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1 대한내시경복강경외과학회지 Vol.. No. 2, 28 대장ㆍ직장암의복강경대장절제술의초기경험 원저 가톨릭대학교의과대학외과학교실 최승혜ㆍ윤상섭ㆍ김성근ㆍ강원경ㆍ이윤석ㆍ이인규ㆍ조현민ㆍ안창혁김형진ㆍ박종경ㆍ오승택ㆍ이성ㆍ김준기 Initial Experience with Colorectal Resection for Treating Colorectal Cancer Seung Hye Choi, M.D., Sang Seob Yun, M.D., Sung Geun Kim, M.D., Won Kyung Kang, M.D., Yun Seok Lee, M.D., In Kyu Lee, M.D., Hyeon Min Cho, M.D., Chang Hyuk Ahn, M.D., Hyung-Jin Kim, M.D., Jong Kyung Park, M.D., Seong Taek Oh, M.D., Seong Lee, M.D., Jun-Gi Kim, M.D. Department of Surgery, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea Purpose: The aim of this study is to evaluate the safety and feasibility of laparoscopic colorectal resection through our initial experience with laparoscopic surgery for treating colorectal cancer, as compared with open surgery. Methods: Between February 26 and August 28, fifty consecutive laparoscopic colorectal operations were performed by one colorectal surgeon who previously had no experience with laparoscopic colorectal surgery, and we retrospectively compared this with forty patients who had undergone open surgery by the same operator. The collected data was the clinicopathologic characteristics, the operation time, the perioperative complications, the oncologic outcomes and the postoperative recovery results. Results: There were no significant differences for the tumor staging, the tumor location, the number of harvested lymph nodes, the resection margin, perioperative complications, the recurrent rate and the operative time between the two groups. The laparoscopic surgery group had significant benefits for the time of first flatus (3.7 days vs. 4.7 days, respectively, p=.4), first water intake (4.7 days vs.. days, respectively, p=.3), start of diet (.4 days vs. 7. days, respectively, p=.2), and the length of the postoperative hospital stay (.3 days vs. 8.8 days, respectively, p=.4). The operation time in the late period of the learning curve for the laparoscopic surgery group seemed to be shorter than that of the early period, although there was no significant difference between the two periods. Conclusion: Our initial experience with laparoscopic colorectal resection for treating colorectal cancer seems to be acceptable in terms of recovery and the postoperative morbidity. As we gain more experience and determine the long term follow-up oncologic outcomes, laparoscopic surgery maybe become a feasible and safe procedure to treat colorectal cancer. Key words: colorectal resection, surgery, Learning curve 중심단어 : 복강경대장절제술, 개복술, 학습곡선 서 98년대후반 Dubois 등 이처음으로복강경담낭절제술을성공한이후복강경수술기구및수술기법의발전으로복부수술의많은분야에서복강경수술이적극적으로시행되고있다. 99년대부터결장, 직장의양성질환의수술방법으로도입된복강경대장절제술은진행성결장, 직장암으로그영역이확대되었다. 2 복강경담낭절제술및복강경충수절제술은개복술에비해출혈및통증감소, 조기회복및입원기간의단축으로사회복귀가빨라현재기본술식으로자리잡았으나복강경대장절제술은병소위치에 론 통신저자 : 박종경, 서울시동대문구전농 2 동 62-6 우편번호 :3-79 가톨릭대학교성바오로병원외과 Tel: , Fax: jkpark@catholic.ac.kr 따라광범위한수술조작이필요하고, 장관의해부학적구조가복잡하여주요혈관의결찰및장관의박리가까다로우며, 복강내장관문합등부위에따른수술방법의차이가많아개복술에비하여학습곡선이길어아직까지복강경담낭절제술이나복강경충수절제술처럼보편화되지않았다. 3-6 또한대장암의경우장의적절한절제범위의확보와투관침재발등종양학적문제점으로인한재발및생존율에대한논쟁이있어왔으나최근여러연구에서종양학적안정성이개복술에비하여차이가없음이입증되었다. 3,7-4 일반적으로복강경대장절제술의학습곡선은 3예에서 7 예정도로보고되고있다. 2, 본연구는결장, 직장암으로복강경대장절제술을시행받은 예의환자를대상으로임상성적, 수술시간, 수술합병증, 종양학적결과와수술후조기회복상태등을후향적으로조사하여어느정도의초기경험을쌓으면복강경대장절제술의학습곡선이안정화될수있는지를알아보았다.

