untitled

Size: px

Start display at page:

Download "untitled"

길수 근
5 years ago
Views:

1 Korean Journal of HBP Surgery 원 저 Vol. 13, No. 4, December 2009 Binding 췌공장문합술의초기경험및 Dunking 췌공장문합술과의비교 Binding Pancreaticojejunostomy Compared with Dunking Pancreaticojejunostomy Purpose: Pancreatic fistulas are a leading cause of mortality and morbidity following pancreaticoduodenectomy. The objective of this study was to evaluate the possibility of controlling pancreatic fistula formation by binding pancreaticojejunostomy into the operative procedure, as proposed by Peng, which results in a 3 cm invagination of the pancreatic remnant by the jejunal segment bearing electrically-destroyed mucosa reinforced by inner and outer sutures. Methods: Prospectively collected data of patients undergoing pancreaticoduodenectomy in the Department of Surgery of Daejeon St. Mary s hospital between April 2007 and May 2009 were analyzed retrospectively. Thirty-one patients were included in the study; 16 patients underwent dunking pancreaticojejunostomy and 15 patients underwent binding pancreaticojejunostomy. Results: The two groups were comparable with respect to demographic data, pre-operative characteristics, underlying pathologies, pancreatic textures, and duct diameters. The mean operative time did not differ between the two groups (388±29 min vs. 459±21 min, p=0.060). No difference existed in the post-operative course except for the degree of complications. In contrast to the dunking group, in which 2 cases of grade III/V pancreatic fistulas occurred, the binding group had no severe complications. In addition, transformation of amylase data measured from Jackson-Pratt drains into a natural logarithm demonstrated significant differences on post-operative (POD) days 1, 3, and 7 between the dunking and binding groups (POD1, 6.97±0.41 vs. 6.10±0.44 [p=0.037]; POD3, 6.97±0.41 vs. 6.10±0.44 [p=0.032]; POD7, 4.69±0.35 vs. 3.88±0.25 [p=0.034], respectively). Conclusion: Bindning pancreaticojejunostomy is equivalent to dunking pancreaticojejunostomy with respect to operative difficulties, and more effective in preventing complications related to pancreatic fistulas. 김세준 1, 이동호 1, 김정구 1, 이광진 2 1 가톨릭대학교의과대학대전성모병원외과학교실, 2 목원대학교정보컨설팅학과 Say June Kim, M.D. 1, Dong Ho Lee, M.D. 1, Jeong Goo Kim, M.D. 1, Kwang Jin Lee, Ph.D. 2 1 Department of Surgery, Deajeon St. Mary s Hospital, The Catholic University of Korea College of Medicine, 2 Department of Information Consulting, Mokwon University 책임저자 김세준대전시중구대흥동 가톨릭대학교의과대학대전성모병원외과학교실우편번호 Tel: Fax: sejoonkim@hanmail.net Key Words : Pancreaticoduodenectomy, Pancreatic fistula, Dunking pancreaticojejunostomy, Binding pancreaticojejunostomy 중심단어 : 췌십이지장절제술, 췌장루, Dunking 췌공장문합술, Binding 췌공장문합술 Received: Accepted: 서론 팽대부주위종양 (periampullary tumor) 에대한표준술식으로도입된췌십이지장절제술은최근수술기술및수술전후관리의향상에힘입어술후사망률은현저히감소되었지만, 술후이환율은 20 50% 로여전히높은편이다. 1 이렇게 타수술보다높은이환율을보이는이유는췌장수술후의독특한합병증인췌장루 (pancreatic fistula) 와관련된것으로알려져있다. 2 췌장루는췌장절제및문합후췌장액이기대했던문합부위로배액되지않고복강내로누출되어발생하는합병증의총칭으로문합부파열, 복강내농양및출혈등의직접적인원인을제공하며재수술, 장기입원, 패혈증및사망의궁극적인원인이되기도한다. 1,3 286

