염환자중입원후항생제치료에도불구하고담낭염의증상이 24시간이상지속되는경우에합병성담낭염의위험이있는것으로보고, 급성합병성담낭염으로진단된환자또는합병성담낭염의위험이있는환자는즉시 PTGBD를시행하였고, 환자의증상이소실되고배액관으로나오는담즙이정상이되면 PTGBD후 5 7일사이에 tubogram을시행하여총담관과담낭관에대한평가후배액관을제거하였다. 복강경담낭절제술은 PTGBD 를제거한뒤퇴원하였다가평균퇴원후 10 14일사이에재입원하여시행하였다. 일부담낭관에담석이막혀염증이호전되지않은경우에서는 PTGBD를제거하지않고바로수술을시행하였다. 모든환자에대한자료는전향적으로수집된간담췌데이터베이스를이용하였다. 환자의과거력상수술의위험성을증가시킬수있는당뇨, 고혈압을포함한심혈관질환, 뇌혈관질환, 만성폐쇄성폐질환중 2가지이상의질환을동반한환자를합병성내과적병력을지닌환자로분류하였고, 70세이상의고연령군과 70세미만환자중합병성내과적병력을가진환자를합쳐서수술의고위험군으로정의하였다. Table 2. Cause of conversion in cholecystitis patients Anatomical anomaly Unknown 22 (33) 21 (31) 9 (13) 6 (9) 67 (100) conversion rate: 67/2,067 = 3.24% conversion rate d/t inflammation: 1.74%. 1) 환자의일반적특성 결 담낭염으로수술을시행한 2,067명의환자의평균연령은 52.5세 (14 89) 였으며여성이 1,157명 (55.0%) 으로남성 (901명, 45.0%) 보다많았다. 1,174명 (56.8%) 이만성담낭염환자였고, 893명 (43.2%) 이급성담낭염환자였다. 급성담낭염환자중 103명 (11.5%) 의환자는비결석성담낭염환자였다. 과거력상복부수술의기왕력이있는환자는 672명 (32.5%) 이었고, 급성합병성담낭염으로진단되어 PTGBD 를시행한환자는 374명 (18.1%) 였다 (Table 1). 평균수술시간은 25.8분 (±11.6) 이었으며남성 (27.9±12.6 분 ) 이여성 (24.2±10.6분) 에비해오래걸렸으며 (p=0.001), 급성합병성담낭염환자에서는 34.9분 (±13.6) 으로급성담낭염 (30.0±13.3분) 이나만성담낭염 (22.8±9.1) 에비해유의하게길었다 (p=0.001). 2) 개복술로의전환율 2,067명의환자중 67명의환자에서수술도중개복술로의전환이있어전환율은 3.2% 였다. 원인은상복부수술기왕력으로인한유착이가장많았으며 (22명, 33.0%), 심한염증 (21명, 31.0%), Mirizzi's syndrome을포함한해부학적구조이상 (15명, 22.0%), 악성종양의심 (3명, 4.5%), 총담관손상 (3명, 4.5%) 등이었다. 따라서상복부수술기왕력으로인한개복술이아닌심한염증으로인한개복전환율은 1.74% 였다 (Table 2). 급성담낭염환자 893명중개복술로의전환율은 5.2% (46명) 로심한염증으로인한경우가 41.0% (19명) 으로가장많았으며, 상복부수술기왕력 (12명, 26.0%), Mirizzi's syndrome을포함한해부학적구조이상 (10명, 21.5%), 악성종양의심 (2명, 4.0%), 총담관손상 (3명, 6.5%) 등의원인이있어, 해부학적구조이상이아닌염증으로인한개복전환율은 3.2% 였다 (Table 3). 과

3 14 대한내시경복강경외과학회지제 14 권제 1 호 2011 Table 3. Cause of conversion in acute cholecystitis Anatomical anomaly 12 (26) 19 (41) 7 (15) 2 (4) 46 (100) conversion rate: 46/893 = 5.2% conversion rate d/t inflammation: 29/893 = 3.2%. Table 5. Mortality rate PTGBD No Yes Chronic cholecystitis Acute cholecystitis Operative mortality: 0%. Hign risk patients No 1,348 (85.4) 230 (14.6) 981 (62.2) 597 (37.8) 1,578 Yes 345 (70.6) 144 (29.4) 193 (39.5) 296 (60.5) 489 1, , ,067 Table 4. Cause of conversion in acute complicated cholecystitis 7 (25) 14 (50) 3 (10.7) 1 (3.6) 28 (100) conversion rate: 28/374 = 7.5% conversion rate d/t inflammation: 14/374 = 3.7%. 