2 최승혜외 2 인 : 대장ㆍ직장암의복강경대장절제술의초기경험 대상및방법 26년 2월부터 28년 8월까지가톨릭대학교의과대학성바오로병원에서결장, 직장암으로진단되어복강경대장절제술을시행받은환자 63명중복강경대장절제술의충분한경험을가진 3명의수술자가집도한 예와개복술로전환된 3예를제외한 예를대상으로하였다. 모든환자는수술전복부전산화단층촬영과대장내시경하조직생검을시행하였고수술전장처치및예방적항생제를투여하였다. 동일기간내에개복술을시행받은대장암환자에서병변의위치및병기가비슷한 4예를대조군으로삼았다. 병소의위치에따라표준술식으로수술이진행되었고복강경수술과개복술모두동일한 명의수술자에의해동일한수술범위로시행되었다. 수술자는대장암의개복술에대한충분한경험을가진대장항문외과전문의로이전에복강경대장절제술을시행한경험이전혀없고, 다만학습곡선을빠른기간에안정화시키고자복강경대장절제술술기가뛰어난수술자의수술을 6회이상참관하였고본원에서시행된초기 예의복강경대장절제술에 Table. Clinical characteristics of patients 카메라조수로참여하여복강경수술과정을배우고익혔다. 두군간임상소견, 수술방법, 수술시간, 합병증, 병리학적소견, 첫가스배출일, 식사개시일및수술후재원기간을조사하였고복강경대장절제술을시행한군을 2명씩전반기와후반기로나누어복강경수술을습득하는과정에서시기별로수술시간, 수술합병증, 종양학적소견및조기회복상태, 수술후재원기간등에차이가있는지를비교하였다. 통계처리는 SPSS software version 2. for windows 통계프로그램을사용하여 t-검정과 chi-square 검정을시행하였고 p 값이. 미만일때통계학적의미가있는것으로판단하였다. 결과 ) 환자의임상특성복강경대장절제술을시행받은환자 명의평균연령은 62. (23 82) 세, 남녀비율은.2:였다. 개복술군 4예의평균연령은 6.3 (37 89) 세이고남녀비율은.7:로서두군간의통계학적차이는없었다. 체질량지수 (body mass index), 종양표지인자, 복부수술의기왕력, 수술전병기및종양의발생부위도두군간의통계학적차이는없었다 (Table ). 2) 수술방법및수술시간 Sex (M:F) Age (years) BMI* (kg/m 2 ) Tumor marker CEA (ng/ml) CA9-9 (U/mL) Previous abdominal operation No Yes ctnm stage I II III IV Tumor location Cecum Ascending colon Hepatic flexure Transverse colon Splenic flexure Descending colon Sigmoid colon Rectum.2: 62.±2. 23.±3.4.9± ± (88.%) 6 (2.%) (22.%) 3 (26.%) 24 (48.%) 2 (4.%) 2 (4.%) 6 (2.%) 2 (4.%) 4 (8.%) 3 (26.%) 2 (42.%).7: 6.3± ± ± ±3. 3 (77.%) 9 (22.%) (2.%) 8 (2.%) 2 (62.%) 2 (.%) 6 (.%) 2 (.%) (2.%) 8 (2.%) 7 (42.%) 수술은두군모두저위전방절제술, 우반결장절제술, 전방절제술의순서로많았고복강경대장절제술을시행한군에서는 3예의 LATA (laparoscopic transabdominal transanal proctosigmoidectomy with coloanal anastomosis) 수술이시행되었다. 수술시간은피부절개에서피부봉합까지의시간을측정하였고, 평균수술시간은복강경수술군이 342.9분으로개복술군 분에비해길었으나통계학적인차이는없었다 (Table 2). Table 2. Operation types and operation time Operation type Right hemicolectomy Extended right hemicolectomy Left hemicolectomy Segmental resection Anterior resection Lower anterior resection Abdominoperineal resection LATA* Hartmann's procedure Operation time(min) (22.%) 4 (8.%) 2 (24.%) 7 (34.%) 3 (6.%) 342.9±2.4 7 (7.%) 3 (7.%) 4 (.%) 4 (.%) 8 (4.%) 2 (.%) 262.7± *BMI = body mass index; CEA = carcinoembryonic antigen; CA = cancer antigen. *LATA = laparoscopic transabdominal transanal proctosigmoidectomy with coloanal anastomosis.