2 김세준외 :Binding 췌공장문합술의초기경험및 Dunking 췌공장문합술과의비교 Yeo 등 4 은 145명의췌십이지장절제술을시행받은환자들에대한전향적분석에서췌장루에영향을미치는독립요인이해당병원에서의췌십이지장절제술의건수와병변의위치 ( 십이지장, 팽대부>췌장, 담관 ) 라고기술하였다. 이런면에서 1년에 10예내외의췌십이지장절제술이행해지는본원은췌십이지장절제술이적게시행되는병원 (low volume center) 에해당되므로췌장루를낮추려는노력이더욱절실한상황이다. 이러한환경에서저자들은위해 2008년국제간담췌학회 (the International HepatoPancreato Biliary Association) 에서 Peng에의해구연된 binding 췌공장문합술 (Binding pancreaticojejunostomy) 을처음으로접하게되어각종문헌고찰과술기연습후본술식을도입하게되었다. 2002년 Peng 등 5 은처음으로 binding 췌공장문합술을발표했고, 2004년 227명의환자에게이술식을시행한결과한명의환자에서도췌장루가발생하지않았음을보고했다. 6 이는지금까지알려진췌장루의빈도인 2 28% 7 보다현격히낮은것으로, 이방법의유용성이입증된다면췌장루로인한합병증을현저히줄일수있을것으로기대된다. 이에저자들은본술식의초기경험을통해본술식이기존의췌공장문합술을성공적으로대치할수있는가능성이있는지를알아보고자하였다. 방법 1. 자료의수집 2005년 4월부터 2009년 5월까지대전성모병원에서시행한췌십이장절제술에대해전향적으로수집한임상기록, 검사실소견및영상소견을후향적으로분석하였다. Binding 췌공장문합술은 2008년 3월에본원에서처음으로시행되었으며, 그이후의모든췌십이장절제술의술식및 2예의간췌십이지장절제술 (hepatopancreaticoduodenectomy) 및 1예의췌중앙구역절제술 (medial pancreatectomy) 에서도사용되었다. 본연구에서는동일술식내에서의비교를위해상기기간동안의췌십이장절제술만을비교하였다. 따라서, 이시점이전에시행했던 16예의췌십이장절제술과 binding 췌공장문합술이도입된 15예의췌십이지장절제술을비교하였다. 술후 5일 ( 포함 ) 이후배액관으로누출되는액의양이 30 ml 이상이고, 배액으로측정한아밀라아제수치가혈청아밀라아제의정상상한치의 5배이상증가했을때췌장루가있다고정의하였다. 7 수술후환자에게 5일간의 octreotide 피하주사하였으며, 경구식이이전까지고단위영양요법을시행받았다. Binding 췌공장문합술도입이전에본원에서췌십이지장절제술시시행했던췌공장문합술은 dunking법을이용한단단문합 (end-to-end dunking invagination method) 8 으로간략히기술하면다음과같다. 내측봉합은공장말단 (stump) 과문합할췌장절단면간에흡수봉합사를이용하여단속봉합 (interrupted suture) 하였다. 먼저공장및췌장의후벽사이의봉합을완료시켰다. 다음으로 Poon 등 9 이제시했던방법과유사한방식으로췌관의체외배출 (external drainage of pancreatic duct) 을시행했다. 즉, 췌관내에외측외경 (outer diameter) 이 mm인 cutdown tube (polyvinyl chloride, Korea medical Co, Korea) 를설치해서공장을통해체외로연결하여췌액을체외로배출시키되, 공장내에위치한 cutdown tube 분획에옆길 (side holes) 을만들어체내로도배액될수있도록하였다. cutdown tube는흡수성봉합사로췌장과연결하여, 향후제거가용이하도록하였다. 다음으로췌장과공장의전면을단속봉합하여내측췌공장문합을완료하였다. 이어서공장의장막과췌장피막간에 silk 3-0를이용한외측봉합을시행했다. 췌공장후벽의외측봉합은전벽의외측봉합후문합부을들어올린뒤시행했다. 봉합후공장말단이췌장을 5 15 mm가량함입하는형태를지니게되었다. 2. Binding pancreaticojejunostomy 술기남은췌장 (pancreatic remnant) 을췌장절단면으로부터 3 4 cm가량후복막으로부터분리시켰다. 이렇게분리하는과정에서췌장뒤쪽의지라정맥및위창자간막정맥의분지들이노출되었고, 경우에따라서몇몇혈관가지들을결찰해야했다. 이렇게췌장을가동화시키는이유는이렇게가동화시킨췌장이향후공장에의해함입되는부분이기때문이다. 췌공장문합술을위해준비한공장말단 (stump) 의직경이함입될췌장절단부위직경보다작다고판단되면 mm EEA sizer (Covidien, USA) 로공장직경을확장시켰다. 그후공장말단을 3 cm가량뒤집어공장점막을노출시켰다 (Fig. 1). 즉, 공장절단면과절단면으로부터 6 cm가량떨어진근위부의공장간에느슨한봉합을한뒤 (180 o 간격으로두군데 ) 조심스럽게공장을뒤집었다. 이렇게노출된 3 cm 길이의공장점막에전기소작을시행했다 (Fig. 2). 이렇게전기소작된점막은향후췌장을함입하게되는부위로, 전기소작을하는이유는췌장을함입하는공장내측에서의분비물을차단하고염증반응을 287