급성합병성담낭염으로 PTGBD 시행한 374명중개복한환자는 28명으로 7.5% 의개복전환율을보였고이중심한염증으로인한경우는 3.7% (14명) 였다 (Table 4). 3) 수술전총담관에대한적절한확인및치료 수술전총담관담석이의심되어 ERCP를시행한환자는 427명으로그중임상적으로담도염이나담석췌장염증상을보이거나혈액검사상빌리루빈이나 ALP, LDH의증가또는초음파나복부 CT상담석이나담관의확장이보이는 348명의환자에서 ERCP를시행하여 244명 (70.0%) 의환자에서총담관담석을발견하여제거하였고, 임상적또는혈액검사, 초음파, 컴퓨터단층촬영상에서는의심되지않았으나 PTGBD 후시행한 tubogram 상에서총담관담석이의심이되어 ERCP를시행한환자는 79명으로이중 59명 (74.7%) 에서총담관담석이발견되어제거되었다. 4) 수술사망율 2,067명의환자중 70세미만이면서합병성내과적병력을가진환자 177명과 70세이상의환자 312명을합친수술고위험군의환자는총 489명이었다. 수술고위험군환자중 60.5% 인 296명의환자는급성담낭염진단을받은환자이고, 이중 144명에서는급성합병성담낭염진단을받고 PTGBD를시행을받은후모든환자에게서복강경담낭절 제술을시행하였고수술후이기간중시행한개복담낭절제술을포함하여도수술사망은없었다 (Table 5). 고 과거급성담낭염의주치료는개복담낭절제술이었으나 1987년 Mouret에의해도입된이래현재에는복강경담낭절제술이급성담낭염의표준적치료법으로인정받고있다. 5-8 복강경담낭절제술시행초기에는급성담낭염이나상복부수술병력등이금기증으로여겨져왔으나외과의의경험의축적과수기의발달에따라복강경수술이급성담낭염의수술에서도표준술식이되었다. 그러나급성담낭염의경우과도한담낭팽만이나담낭주위의염증과주위장기와의유착, 불명확한해부학적구조 ( 담낭관이나총수담관등 ), 신생혈관의발달등으로인해수술중과다한출혈이나담관손상등으로개복수술로전환되는경우가많았다. 9 따라서수술사망률을높이는기왕증의확인과치료가가능하고총담관의결석유무와처치가가능하며개복술로의전환이최소화될수있는치료방법으로수술전담낭배액술이급성합병성담낭염의치료에서적극적으로고려되고있다. 10 본원에서는급성합병성담낭염으로진단또는의심되는모든환자에서 PTGBD를시행하였는데 24시간이내에대부분의환자들에게서통증을포함한증상의호전을보였다. 이는 PTGBD를통한배액으로급성염증의소실과팽만된담낭의감압으로인해증상을호전시킨것으로보인다. 또한 PTGBD 시행일기준약 3주전후에담낭절제술을시행하였는데, 이시기가조기에수술을시행하는것보다개복전환율이나수술후의합병증이적기때문이다. 10 본연구에서의대상환자의개복술로의전환율은 3.2% 였고, 이중급성담낭염환자에서의개복률은 5.2% (46/893) 였으나상복부수술기왕증이아닌염증으로인한실질개복 찰

4 김정혁외 5 인 : 급성합병성담낭염의치료에서 PTGBD 의유용성 15 전환율은 3.2% 이었으며, 급성합병성담낭염환자에서염증으로인한개복율은 3.7% (14/374) 로급성담낭염환자에서보이는개복전환율과비슷한수치를보이며, 다른연구들에서보인개복전환율의 16 32% 에비해현저히낮은것을볼수있다. 6,7 이는 PTGBD에의해담낭과주변의염증을최소화했기때문으로생각된다. 급성담낭염에서조기에복강경담낭절제술을시행함으로써개복수술로의전환과이에대한합병증의발생을감소시키고있지만개복술로의전환이필요한경우가여전히 6 32% 남아있고개복술시수술에따른사망률도 3.4% 보고되었다. 11 특히고령이나동반질환이있는고위험군에서는 6 46% ( 평균 15%) 의수술사망률이보고되고있다. 1-3,12-17 이에대해최근에는경피간담낭조루술을시행하고환자의상태가호전된후안전하게담낭절제를시행한결과가보고되고있고 18 본원에서도 PTGBD를시행한급성합병성담낭염을포함한급성담낭염환자에서담낭절제술을시행한예와이기간중개복담낭절제술을시행한전예에서현재까지사망한환자는없어 0% 의사망률을보이고있다. 담낭결석으로수술하는환자에서총담관결석의동반비율은 5 20% 정도로알려져있는데 19,20 예측인자로는오한, 발열, 황달의증상, 확장된총담관직경, 간효소및빌리루빈상승, 담석의크기가작으면서다발성인경우, 췌장염이동반된경우등이있다 이를확인하기위해서는혈액검사, 초음파, 담도전산화촬영, MRCP 등이이루어지지만가장좋은방법은 ERCP이다. 하지만 ERCP는침습적인검사로서모든환자에게시행하기는어려워혈액검사나초음파검사등에서총담관결석이의심되는상황에서만 MRCP와같이제한적으로시행되고있다. 