3 2 대한내시경복강경외과학회지제 권제 2 호 28 3) 수술합병증 예의복강경수술군중주요한합병증은문합부누출 예, 문합부협착 예, 장폐색 예, 요관손상 2예, 직장-질누공 예씩총 6명 (2%) 에서발생하였다. 문합부누출은수술후 3일째에폐쇄배액관을통해소량의장내용물이관찰되었으나활력증후가안정적이고이학적검사상양호하여보존적으로치료도중 4일째에배액량이증가하면서복부압통및복부팽만이심해지고 38 o C 이상의고열이발생하여당일응급으로개복하여하트만씨수술을시행하고잘회복되었다. 요관손상 2예중한환자는수술도중에좌측미부요관의가로절단손상 (transection) 이발견되었다. 복강경하장관박리를끝내고나서 double-j 카테터를삽입한후좌하복부투관침부위를 6 cm 절개한다음수술표본을끄집어내기전에요관문합을먼저시행한후수술을성공적으로끝마쳤고, 다른환자는수술후 2일째폐쇄배액관으로배액되는양이갑자기많이늘어나면서복막자극증상이있어경정맥신우조영술을시행한결과좌측두부요관의누출이발견되었으나개복하지않고 double-j 카테터삽입만으로해결되었다. 수술후장마비환자는보존적요법으로잘회복되었고, 직장-질누공환자는산부인과협진을통해에스트로젠호르몬복용으로질벽을비후, 경화시켜재수술없이회복되었다. 개복술군 4예에서는 명 (2.%) 의환자에서수술후장마비만이발생하였고모두보존요법을통해회복되었다. 두군간합병증에따른통계학적차이는없었다 (Table 3). 4) 종양학적결과 수술시획득한림프절은복강경수술군 6.개, 개복술군.9개였고그중전이림프절은각각.4개,.7개로두군간의통계학적차이는없었다. 종양절제연길이는각군에서전방절제술및저위전방절제술을시행한경우만비교한결과복강경수술군 29예서근위부절제연 9.6 cm, 원위부절제연 3.8 cm였고개복술군 22예는근위부절제연 8.4 Table 3. Perioperative complications Anastomotic leakage Anastomotic stenosis Bleeding Ileus Ureter injury Rectovaginal fistula Wound dehiscence Total 2 6 (2.%) (2.%).6 cm, 원위부절제연 4.2 cm로두군간의통계학적차이는없었다. 평균추적기간은 2.2 (2 32) 개월이었으며복강경수술군은 예 (%), 개복술군은 7예 (7.%) 에서재발이있었고모두원격전이었으며두군간의통계학적차이는없었다 (Table 4). 추적기간동안사망환자는복강경수술군은 명으로수술후 4개월에항암치료도중범혈구감소증이발생하여패혈증으로사망하였다. 개복술군에서의사망환자는 2명으로대장암과무관한각각의선행질환 ( 기관지천식, 뇌경색 ) 때문에사망하였다. ) 수술후회복상태및재원기간 수술후첫가스배출은복강경수술군 3.7일, 개복술군 4.7일 (p=.4), 수분섭취는복강경수술군 4.일, 개복술군.일 (p=.3), 식사개시는복강경수술군.4일, 개복술군 7.일 (p=.2) 로복강경수술군에서모두통계적으로유의하게빨랐으며수술후재원기간도복강경수술군.3일, 개복술군 8.8일 (p=.4) 로복강경수술군에서역시통계적으로유의하게빨랐다 (Table ). 6) 복강경대장절제술군에서전, 후반기학습곡선의비교 복강경수술군의초기학습곡선의변화를비교하고자환자를전반기 2명, 후반기 2명으로나누어수술시간, 수술방법, 수술합병증, 종양학적소견및조기회복상태, Table 4. Pathologic and oncologic results Follow-up period (months) Lymph nodes status Harvested lymph nodes Metastatic lymph nodes Resection margin (cm) Proximal Distal Number of recurrences Port site Local Distant Table. Data of postoperative recovery First flatus (day) First water intake (day) Start of diet (day) Postoperative hospital stay (day) 6.±7.7.4± ± ±2.6 (.%) 2.2 (2 32) 3.7±.4 4.±.4.4±.6.3±.2.9±8.2.7± ± ±3.6 7 (7.%) 7 4.7±2.7.±2.8 7.±4. 8.8±

4 최승혜외 2 인 : 대장ㆍ직장암의복강경대장절제술의초기경험 3 Table 6. Difference between ealry period and late period of learning curve in laparoscopic colorectal surgery group Operation time (min) Operation types Right hemicolectomy Extended right hemicolectomy Left hemicolectomy Segmental resection Anterior resection Lower anterior resection Abdominoperineal resection LATA* operation Perioperative complications Anastomotic leakage Anastomotic stenosis Bleeding Ileus Ureter injury Rectovaginal fistula Lymph nodes status Harvested lymph nodes Metastatic lymph nodes Resection margin (cm) Proximal Distal Number of recurrences First flatus (day) First water intake (day) Start of diet (day) Postoperative hospital stay (day) Early period (n=2) 364.2± (2%) 2.6±7.8.9±2..7±..±3.9 3 (2%) 3.6±. 4.±..3±. 7.2±4.9 Late period (n=2) 3.3± (4%) 7.4±7.7.8±3. 8.9± ±2.7 2 (8%) 3.7±.7 4.4±.7.±2. 3.4± *LATA = laparoscopic transabdominal transanal proctosigmoidectomy with coloanal anastomosis. 수술후재원기간등을알아보았다. 수술범위는두군간에유사하였고 (Table 6), 전반기의평균수술시간은 364.2분에비해후반기는 3.3분으로통계적으로유의한차이는없었지만경험이조금씩쌓이면서평균시간이점차줄어드는것으로생각되었다 (Fig. ). 수술합병증은전반기 예 (2%), 후반기 예 (4%) 로감소하였으나통계적으로유의한차이는없었고획득림프절개수, 전이림프절개수, 종양절제연길이 ( 전방절제술및저위전방절제술을시행한경우만비교 ), 재발율도두군간통계학적차이는없었다. 환자의조기회복상태나수술후재원일은다소짧아졌으나역시두군간통계적으로유의한차이는없었다 (Table 6). 고 복강경담낭절제술이나복강경충수절제술은개복술에 찰 Fig.. Operation time of consecutive laparoscopic colorectal surgery (Linear regression equation y= 2.x+388.7, R 2 =., p<.). 비해단점은드물고출혈및동통의감소, 장유착감소, 조기회복및빠른사회복귀등의많은장점으로인하여현재표준술식으로시행되고있지만복강경대장절제술은이러한잇점에도불구하고종양학적안정성에대한의문과까다로운술기때문에학습곡선을극복하기가어려워 99년에첫보고된이후에 6 복강경담낭절제술이나복강경충수절제술과같은광범위한보급은이루어지지않았다. 직장암의경우는아직다소의논쟁이남아있으나대부분의연구에서대장암의복강경수술이개복수술과종양학적안정성에서통계적으로차이가없는것으로보고되고있다. 3,7- 이러한연구결과를토대로국내에서복강경대장절제술을시행하는외과의사의수가크게증가하였으나아직도긴학습곡선때문에개복술에비해보편화되지는못하고있는실정이다. 강등 7 은초기학습단계에서복강경저위전방절제술이종양학적으로개복술군과차이가없다고보고하였는데본연구에서도초기학습곡선을극복하는과정에서종양학적안정성을확인하기위해획득한림프절개수및종양절제연, 단기추적관찰을통한재발율등을비교해보았다. 획득림프절은복강경수술군에서 6.개개복술군에서.9개로두군간통계학적차이는없었고, 전방절제술및저위전방절제술을시행한예에서비교한절제연길이도복강경수술군에서근위부절제연 9.6 cm, 원위부절제연 3.8 cm였고개복술군은근위부절제연 8.4 cm, 원위부절제연 4.2 cm로두군간의통계학적차이는없어여러보고들과동일한결과를보였다. 3,8,8,9 최근 % 내외로보고되고있는투관침부재발이저자들의증례에는없었고, 2 복강경수술군은 예 (%), 개복술군은 7예 (7.%) 에서재발하여두군간의재발율의통계학적차이는없었지만장기적인추적관찰및추가적인증례수집이재발율을확인하는데더필요할것으로생각된다. 2,22

5 4 대한내시경복강경외과학회지제 권제 2 호 28 복강경대장절제술의중요한장점으로빠른장운동의회복으로인해재원기간을단축시킨다고보고되고있고, 3,4,23,24 본연구에서도익숙하지않은초기경험임에도불구하고복강경수술군에서첫가스배출은 3.7일, 수분섭취는 4.일, 식사개시는.4일로개복술군에비해통계적으로유의하게모두빨랐으며수술후재원기간도복강경수술군에서.3일로역시통계적으로유의하게단축되었다. 초기에문합부누출에대한염려로배액관의제거를너무늦게하였고식사개시후조기에일차항암치료를시작하여재원일이늘었으며합병증이발생했던 6예에서재원기간이현저하게늘어난점을감안할때앞으로경험이더욱축적되면재원기간을 8 9일미만으로단축시킬수있으리라여겨진다. Weeks 등 8 은복강경수술군이개복술군에비해합병증빈도가낮다고보고한반면 Veldkamp 등 2 은복강경수술군과개복술군의합병증빈도는차이가없다고주장하였는데본연구에서는합병증이복강경수술군에서 6예 (2.%), 개복술군에서 예 (2.%) 발생하여두군의합병증에따른통계학적차이는없었다. 복강경대장절제술은병소위치에따른광범위한수술조작, 복잡한장관의해부학적구조, 주요혈관의결찰및까다로운장관의박리, 복강내장관문합등기술적어려움이있으나현재까지보고된논문들에의하면개복술군과비교하여수술범위의차이는없다고확인되고있는데 저자들의경우에도종양의위치, 수술전병기, 수술방법에따른두군간의통계적차이는없었다. 일반적으로개복술군에비해평균수술시간이많이소요되며복강경대장절제술의학습곡선은대개 3예에서 7예정도로다양하게보고되고있다. 2, 본연구에서평균수술시간은복강경수술군이 342.9분, 개복술군 262.7분으로복강경수술군에서역시오래걸렸으나통계학적인차이는없었다. 초기학습곡선이안정화되는과정에서일어나는문제점을알아보고자복강경수술군을각각 2예씩전, 후반기로구분하여비교한결과수술방법, 수술합병증, 종양학적소견및조기회복상태, 수술후재원기간등에서두군간에통계학적인차이는없었다. 또한전반기의평균수술시간은 364.2분에비해후반기는 3.3분으로통계적으로유의한차이는없었지만선형회귀분석을통해수술시간과수술증례와의관계에대하여알아본결과수술증례가증가할수록수술시간이줄어드는추세를보임을알수있었다 (Fig. ). 본연구결과를토대로경험및술기가충분한수술자의수술에참여하여복강경수술과정을철저하게준비한후복강경수술을시행한다면학습곡선이어느정도빠르게안정될것으로생각되었다. 또한경험이어느정도축적된후반기에합병증이 예 (4%) 로전반기의 예 (2%) 에비해통계학적차이는없었으나많이감소하였다. 따라서학습곡선이안정화되기까지걸리는시간과기술적어려움을 두려워하지말고적극적으로복강경대장절제술에접근하는노력을경주했으면한다. 결 복강경대장절제술은개복술을대체할수있는결장, 직장암의하나의수술술기로서개복술에비해오래걸리는수술시간을줄이기위해서는더많은수술증례를경험해야할것으로생각되고철저한준비와함께본저자의수술증례이상의복강경대장절제술을시행한다면초기학습곡선이안정화되는시기를어느정도앞당길수있을것으로판단된다. 또한더욱경험이축적되고장기적인추적관찰을통해종양학적인안정성이확인되면복강경대장절제술이대장, 직장암의표준술식으로자리잡을것으로기대된다. 론 참고문헌 ) Dubois F, Icard P, Berthelot G, Levard H. Coelioscopic cholecystectomy. Preliminary report of 36 cases. Ann Surg 99;2: ) Reissman P, Cohen S, Weiss EG, Wexner SD. colorectal surgery: ascending the learning curve. World J Surg 996;2: ) Lacy AM, García-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 22;39: ) Hoffman GC, Baker JW, Fitchett CW, Vansant JH. -assisted colectomy. Initial experience. Ann Surg 994;29: ) Bennett CL, Stryker SJ, Ferreira MR, Adams J, Beart RW Jr. The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 94 laparoscopic-assisted colectomies. Arch Surg 997;32: ) Lumley JW, Fielding GA, Rhodes M, Nathanson LK, Siu S, Stitz RW. -assisted colorectal surgery. Lessons learned from 24 consecutive patients. Dis Colon Rectum 996;39:-9. 7) Veldkamp R, Kuhry E, Hop WC, et al. Colon cancer or Resection Study Group (COLOR). surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 2;6: ) The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 24;3: ) Curet MJ, Putrakul K, Pitcher DE, Josloff RK, Zucker KA. ally assisted colon resection for colon carcinoma: perioperative results and long-term outcome. Surg Endosc

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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