한국간담췌외과학회지 : 제 13 권제 4 호 2009 Fig. 1. Eversion of jejunal end for preparation of binding pancreaticojejunostomy.

The everted mucosa (A) was electrocauterized for more favorable attachment to pancreatic remnant (B). 유발하여췌장과의유착을형성할것으로기대하기때문이다. Fig. 3과같이공장점막과췌장절단면과봉합을시도하였다.

췌관내 cutdown tube 설치는 binding 췌공장문합술도입이전과동일하게시행했다. Fig. 4는이렇게내측봉합이완료된뒤의사진이다. 췌장-공장간내측봉합이완료된후공장을뒤집기위해시행했던 2개의봉합을절제한뒤조심스럽게뒤집어진공장을펴서원래위 치로복원하였다.

3 한국간담췌외과학회지 : 제 13 권제 4 호 2009 Fig. 1. Eversion of jejunal end for preparation of binding pancreaticojejunostomy. After pacing 2 stitches and suturing (A), 3 cm length jejunal end is everted (B). Fig. 2. Jejunal mucosa preparation of binding pancreaticojejunostomy. The everted mucosa (A) was electrocauterized for more favorable attachment to pancreatic remnant (B). 유발하여췌장과의유착을형성할것으로기대하기때문이다. Fig. 3과같이공장점막과췌장절단면과봉합을시도하였다. 이때봉합사가공장근육층으로깊게봉합하지않고, 점막깊이로만봉합이이루어지도록주의하였다. 봉합사는 silk 3-0 ( 또는 2-0) 를이용하였고뒷면은연속봉합 (continuous suture) 을, 앞면은단속봉합하였다. 췌관내 cutdown tube 설치는 binding 췌공장문합술도입이전과동일하게시행했다. Fig. 4는이렇게내측봉합이완료된뒤의사진이다. 췌장-공장간내측봉합이완료된후공장을뒤집기위해시행했던 2개의봉합을절제한뒤조심스럽게뒤집어진공장을펴서원래위 치로복원하였다. 이렇게하면처음에전기소작을시행했던 3 cm가량의공장점막이췌장을밖에서둘러싸게된다. 췌공장외측봉합은 silk 3-0을이용하여공장말단부의장근육층 (seromuscular layer) 과췌장피막간에단속봉합으로시행하였다. 췌장을둘러서모두 8 10개가량의봉합을시행했다. 췌장뒷면봉합엔공장말단부를들어올려서봉합하였고이때지라정맥및위창자간막정맥의손상이가지않도록주의하였다. 이렇게췌공장문합술이완료된이후 vicryl 2-0 봉합사로공장절단면에서 cm 안쪽의췌장을함입한공장둘레를감싸도록봉합하였다 (Fig. 5). 그봉합의강도는 forceps같 288

김세준외 :Binding 췌공장문합술의초기경험및 Dunking 췌공장문합술과의비교 Fig. 3. Pacing an inner suture between jejunal mucosa and the cut end of pancreas.

Operative illustration after finishing of inner sutures of binding pancreaticojejunostomy. Fig. 5. Completion of binding pancreaticojejunostomy.

A binding ligature using an absorbable material was applied on the midpoint of the jejunal segment containing pancreatic stump (B). 은수술용기구가통과될정도로너무느슨하지도않으면서너무세지도않게하였다.

4 김세준외 :Binding 췌공장문합술의초기경험및 Dunking 췌공장문합술과의비교 Fig. 3. Pacing an inner suture between jejunal mucosa and the cut end of pancreas. Special attention was paid not to suture deeper than mucosal layer of the jejunum. Fig. 4. Operative illustration after finishing of inner sutures of binding pancreaticojejunostomy. Fig. 5. Completion of binding pancreaticojejunostomy. Note that about 3 cm pancreatic stump was well intussuscepted into jejunal lumen (A). A binding ligature using an absorbable material was applied on the midpoint of the jejunal segment containing pancreatic stump (B). 은수술용기구가통과될정도로너무느슨하지도않으면서너무세지도않게하였다. 또한이봉합으로인해봉합원위부공장쪽으로의혈액공급에지장이없도록창자간막쪽에서의이봉합의위치는창자간막혈관을포함하지않는공장벽쪽에있게하였다. 이봉합을가리켜 binding 결찰 (binding ligature) 이라고한다. 배액관은 Jackson-Pratt (JP) 배액관 2개을이용했으며 Morrison s pouch 및췌공장문합부위에각각의끝이놓여지도록위치시켰다. 통계프로그램은 SPSS 12K (SPSS Inc, Chicago IL, USA) 를이용하였다. 각군의비교는비연속변수의경우는카이제곱값을이용한교차분석을이용하였고, 연속변수의경우는정규분포를따른다고확인되면독립성 t검정법을이용하였다. JP 배액관에서측정된아밀라아제치는정규성을지니지않았는데이경우아밀라아제의자연로그값을구해정규분포화시켜비교하였다. p-value가 0.05 미만일때통계학적으로의미가있다고간주하였다. 3. 통계분석 본논문에서의숫자정보는평균과표준오차로표시하였다. 289

5 한국간담췌외과학회지 : 제 13 권제 4 호 2009 Table 1. Preoperative and demographic characteristics of patients Dunking pancreaticojejunostomy (n=16) (%) Binding pancreaticojejunostomy (n=15) (%) p-value Age, Years (mean±se*) 64.8± ± Male-to-female ratio 10/6 (62.5/37.5) 6/9 (40.0/60.0) BMI 22.0± ± Presence of comobid illnesses 9 (56.3) 5 (33.3) Primary lesion sites Pancreas 7 (43.8) 4 (26.7) Distal bile duct 4 (25.0) 4 (26.7) Ampulla of Vater 3 (18.8) 4 (26.7) Stomach 1 (6.3) 3 (20.0) Duodenum 1 (6.3) 0 (0.0) Major laboratory findings Hematocrit (%) 36.5± ± Total bilirubin (mg/dl) 3.4± ± Alkaline phosphatase 276±62 151± Albumin (g/l) 3.6± ± Presence of preoperative 4 (25.0) 8 (53.3) external biliary drainage *SE=standard error; BMI=Body-mass index; Comorbid illnesses included chronic cardiovascular disease; chronic pulmonary disease, chronic renal disease and diabetes mellitus Table 2. Comparison of operative & postoperative variables between the conventional procedure (dunking pancreaticojejunostomy) and binding pancreaticojejunostomy Dunking pancreaticojejunostomy (n=16) (%) Binding pancreaticojejunostomy (n=15) (%) p-value Mean operative time (min) 388±29 459± Intraoperative blood loss 1,300±198 1,146± Intraoperative blood transfusion 3.0± ± (Units of RBC ) Pylorus preservation 3 (18.8) 8 (53.3) Texture at transected neck Hard 3 (18.8) 2 (13.3) Intermediate 6 (37.5) 7 (46.7) Soft 7 (43.8) 6 (40.0) Mean diameter of pancreatic duct 2.3± ± at transected neck (mm) Postoperative course (days) ICU stay 3.0± ± Levin tube removal 5.0± ± Resuming of soft diet 9.3± ± Removal of JP* drains 11.8± ± Postoperative hospital stay (day) 29.5± ± *JP=Jackson-Pratt; RBC=red blood cells; ICU=intensive care unit 290