25 Son 등 26 의연구에의하면 PTGBD 후의담낭조영술로담도의해부학적구조를알수있다는장점과함께총담관결석을진단하는데유용하게사용될수있다고했다. 본연구에서도급성합병성담낭염환자에서 US나 CT상에서는정상소견을보였으나 PTGBD 시행후 79명의환자에서담낭조영술에서총담관결석이의심되거나확진되어 ERCP 를시행하였고, 이중 59명 (74.7%) 에서결석이발견되었는데이는전체 ERCP상발견된 303명의환자중 19.5% 에해당되는수치로 PTGBD가수술전총담관결석의진단에도움을준다는것과수술시총담관촬영이필요치않고총담관결석이발견된경우총담관에대한수술이필요치않아환자의회복및예후에큰장점을보인다는것을알수있다. 결 급성합병성담낭염환자에서 PTGBD 시행후경과적복강경담낭절제술을시행함으로써급성담낭염의증상을조기에소실시키고환자의기왕증을확인, 치료함으로써수 론 술합병증과사망률을낮출수있으며총담관결석에대한확인과처치가가능하여치료의적절성과편의성이확보되며담낭주위와의유착을최소화하여개복담낭절제술로의전환을최소화할수있어 PTGBD 시행후경과적복강경담낭절제술을시행하는것이급성합병성담낭염환자의치료에많은도움이되리라생각된다. 참고문헌 1) Werbel GB, Narhrwold DL, Joehl RJ, Vogelzang RL, Rege RV. Percutaneous cholecystostomy in the diagnosis and treatment of acute cholecystitis in the high-risk patient. Arch Surg 1989;124: ) Malone DE, Burhenne HJ. Advantages and disadvantages of the newer interventional procedures for the treatment of cholecystolithiasis. Hepatogastroenterology 1989;36: ) Van Steenbergen W, Ponette E, Marchal G, Pelemans W, Aerts R, Fevery J, et al. Percutaneous transhepatic cholecystostomy for acute complicated cholecystitis in elderly patients. Am J Gastroenterol 1990;85: ) Masanori S, Makoto T, Yutaka A. Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg 1998;22: ) Zucker KA, Flowers JL, Bailey RW, Graham SM, Buell J, Imbembo AL. Laparoscopic management of acute cholecystitis. Am J Surg 1993;165: ) Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998;351: ) Habib FA, Kolachalam RB, Khilnani R, Preventza O, Mittal VK. Role of laparoscopic cholecystectomy in the management of gangrenous cholecystitis. Am J Surg 2001;181: ) Kim HD, Kim HO, Shin JH. Comparison of early versus delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) for patient with complicated acute cholecystitis. J Korean Surg Soc 2007;73: ) Kim JS, Cho BS, Kang YJ, Park JS. Effect of percutaneous cholecystostomy on laparoscopic cholecystectomy. J Korean Surg Soc 2001;60: ) Kim HO, Son BH, Shin JH. Impact of delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis. Surg Laparosc Endosc Percutan Tech 2009;19: ) Glenn F. Acute cholecystitis. Surg Gynecol Obstet 1976;143: ) Glenn F. Surgical management of acute cholecystitis in patients 65 years of age and older. Ann Surg 1981;193: ) Huber DF, Martin EW Jr, Cooperman M. Cholecystectomy in elderly patients. Am J Surg 1983;146: ) Thorton JR, Heaton KW, Espiner HJ, Eltringham WK. Empyema of the gallbladder: reappraisal of a neglected

