< D C1A4BCBAC0BA28B9DAC8F1B0E6292E687770>

Size: px

Start display at page:

Download "< D C1A4BCBAC0BA28B9DAC8F1B0E6292E687770>"

민혁 채
5 years ago
Views:

1 141 소아외과 : 제 15 권제 2 호 2009 년 Vol. 15, No. 2, December 2009 복막투석중인소아에서발생한서혜부탈장의임상상 서울대학교병원소아외과, 삼성서울병원소아외과 1 박희경 정규환 문석배 1 정성은 박귀원 서 론 복막투석은말기신질환환아에서보편적으로쓰이고있는신대체요법이다 1,2,3. 복막투석의합병증으로는부적절한도관위치, 복막염, 도관삽입부감염, 도관폐색, 투석액누출등이있으며, 투석액에의한복압증가로인해서혜부탈장이더많이발생하는것으로보고되고있다 3,4,5,6. 또한복막투석중인환자가탈장수술을받게되는경우, 수술후에도투석액으로인해복강내정수압이지속적으로높게유지되고요독증의영향으로수술상처가늦게치유되어일반환자에비해더높은탈장재발률을보인다 5. 이를예방하기위해탈장수술후완전히치유될때까지복막투석시작시기를늦추는것이추천되고있으나, 환자의신기능에따라혈액투석으로대체가필요하거나혈액투석이불가능한경우복막투석의재개가 접수일 : 09/9/1 게재승인일 : 09 /12 / 30 교신저자 : 정성은, 서울특별시종로구연건동 28 번지서울대학교병원소아외과 Tel : 02) , Fax : 02) sejung@snu.ac.kr 1. 현근무지 ; 삼성의료원 불가피한경우도있어, 현재까지이러한환자들의탈장수술후표준화된투석방법은아직정립되어있지않은실정이다. 이에저자들은복막투석중인소아환자에서서혜부탈장의발생률을비롯한임상적특징과탈장교정술후복막투석을시작하는시기및방법에따른재발유무에대해분석하고자하였다. 대상및방법 1996년 1월부터 2007년 6월까지서울대학교병원소아외과에서신부전으로복막투석도관을삽입한 155례의환자중도관삽입후서혜부탈장이발생한 16례를대상으로하였다. 도관삽입술전에이미서혜부탈장교정술을받은 2례와, 서혜부탈장이있으면서복막투석시행중에전원되어복막투석과서혜부탈장발생의선후관계를알수없는 1례는모두대상에서제외하였다. 탈장이발생한모든환자는수술적치료 ( 고위결찰술 ) 를받았다. 대상환자의성별, 복막투석도관삽입시및탈장수술시의연령, 도관삽입후탈장이발생하기까지의기간,

2 142 소아외과제 15 권제 2 호 2009 년 체중, 탈장의위치, 탈장관련합병증의발생, 수술후재발, 수술후투석방법등에대해의무기록을바탕으로후향적으로분석하였다. 통계처리는 Pearson 단순상관분석, Kruskal-Wallis 검정, Kaplan-Meier 생존분석을이용하였다. 결과복막투석도관삽입술을받은전체 155례 ( 남 : 여 79:76) 중복막투석시작후서혜부탈장이발견된경우는 16례 ( 남 : 여 8:8) 로 10.3 % 의발생빈도를보였다. 탈장이발생한 부위는우측이 8례 (50 %), 좌측이 6례 (37.5 %), 양측이 2례 (12.5 %) 였다. 복막투석도관삽입후서혜부탈장이발생한전체 16례환자의도관삽입시평균나이는 6.7 ± 3.9세 ( 범위 : 10개월~15세 ), 탈장이발생한평균나이는 7.9 ± 4.8세 ( 범위 : 17개월~17세 3개월 ) 였다 (Table 1). 도관삽입시연령과탈장의발생률간에상관관계는없었으며, 연령에따른탈장발생률간에통계적으로유의한차이도없었다 (p=0.446, Table 2). 도관삽입후서혜부탈장의발견까지의기간은 55일에서 6년 9개월 ( 평균 1.2 ± 1.9년 ) Table 1. Relationship between PD Catheter Insertion and Hernia Occurrence Case Age at Catheter Insertion Time Interval* Hernia Location 1 10m 11m R 2 1y 3m 2m R 3 1y 6m 6m R 4 3y11m 3m R 5 5y 3m 32m L 6 5y 5m 4m L 7 5y 5m 5m L 8 5y10m 2m R 9 6y 8m 5m Bilateral 10 6y11m 58m L (Contrarateral) 11 8y 4m 4m L 12 9y 4m 5m Bilateral 13 9y 5m 2m L 14 10y 6m 81m R 15 11y 1m 1m R 16 15y 15m R (Recur) PD ; Peritoneal dialysis Time Interval* ; Duration between PD catheter insertion and hernia occurrence R; Right, L; Left

박희경외 : 복막투석중인소아에서발생한서혜부탈장의임상상 143 Table 2. Occurrence of Inguinal Hernia After PD Catheter Insertion According to Age Age (yr) No. of PD No. of Hernia (%) <1 35 1 ( 2.9) 1~2 8 2 (25.

3 박희경외 : 복막투석중인소아에서발생한서혜부탈장의임상상 143 Table 2. Occurrence of Inguinal Hernia After PD Catheter Insertion According to Age Age (yr) No. of PD No. of Hernia (%) < ( 2.9) 1~2 8 2 (25.0) 2~ ~4 4 1 (25.0) 4~ ~ (33.3) 6~7 7 2 (28.6) 7~ ~9 5 1 (20.0) 9~ (25.0) 10~ (12.5) 11~ ( 8.3) > ( 2.4) Total (10.3) PD ; Peritoneal dialysis Fig. 1. Occurrence of Inguinal Hernia According to Duration of Peritoneal Dialysis 까지였고, 중앙값은 161일 (95 % 신뢰구간 139일 ~183일 ) 이었으며약 6개월까지의기간에해당하는 185일이내에탈장이발생한경우가 69 %( 표준편차 11.6 %) 였다 (Fig. 1). 전체 16례중 2례는수술직후부터수술전과같은방법으로복막투석을재개하였으며, 2례는투석액의양을각각평소의 26.7 %, 37.5 % 로줄여서복막투석을재개하였다. 6례는혈액투석으로대체하였고, 4례는투석자체를 2일~1주일간중지하였다. 2례는수술후투석방법에대해기록이남아있지않아분석할수없었다 (Table 3). 서혜부탈장의수술후재발은 16례중 1 례 (6.3 %) 에서발생하였다. 도관삽입 1년 3 개월후에우측서혜부탈장이발견되어수술을받았던환자로, 수술소견상특이소견은없었다. 이환자는복막투석을수술일자정부터수술전과같은방법으로계속하였으며 1년후재발하여다시탈장교정술을시행받았다. 도관삽입 4년 10개월후에좌

4 144 소아외과제 15 권제 2 호 2009 년 Table 3. Postoperative Dialysis Methods After Inguinal Hernia Repair Procedure Postoperative dialysis] method Age PD hold (day) Recur Immediate continuation of PD 5y 5m none with same preop. settings (n=2) 15y none Yes Continuation of PD 6y11m none C* with reduced dialysate volume (n=2) 8y 4m none Discontinuation of PD 5y 5m 10 with interim hemodialysis (n=6) 5y10m 5 9y 4m 6 9y 5m 9 10y 6m unknown 11y 1m 3 Discontinuation of PD only (n=4) 10m 4 1y 6m 4 5y 3m unknown 6y 8m 3 No record (n=2) 1y 3m unknown PD ; Peritoneal dialysis C* ; Contralateral occurrence 3y11m unknown 측서혜부탈장교정술을받고, 수술후 6개월만에반대쪽에서또서혜부탈장이발생한경우도 1례있었다. 수술전감돈이나교액등의탈장관련합병증이있었던환자는없었으며, 수술후합병증이발생한경우도없었다. 고찰복막투석은혈액투석에비해혈관확보및유지의어려움이없고, 식이제한의정도를완화할수있으며, 환자의활동이자유롭다는이점이있어현재소아에서가장적합 한투석치료로인정되고있다 7,8. 복막투석을시행할경우투석액에의한복압의상승으로인해서혜부탈장의발생이증가하게되는데 3,5, 성인에비해소아에서더높은발생률이보고되고있다 9,10,11. von Lilien 등이 93명의복막투석도관삽입술을시행한소아를대상으로한연구에서는 15 % 9, Stone 등이 93명을대상으로한연구에서는 11.8 % 의발생률을보여 12, 일반적인경우 3.5~5 % 13 에비해높은발생률을보였다. 본연구에서도발생률은 10.3 % 로앞의결과들과큰차이는없었다. 일반적으로소아에서발생하는서혜부탈

5 박희경외 : 복막투석중인소아에서발생한서혜부탈장의임상상 145 장은나이가어릴수록발생빈도가높다고알려져있다 14. 복막투석중인소아의서혜부탈장과연령간의관계는잘밝혀져있지않으나, van Asseldonk, von Lilien 등은복막투석중인소아에서서혜부탈장, 제대탈장등을포함한복벽탈장의발생이연령이어린환자에서더많이발생한다고보고하였다 9,10. 그러나본연구에서는복막투석시작연령과탈장의발생률간에유의한차이가없었는데, 탈장의발생률이높을것으로예상되는영아기의경우다수가선천적으로치명적인기형이나질환이동반되어투석시작후탈장이발생할때까지생존하지못한경우가많았으며, 연령이어린경우일반적인기준에비해적은양의투석액으로복막투석을시행하여서혜부에가해지는복압의증가가적었을것이라는점등이어린환자에서예상보다낮은탈장의발생률을보인원인이될수있을것으로생각된다. 본연구에따르면투석도관삽입후약 6개월의기간에해당하는 185일이내에서혜부탈장이발생할확률은 69 % 였으며, 이후탈장의발생률은현저한감소를보였는데 (Fig. 1), 이는투석시작전부터이미임상증상이없는잠재적인서혜부탈장이있었거나, 복막초상돌기의폐쇄지연등을동반한탈장이발생하기쉬운상태의환자가존재할가능성이있음을시사한다. 따라서도관삽입술을시행한환자를외래추적관찰시도관삽입후최소한 6개월까지는서혜부탈장의발생가능성이높다는것을염두에두어야하겠다. 복막투석중인소아에서탈장이발생한경우탈장수술후신대체방법에대해서는 현재까지표준화된방법은없으며, 크게복막투석을유지하거나, 혈액투석으로전환하는두가지방법이사용되고있다 15,16. 여러연구에서탈장교정술후일시적인혈액투석으로의전환없이복막투석을유지하는것이전해질이상이나요독증, 투석액누출, 탈장의재발등의합병증을증가시키지않았다고보고하고있는데, 이저자들은탈장수술후 1~3일가량투석을중단하고, 적은양의투석액으로투석을재개, 이후점차양을늘려가는방법으로복막투석을진행하였다 16,17,18. 복막투석환자에서서혜부탈장으로수술을시행하는경우탈장의재발률은소아의경우보고된예가거의없으나, 성인의경우 22~29 % 로일반서혜부탈장환자의 6~ 11.2 % 에서보다높은재발률을보이는것으로보고되고있다 5,19,20. 본연구에서는서혜부탈장수술을받은 16례중 1례에서재발이발생하였다. 이환자는도관삽입 1년 3 개월후에우측서혜부탈장이진단되어탈장교정술을받았으며수술일자정부터복막투석을시작하였고, 1년후재발하여다시탈장교정술을받았다. 수술직후부터복막투석을수술전과같은방법으로유지한 2 례의환자중 1례에서재발이발생한것으로보아, 수술직후복막투석을시작하는경우에는수술상처가치유되기전에투석액으로인한높은복강내압력으로수술상처의불완전한치유를유발하고이로인해탈장이재발할가능성을높일수있을것으로생각된다. 따라서복막투석중인환자는탈장교정술후일시적으로복막투석을중단하거나, 투석액의양을줄여서시행하는

6 146 소아외과제 15 권제 2 호 2009 년 것이탈장의재발률을낮추는데에도움이될수있을것으로생각된다. 결 론 복막투석중인소아에서서혜부탈장의발생률은 10.3 % 로일반적인발생률보다높았다. 복막투석도관삽입후 6개월이내에탈장의발생률이높았으며, 이후탈장발생률은현저히낮아지므로복막투석시작후첫 6개월동안은탈장발생가능성을염두에두고주의깊게환자를관찰해야하겠다. 또한, 탈장수술직후부터복막투석을재개한경우재발에영향을줄수있으므로수술전신기능에따라수술후일시적으로복막투석을중지하거나, 투석액의양을줄이는것이재발률을낮추는방법이될수있을것으로생각된다. 참고문헌 1. Foreman JW, Chan JC: Chronic renal failure in infants and children. J Pediatr 113(5): , Baum M, Powell D, Calvin S, McDaid T, McHenry K, Mar H, Potter M: Continuous ambulatory peritoneal dialysis in children. N Engl J Med 307: , Rὃnnholm KA, Holmberg C: Peritioeal dialysis in infant. Pediatr Nephrol 21(6):751-6, Guzman-Valdivia G, Zega I: Abdominal wall hernia repair in patients with chronic renal failure and a dialysis catheter. Hernia 5:9-11, Wetherington GM, Leapman SB, Robinson RJ, Filo RS: Abdominal wall and inguinal hernias in continuous ambulatory peritoneal dialysis patients. Am J Surg 150:357-60, Afthentopoulos IE, Panduranga Rao S, Mathews R, Oreopoulos DG: Hernia development in CAPD patients and the effect of 2,5L dialysate volume in selected patients. Clin Nephrol 49:251-7, White CT, Gowrishankar M, Feber J, Yiu V, Canadian Association of Pediatric Nephroloist (CAPN), Peritoneal Dialysis Working Group: Clinical practice guidelines for pediatric peritoneal dialysis. Pediatr Nephrol 21: , 김병길 : 한국소아복막투석의현황. 대한소아신장학회지 2:95-103, von Lilien T, Soulsky IB, Yap HK, Fonkalsrud EW, Fine RN: Hernia: a frequent complication in children treated with continuous peritoneal dialysis. Am J Kidney Dis 10(5):356-60, van Asseldonk JP, Schroder CH, Severijnen RS, de Jong MC, Moneus LA: Infectious and surgical complications of childhood continuous ambulatory peritoneal dialysis. Eur J Pediatr 151:377-80, Alexander SR, Tank ES: Surgical aspects of continuous ambulatory peritoneal dialysis in infants, children and adolescents. J Urol 127(3):501-4, Stone MM, Fonkalsrud EW Salusky IB, Takiff H, Hall T, Fine RN: Surgical Management of peritoneal dialysis catheter in children: five-year experience with 1,800 patient-month follow-up. J Pediat Surg 21: , Kliegman RM: Nelson Textbook of Pediatrics, 18th ed. Philadelphia, W.B. Saunders, 2007, Pp Rowe MI, Copelson LW, Clatworthy HW: The patent processus vaginalis and

7 박희경외 : 복막투석중인소아에서발생한서혜부탈장의임상상 147 the inguinal hernia. J Pediatr Surg 172:602-5, Morris-Stiff GJ, Bowrey DJ, Jurewicz WA, Lord RH: Management of inguinal herniae in patients on continuous ambulatory peritoneal dialysis: an audit of current UK practice. Postgrad Med J 74:669-70, Shah H, Chu M, Bargman JM: Perioperative management of peritoneal dialysis patients undergoing hernia surgery without the use of interim hemodialysis. Perit Dial Int 26(6):684-7, Mettang T, Stoeltzing H, Alscher DM, Magadum S, Dunst R, Kuhlmann U: Sustaining continuous ambulatory peritoneal dialysis after herniotomy. Adv Perit Dial 17:84-7, Imvrios G, Tsakiris D, Gakis D, Takoudas D, Koukoudis P, Papadimitriou M, Antoniadis AA: Prosthetic mesh repair of multiple recurrent and large abdominal hernias in continuous ambulatory peritoneal dialysis patients. Perit Dial Int 14:338-43, Suh H, Wadhwa NK, Cabralda T, Sokunbi D, Pinard B: Abdominal wall hernias in ESRD patients receiving peritoneal dialysis. Adv Perit Dial 10:85-8, Brunicardi FC: Schwartz's Principles of Surgery, 9th ed. McGraw-Hill Companies, Inc. 2009, Pp1334-6

8 148 소아외과제 15 권제 2 호 2009 년 Clinical Characteristics of Inguinal Hernia in Children on Peritoneal Dialysis Hee-Kyung Park, M.D., Kyu-Whan Jung, M.D., Suk-Bae Moon, M.D. 1, Sung-Eun Jung, M.D., Kwi-Won Park, M.D. Department of Pediatric Surgery, Seoul National University Children s Hospital, Department of Pediatric Surgery 1, Sungkyunkwan University Children s Hospital, Seoul, Korea Peritoneal dialysis (PD) has been utilized for the children with end stage renal disease. Nevertheless, it is thought to promote inguinal hernia by increasing intraabdominal pressure. To investigate the clinical characteristics of inguinal hernia in children on PD, 155 cases of PD in children between January 1996 and June 2007 at Seoul National University Children s Hospital were reviewed retrospectively. Inguinal hernia developed in 16 cases (10.3 %, M:F=8:8). Hernia occurrence was not correlated to age. Eleven cases (69 %) of inguinal hernia developed in first 6 months after initiation of PD. All inguinal hernias were surgically repaired. No complications occurred related to inguinal hernia or surgery. Recurrent hernia developed in 1 patient (6.3%) of 2 cases who had PD postoperatively on the day of surgery. In conclusion, inguinal hernia developed more frequently with children on PD than general population (3.5~5 %). The rate of hernia development was highest within the first 6 months following initiation of PD. After repair of hernia, we recommend to discontinue PD immediate postoperatively to prevent recurrence. (J Kor Assoc Pediatr Surg 15(2):141~148), Index Words:Inguinal hernia, Peritoneal dialysis Correspondence:Sung-Eun Jung, M.D., Department of Surgery, Seoul National University College of Medicine, 28 Yeongeon-Dong, Jongro-Gu, Seoul, , Korea Tel : 02) , Fax : 02) sejung@snu.ac.kr

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