6 김세준외 :Binding 췌공장문합술의초기경험및 Dunking 췌공장문합술과의비교 결 과 2005년 4월부터 2009년 5월까지대전성모병원에서췌십이장절제술만단독으로시행받은환자가 31명이었다. 전체환자에서남자는 16명 (51.6%), 여자는 15명 (48.4%) 이었으며, 평균연령은 63.4±1.9 (37 82) 세였다. 수술적응증을병변부위별로살펴보면췌장 11명 (35.5%), 담관 8명 (25.8%), 팽대부 7명 (22.6%), 위 4명 (12.9%) 및십이지장 1명 (3.2%) 이었고, 조직검사에서가성췌낭종및췌장두부선종소견을보였던 2 명의환자를제외한 29명 (93.5%) 의환자가악성종양을지녔다. 2008년 3월을기점으로그이후에췌십이지장절제술을시행받은모든환자에게 binding 췌공장문합술이시행되었다. 기존췌공장문합술을시행받은환자 (n=16) 와 binding 췌공장문합술을시행받은환자 (n=15) 를비교하였다 (Table 1). 각각의췌공장문합술을시행받은환자들의분포를살펴보면평균연령, 남녀비, BMI (body mass index), 동반질환의유무, 병변의위치, 각종실험실결과 ( 혈색소, 총빌리루빈, 알칼리인산분해효소 [alkaline phosphatase], 알부민 ) 및수술전체외담즙배액여부에서유의한차이가없었다. 다음으로수술중및수술후임상양상을비교하였다 (Table 2). 기존의췌공장문합술에비해 binding 췌공장문합술시행시수술시간이더오래걸렸지만통계학적으로유의하지는않았다 (388±29 vs 459±21; p=0.060). 췌장관련요 Fig. 6. Comparison of natural logarithmic transformation data of amylase in drains measured on postoperative 1, 3, 5 and 7 days between dunking and binding pancreaticojejunostomy procedures. *p<0.05. 인중췌장루와연관성이있다고알려진췌장의경도 (texture) 와췌관의직경에서두군간에차이는없었다. 환자의수술후경과와관련된중환자실경유기간, 비위관삽입기간, 경구식이의시작, 배액관유지기간및술후재원기간에서도두군간에유의한차이가없었다. 술후 1일, 3일, 5일그리고 7일째 JP 배액관으로부터아밀라아제치를구하여두군간에차이가있는지비교하였다. 두군의비교에서배액관아밀라아제치는정규성을지니지않으므로, 그수치의상용로그값을이용해정규분포화시킨뒤비교하였다 (Fig. 6). 술후 1일째, 3일째그리고 7일째값에서 binding 췌공장문합의배액관아밀라아제상용로그값이기존수술후의배액관아밀라아제상용로그값보다유의하게높게나타났다 (1일째 6.97±0.41 vs 6.10±0.44, p=0.037; 3일째 6.97±0.41 vs 6.10±0.44, p=0.032; 7일째 4.69±0.35 vs 3.88±0.25, p=0.034). 췌공장문합술의차이에따른합병증의비교에서는전체합병증에서는차이가없었지만 (6/16 [37.5%] vs 5/15 [33.3%]), Clavien씨분류법 10 에따른합병증의중등도에는차이를보였다 (Table 3). 즉, dunking 췌공장문합군에서는 3도및 5도합병증 ( 중등도합병증 ) 이각각 1명씩있었지만, binding 췌공장 Table 3. Postoperative complications according to the operative technique (dunking pancreaticojejunostomy versus binding pancreaticojejunostomy in pancreaticoduodenectomy Operative techniques Clavien s grade* Complications Patient number Dunking pancreatico- I Bile leakage 1 jejunostomy II Delayed gastric 2 (n=6/16) emptying Wound infection 1 III Pancreatic leakage 1 V Pancreatic leakage 1 Binding I Bile leakage 2 pancreatico- II Delayed gastric 1 jejunostomy emptying (n=6/15) Wound infection 1 Pleural effusion 1 *Clavien s classification. Grade I=any deviation from the normal postoperative course; Grade II=requiring of pharmacological treatment; Grade III=requring surgical, endoscopic or radiological intervention; Grade IV=life-threatening complication requiring ICU management; Grade V=death of a patient 291

7 한국간담췌외과학회지 : 제 13 권제 4 호 2009 문합군에서는 1도와 2도의합병증 ( 경도합병증 ) 만이존재했다. 기존췌공장문합군에서의 3도및 5도합병증은모두췌장루이었으며, 이로인해 1명의술후사망자도발생하였다 ( 사망률 0.6% [1/16]). 하지만 binding 췌공장문합술이도입된이후췌장루및사망자는발생하지않았다. 고찰 췌십이지장절제술후췌장루는그빈도가 0 28% 로알려졌듯이비교적흔하며환자의술후경과에결정적인역할을하는중요한합병증이다. 2 Lin 등 3 은췌장루가동반된환자에서재수술빈도, 술후재원기간및췌장염, 담즙누출, 창상감염등의합병증이의미있게증가했다고보고하였다. 따라서췌장루의원인을찾아이를낮추려는노력이있어왔다. 일반적으로췌장루에영향을미치는요인은췌장요인 ( 췌장의경화도, 췌관크기, 췌액분비량, 췌장의병리소견 ), 환자요인 ( 나이, 성별, 황달정도, 동반질환의심각도, 영양결핍여부 ) 및수술요인 ( 수술시간, 출혈량, 문합방법 ) 의 3가지로나누어생각할수있다. 6,11 Yang 등 11 은 62명의환자들에대한다변량분석에서췌장의연한경도 (soft texture) 와직경 3 mm 이하의췌관이췌장루의독립적인위험요인이라고보고하였으며, 그밖의많은연구에서도췌장의경도 3,12 와췌관의크기 9,13 가췌장루와의관련됨을확인하였다. 이외에도췌장요인중문합부로의혈류 14 및췌액분비량 15 과의관련성도보고되었으며, Ishikawa 등 16 은수술전췌공장문합예상부위로의방사선조사를통해췌액분비감소를유도한결과췌장루의빈도가감소되고환자생존율의향상되었다고보고하였다. 환자요인들중에선남성 17 및고령 (>70세) 18 등이위험요인으로언급되었으며, Lin 등 3 은 1,891명의환자를대상으로했던광범위한후향적연구에서췌장의연한경도와더불어환자의관상동맥질환병력또한췌장루의독립위험인자이라고기술하였다. 췌장루의위험요인들중수술요인에대한분석은매우중요한데이는이수술요인이유일하게교정가능한요인이기때문이다. 먼저 dunking법과관점막문합법 (duct-to-mucosa anastomosis) 의비교는수십년전부터가장많이논의되었던주제중에하나였다. 1980년대의논문들은췌장루의빈도에서두수술법간에차이가없다는결론이많았다. 19,20 하지만, 1991년 Bartoli 등 21 은 15년간시행된 2,361예의수술을분석한결과 dunking법후의췌장루는 26% 인데비해, 관점막문합 법후의빈도는 16% 라고보고였으며, 그이후관점막문합법의우월성에대한논문이계속발표되었다. 22,23 아직까지두수술법에대해전향적비작위연구가이루어지지않아정확한차이를알수없다. 한편으론 Marcus 등 17 은췌관이확장되어있으며췌장이딱딱할때 (firm fibrotic pancreas) 는관점막문합법이적합하며, 췌관이가늘고췌장이연할땐 (soft friable pancreas) dunking법이적절하다는논문을발표하기도하였다. 다음으론췌공장문합과췌위문합 (pancreaticogastrostomy) 와의비교이다. 췌위문합은문합할잔여췌장과위가가깝게위치하고있어장력이없는문합 (tension-free anastomosis) 이가능하다는점, 위의풍부한혈류가문합부혈액공급을용이하게한다는점및위내로배출된췌장액이산성인위액과만나불완전하게비활성화되어췌액으로인한문합부손상을줄일수있다는점에서췌장루를낮출수있는방법으로각광을받았었다. 24 실제로 Mason 등 25 은 813명에서췌위문합술을시행한결과 4% 의낮은췌장루빈도를보고하였다. 하지만위점막증식에의한문합부협착 26 및무엇보다도위산으로인한췌장액의비활성화로인해발생한다고생각되는췌장외분비기능저하 27 가췌위문합으로의전환을주저하게만든다. 또한아직까지충분한췌공장문합과의전향적무작위비교논문이없어췌공장문합과의우월성비교가힘든상황이다. 한편, 췌관내도관삽입이췌장루를낮출수있을것이라는가정으로체내및체외로배액되는도관삽입술이시행되었지만아직까지췌장루의빈도를의미있게낮추었다는보고는없다. 28,29 이렇게췌장루를줄이기위한수술방법의제고가이루어지고상황에서, 2002년 Peng 등은처음으로 binding 췌공장문합술을발표했고, 년 227명의환자에게이술식을시행한결과한명의환자에서도췌장루가발생하지않았다고놀랄만한보고를하였다. 6 이보고에따르면 2004년당시 binding 췌공장문합술를시행하는병원이중국에 83개이며, 이들병원에서췌십이지장절제술을시행받은 1,020명의환자들중 4명 (0.39%) 에서만췌장루가발생했다고하였다. 6 Peng 등 30 이제시하는 binding 췌공장문합술의장점은첫째, 외측췌공장문합으로공장의장근육막층 (seromuscular layer) 이잔여췌장에단단히부착된다는점, 둘째, 내측췌공장문합시공장점막의깊이로만봉합을하여공장근육층이상의손상을피할수있다는점및췌장을함입하는공장점막에전기소작이나화학적소작 (10% carbonic acid와 75% 알코올을이용 ) 을가함 292

8 김세준외 :Binding 췌공장문합술의초기경험및 Dunking 췌공장문합술과의비교 으로써점막액분비를막고, 유착등을유발하여빠른치유가이루어진다는점이다. 본술식은저자들의병원과같이췌십이지장절제술을많이시행하지않는병원 (low volume center) 에서도손쉽게시행할수있을정도로수술방법이어렵지않았다. 시행초기에예기치못했던어려움은췌장의크기가크고, 공장의직경이작은경우췌장을함입시키기어려웠던점이다. 이경우 EEA sizer를이용한공장직경확장을시도하였다. 그과정에서공장점막파열이나타나기도했으며 3명의환자에서는함입되는췌장의길이가 3 cm가되지못해서외측췌공장문합을촘촘히하는것으로 binding 결찰을대신하기도했다. 따라서이러한초기의어려움을겪은뒤, 저자들은수술예정환자의술전컴퓨터단층사진을통해췌장경부 ( 및향후수술에서췌장절단면으로예상되는부위 ) 의최장직경을구하여향후수술에서의난이도를가늠할것을권고한다. 지금까지의 15예중에서 binding 췌공장문합술이불가능할정도로췌장의크기가크거나공장직경이작은경우는없었다. 결론적으로, Peng이제시한 binding 췌공장문합술은기존의췌공장문합술에익숙한술자가쉽게시행할수있다고생각된다. 이술식을시행받은환자를 dunking 췌공장문합술을시행받았던환자와비교했을땐수술시간, 출혈, 술후식이시작등의일반적인경과면에서큰차이가없었고, 술후합병증에있어서도그빈도에서는차이가없었으나, 중증도합병증 (Clavien s classification grade III V) 의빈도는낮았으며특히, 시행받은 15명의환자중췌장루는발생하지않았다. 따라서본술식은췌장루의빈도를낮춤을통해환자의이환율을감소시킬수있을것으로기대된다. 이러한본연구에서의결과를입증하기위한좀더많은환자를대상으로한전향적무작위비교연구가뒷받침되어야할것이다. 참고문헌 1. Molinari E, Bassi C, Salvia R, et al. Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients. Ann Surg 2007;246: Benzoni E, Saccomano E, Zompicchiatti A, et al. The role of pancreatic leakage on rising of postoperative complications following pancreatic surgery. J Surg Res 2008;149: Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 2004;8: Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995; 222: Peng S, Mou Y, Cai X, Peng C. Binding pancreaticojejunostomy is a new technique to minimize leakage. Am J Surg 2002;183: Peng S, Wang J, Li J, Mou Y, Liu Y, Cai X. Binding pancreaticojejunostomy-a safe and reliable anastomosis procedure. HPB (Oxford) 2004;6: Shinchi H, Wada K, Traverso LW. The usefulness of drain data to identify a clinically relevant pancreatic anastomotic leak after pancreaticoduodenectomy? J Gastrointest Surg 2006; 10: Sikora SS, Posner MC. Management of the pancreatic stump following pancreaticoduodenectomy. Br J Surg 1995;82: Poon RT, Fan ST, Lo CM, et al. External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg 2007;246: Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: Yang YM, Tian XD, Zhuang Y, Wang WM, Wan YL, Huang YT. Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenterol 2005;11: Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg 2000;232: van Berge Henegouwen MI, De Wit LT, et al. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg 1997;185: Strasberg SM, Drebin JA, Mokadam NA, et al. Prospective trial of a blood supply-based technique of pancreaticojejunostomy: effect on anastomotic failure in the Whipple procedure. J Am Coll Surg 2002;194: Hamanaka Y, Nishihara K, Hamasaki T, et al. Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage. Surgery 1996;119: Ishikawa O, Ohigashi H, Imaoka S, et al. Concomitant benefit of preoperative irradiation in preventing pancreas fistula formation after pancreatoduodenectomy. Arch Surg 1991;126: Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221:

9 한국간담췌외과학회지 : 제 13 권제 4 호 Matsusue S, Takeda H, Nakamura Y, Nishimura S, Koizumi S. A prospective analysis of the factors influencing pancreaticojejunostomy performed using a single method, in 100 consecutive pancreaticoduodenectomies. Surg Today 1998;28: Grace PA, Pitt HA, Tompkins RK, DenBesten L, Longmire WP Jr. Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg 1986;151: Funovics JM, Zöch G, Wenzl E, Schulz F. Progress in reconstruction after resection of the head of the pancreas. Surg Gynecol Obstet 1987;164: Bartoli FG, Arnone GB, Ravera G, Bachi V. Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature. Anticancer Res 1991;11: Matsumoto Y, Fujii H, Miura K, et al. Successful pancreatojejunal anastomosis for pancreatoduodenectomy. Surg Gynecol Obstet 1992;175: Howard JM. Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection. J Am Coll Surg 1997; 184: Poon RT, Lo SH, Fong D, Fan ST, Wong J. Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg 2002;183: Mason GR. Pancreatogastrostomy as reconstruction for pancreatoduodenectomy: review. World J Surg 1999;23: Amano H, Takada T, Ammori BJ, et al. Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study. Hepatogastroenterology 1998;45: Lemaire E, O'Toole D, Sauvanet A, Hammel P, Belghiti J, Ruszniewski P. Functional and morphological changes in the pancreatic remnant following pancreaticoduodenectomy with pancreaticogastric anastomosis. Br J Surg 2000;87: Imaizumi T, Harada N, Hatori T, Fukuda A, Takasaki K. Stenting is unnecessary in duct-to-mucosa pancreaticojejunostomy even in the normal pancreas. Pancreatology 2002;2: Winter JM, Cameron JL, Campbell KA, et al. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2006;10: Peng SY, Mou YP, Liu YB, et al. Binding pancreaticojejunostomy: 150 consecutive cases without leakage. J Gastrointest Surg 2003;7:

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