5 16 대한내시경복강경외과학회지제 14 권제 1 호 2011 disease. Gut 1983;24: ) Houghton PW, Jenkinson LR, Donaldson LA. Cholecystectomy in the elderly: a prospective study. Br J Surg 1985;72: ) Markinen AM, Nordback I. Conventional cholecystectomy in elderly patients. Ann Chir Gynaecol 1993;82: ) Prousailidis J, Fahadidis E, Apostolidis S, Katsohis C, Aletras H. Acute cholecystitis in aged patients. HPB Surg 1996;9: ) Klimberg S, Hawkins I, Vogel SB. Percutaneous cholecystostomy for acute cholecystitis in high-risk patients. Am J Surg 1987;153: )Thierry M, Simon M, Alain C, Claude R, Nathalie B, Jean-Marie H, et al. Diagnosis of asymptomatic common bile duct stones: preoperative endoscopic ultrasonography versus introperative cholangiography - a multicenter, prospective controlled study. Surgery 1988;124: ) Rattner DW, Ferguson C, Warshaw AL. Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1993;217: ) Matthew EC, Lori S, Crolyn K, Wells MA, Danna KA, Mark T. Prediction of bile duct stone and complication in gallstone pancreatitis using early laboratory trends. Am J Gastroenterol 2001;96: ) Kenny PK, William L. Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy? Am J Surg 1996;171: ) Réemi H, Thierry P, Bernadette D, Marcelo S, Jean-Françcois S. Predicting common bile duct lithiasis: determination and prospective validation of a model predicting low risk. Am J Surg 1995;170: ) Majeed AW, Ross B, Johnson AG, Reed MWR. Common duct diameter as an independent predictor of choledocholithiasis: Is it useful? Clin Radiol 1999;54: ) Eom KS, Kim YB, Song YL. Role of endoscopic retrograde cholangiopancreatography (ERCP) before and after LC relating to prediction of CBD stone. Korean J Gastroenterol 2002; 39: ) Son DH, Kim KS, Kim KH. Beneficial effect of cholecystography following PGBD for complicated acute cholecystitis: detection of unsuspected CBD stone. J Korean Surg Soc 2009;76:43-45.

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic