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1 대한내과학회지 : 제 88 권제 1 호 위내시경점막하박리술후발생한기흉 1 예 경북대학교의학전문대학원내과학교실 이유림 허준 정민규 김성국 강은정 여승재 박혜윤 A Case of Pneumothorax Following Gastric Endoscopic Submucosal Dissection Yu Rim Lee, Jun Heo, Min Kyu Jung, Sung Kook Kim, Eun Jeong Kang, Seong Jae Yeo, and Hye Yoon Park Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea Endoscopic submucosal dissection (ESD) is widely accepted as an alternative treatment to surgical resection for gastric neoplastic lesions. Among the complications of gastric ESD, perforation is usually manifested as a pneumoperitoneum. Here, we report a patient with a right-sided pneumothorax, pneumoperitoneum, and pneumoretroperitoneum as complications of gastric ESD. The patient recovered without further complications using conservative treatment, including endoscopic clipping, nasogastric drainage, and insertion of a chest tube. (Korean J Med 2015;88:54-59) Keywords: Endoscopy; Dissection; Complication; Pneumothorax 서론위장관종양의수술적치료를대신하여비침습적인치료로서내시경절제술이증가하고있다. 특히내시경점막하박리술 (endoscopic submucosal dissection, ESD) 은수술과비교하여적은비용과낮은이환율을가지면서, 비교적큰위선종및조기위암을치료할수있다는장점이있다 [1]. 하지만내시경절제술이증가함에따라이에따른합병증도증가하고있는데, 천공은내시경절제술의심각한합병증중의하나이다. 특히기존내시경점막절제술 (endoscopic mucosal resection, EMR) 의천공발생률이약 0.5% 인데비해, ESD는약 4% 의천공발생률을나타내는것으로보고되었 다 [1]. 위 ESD 후천공은주로공기복막증 (pneumoperitoneum) 으로발견되나, 저자들은 ESD 후기흉 (pneumothorax) 이발생하여치료한증례를경험하였기에문헌고찰과함께보고한다. 증례 76세여자가위 ESD 시행을위하여입원하였다. 환자는내원 5년전직장구불결장암 (rectosigmoid colon cancer) 을진단받고수술한병력이있었다. 수일간의상복부불편감으로타병원에서내시경을시행하였고, 위체부소만 (lesser curvature of distal body of stomach) 부위의편평미란이발견되었다. 조직검사는저도이형성관샘종 (tubular adenoma with low Received: Revised: Accepted: Correspondence to Jun Heo, M.D. Department of Internal Medicine, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu , Korea Tel: , Fax: , hero797@hanmail.net Copyright c 2015 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

- Yu Rim Lee, et al. Pneumothorax following gastric ESD - A B C D Figure 1. Endoscopic findings of the patient.

(B) No definite perforating hole was seen immediately following endoscopy after the pneumothorax, but a deep muscular site was exposed and created suspicion of the perforated

grade dysplasia) 소견을보였다. 입원후 ESD가시행되었다. 지름 20 20 mm의 type IIb 병변이위체부소만에위치해있었다 (Fig. 1A). ESD는표지 (marking), 생리식염수의주입, 선절개 (precutting), 점막하박리 (dissection) 의과정으로진행되었다.

시술후환자는호흡곤란, 흉부불편감, 복통및복부팽만감을호소하였으나활력징후는혈압 148/80 mmhg, 맥박 78회 / 분, 호흡 20회 / 분, 체온 36.5, 산소포화도 98% 로안정적이었다. 신체검진상 청진시폐우측의호흡음감소가있었다.

2 - Yu Rim Lee, et al. Pneumothorax following gastric ESD - A B C D Figure 1. Endoscopic findings of the patient. (A) The lesion (tubular adenoma, type IIb, mm in diameter) was located at the lesser curvature of the mid-body. (B) No definite perforating hole was seen immediately following endoscopy after the pneumothorax, but a deep muscular site was exposed and created suspicion of the perforated site (arrow). (C) Endoscopic clipping was performed at the suspicious perforated site. (D) The perforated site had completely healed with a scar 5 months later. grade dysplasia) 소견을보였다. 입원후 ESD가시행되었다. 지름 mm의 type IIb 병변이위체부소만에위치해있었다 (Fig. 1A). ESD는표지 (marking), 생리식염수의주입, 선절개 (precutting), 점막하박리 (dissection) 의과정으로진행되었다. Hook-knife (Finemedix. Co. Daegu, Korea) 를이용한선절개후점막하층의박리를시행하였다. 점막하층의박리시출혈이발생하였고점막하층의출혈부위를전기응고술 (electrocoagulation) 을사용하여지혈하였다. 시술은 90분간시행되었다. 시술후환자는호흡곤란, 흉부불편감, 복통및복부팽만감을호소하였으나활력징후는혈압 148/80 mmhg, 맥박 78회 / 분, 호흡 20회 / 분, 체온 36.5, 산소포화도 98% 로안정적이었다. 신체검진상 청진시폐우측의호흡음감소가있었다. 증상발생후시행한단순흉부방사선촬영및복부방사선촬영에서우측기흉 (Right sided pneumothorax), 피하기종 (subcutaneous emphysema), 우측가로막하자유공기 (free air at the right subdiaphragm) 그리고신장과후복막강내장윤곽을나타내는후복막강내공기가발견되었다 (Fig. 2A and 2B). 즉시비강을통한산소투여및추적내시경이시행되었으며, ESD에의한궤양이위체부소만에서관찰되었으나저명한천공결함은없었고 (Fig. 1B), 십이지장의특이소견은보이지않았다. 내시경클리핑 (Endoscopic clipping) 을천공이의심되는근육노출부위에시행하였다 (Fig. 1C). 이후시술당일코위흡인 (Nasogastric drainage) 과금식이시행되었고, 정맥내항생제

- 대한내과학회지 : 제 88 권제 1 호통권제 653 호 2015 - A B C D Figure 2.

(A) Plain chest radiography performed immediately after the endoscopic submucosal

This panel shows the right-sided pneumothorax, subcutaneous emphysema, and free air at the

This panel shows gas within the retroperitoneal space, which outlines the kidneys and

3 - 대한내과학회지 : 제 88 권제 1 호통권제 653 호 A B C D Figure 2. Plain chest and abdominal radiographs. (A) Plain chest radiography performed immediately after the endoscopic submucosal dissection (ESD). This panel shows the right-sided pneumothorax, subcutaneous emphysema, and free air at the right sub-diaphragm. (B) Plain abdominal radiography performed immediately after the ESD. This panel shows gas within the retroperitoneal space, which outlines the kidneys and retroperitoneal portions of the bowel. (C, D) Plain chest and abdominal radiography taken the day after ESD. These photographs show an improved pneumothorax with a chest tube, clips in the perorated stomach, and an inserted L-tube. L-tube, levine tube

및양성자펌프억제제 (proton pump inhibitor) 가투여되었다. 또한흉부외과에협진하여흉관삽관을시행하였다. 이후환자는열, 복통등의추가증상은발생하지않았고경과가양호하였다. 시술 3일후식이를진행하였고시술 4일후흉관제거를시행하였다.

4 - 이유림외 6 인. 위내시경점막하박리술후기흉 1 예 - A B Figure 3. Chest computed tomography was performed 7 days after the procedure. (A) It revealed resorption of the right pneumothorax, scant pneumomediastinum and subcutaneous emphysema. The lung parenchyme was normal. (B) No defects were detected in the diaphragm. 및양성자펌프억제제 (proton pump inhibitor) 가투여되었다. 또한흉부외과에협진하여흉관삽관을시행하였다. 이후환자는열, 복통등의추가증상은발생하지않았고경과가양호하였다. 시술 3일후식이를진행하였고시술 4일후흉관제거를시행하였다. 절제된조직검사결과는고도이형성관샘종 (tubular adenoma with high grade dysplasia) 으로크기는 mm였으며, 절제면의선종침범은없었다. 시술 7일후흉부컴퓨터단층촬영 (chest computed tomography) 을시행하였으며우측기흉의호전및소량의피하기종, 공기복막증 (pneumoperitoneum) 및공기후복막증 (pneumoretroperitoneum) 이관찰되었다. 양측폐실질 (lung parenchyma) 은정상소견으로기관지확장증, 폐기종은관찰되지않았고횡격막의저명한결함은없었다 (Fig. 3A and 3B). 환자는점차호전되어시술 8일후퇴원하였다. 시술 5개월후시행된추적내시경상위체부소만의충혈및궤양흉터 (ulcer scar with hyperemic mucosa) 소견이관찰되었고 (Fig. 1D), 궤양흉터에서시행된추적조직검사상재발은없었다. 고찰 ESD는 EMR과비교하여높은일괄절제율과낮은국소재발률을보여주지만높은시술숙련도및긴시술시간을필요로한다 [1,2]. ESD의다양한합병증이보고되고있으며, 그중천공은복막염, 패혈증, 쇼크그리고사망에이를수있는심각한합병증이다. ESD 시발생한천공은내시경이나시술시사용되는도구로부터의직접적, 물리적손상, 전기응고술같은추가치료적시술혹은과도한공기주입으로인한압력손상에의해발생할수있다 [3]. 위 ESD 시발생하는천공은주로공기복막증 (pneumoperitoneum) 과이어지는복막염의증상을보인다. 한편내시경역행담췌관조영술 (endoscopic retrograde cholangiopancreatography, ERCP) 시발생하는천공은십이지장의해부학적위치로인하여주로공기후복막증 (pneumoretroperitoneum) 으로나타나며, ERCP 후기흉 (pneumothorax) 합병증까지동반된몇몇증례들이보고되었다 [4]. 하지만위 ESD의합병증으로서의기흉은거의보고된바가없다. 본증례에서위 ESD 후발생한기흉에대해몇가지기전들이제시될수있다. 첫번째로는긴시술동안지속적으로

5 - The Korean Journal of Medicine: Vol. 88, No. 1, 주입된공기로인해장관내압이상승하여실제천공결함없이, 혹은미세천공을통한후복막강으로의직접적인공기누출가능성을생각할수있다 [5]. 이전구불직장암수술접합부혹은십이지장을통해후복막강내로공기가누출되어근막면을통해종격동, 피하조직으로통과되고, 최종적으로흉막강으로퍼져기흉이발생할수있다 [6]. 또한진단적, 치료적내시경후발생한천공에서공기복막증과공기후복막증이함께발생한증례는극히드물어, 본증례에서의공기복막증은내시경점막하절제술부위의미세천공을통한공기누출로인해함께발생하였을가능성이높다. 두번째로, 복막강과흉막강의연결로인한기흉발생으로구멍횡격막증후군 (porous diaphragm syndromes) 의가능성을생각해볼수있다. 이는선천적혹은후천적으로형성된횡격막의구멍혹은결함을통하여복막투석, 복수를동반한간경화혹은복강경수술과같은복강내압력이증가되는상황에서공기, 액체를포함한물질이복강에서동측흉막강으로이동하는것을의미한다. 이가설에따르면, 공기복막증발생후공기가횡격막의작은틈을통하여흉막강내로이동하여기흉이생길수있으며, 대부분증례의경우본증례와같이횡격막의저명한결함은관찰되지않았다 [7]. 하지만본증례에서발생한공기후복막증과종격동기종 (pneumomediastinum) 의발생을설명할수없어, 두번째기전의가능성은높지않을것으로생각된다. 위천공은전통적으로수술적복원이주된치료방법이었으나, 최근내시경클리핑을사용한내시경치료가가능해졌다. 특히치료적내시경시술에서발생한작은천공에서내시경클리핑시술의성공적인결과가보고되었다 [8]. 대부분의치료내시경시술과관련된천공합병증은내시경클리핑, 코위흡인과금식, 산소공급, 정맥내항생제및양성자펌프억제제 (proton pump inhibitor) 투여를포함한보존적치료로성공적으로치료된다. 하지만수술혹은내시경치료의선택은천공손상의종류와크기, 장관의전처치정도, 병변의종류, 천공후진단까지걸린시간그리고환자의임상적상태등을고려하여신중히결정되어야한다 [9]. 만약환자가내시경클리핑시행후에도임상적악화를보일경우외과협진을통해응급수술을고려해야한다 [8]. 본증례처럼내시경절제술후발생한천공에서기흉이동반되는경우, 산소투여및즉각적인흉부외과와의상의가필요하다. 증상이없는작은크기의기흉은경과관찰이가능하지만혈역학 적으로불안정하거나호흡곤란등의증상이있을때, 그리고기흉의크기가큰경우 ( 폐문위치에서폐가장자리와흉벽과의거리가 2 cm 이상 ) 에는흉관삽관이필요하다 [10]. 기흉은 ESD의합병증으로드물게발생하며예측이어렵다. 본증례처럼내시경절제술후호흡곤란, 활력징후의변화, 산소포화도의감소를보이는환자에서기흉의가능성을생각해야하겠다. 또한신체검진및영상기법을통한신속한진단과함께임상상황에맞는적절한치료가필요할것이다. 요 위장관종양의 ESD는상대적으로안전한시술이지만다양한합병증이보고되고있다. 그중에서위 ESD 후발생한기흉은아주드문합병증으로저자들은위 ESD 후기흉, 공기복막증및공기후복막증이발생한환자에서내시경클리핑과흉관삽관을포함한보존적치료로호전이있었던증례를문헌고찰과함께보고한다. 약 중심단어 : 내시경검사 ; 절제 ; 합병증 ; 기흉 REFERENCES 1. Oda I, Gotoda T, Hamanaka H, et al. Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series. Digestive endoscopy 2005;17: Gotoda T, Kondo H, Ono H, et al. A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. Gastrointest Endosc 1999;50: Saito I, Tsuji Y, Sakaguchi Y, et al. Complications related to gastric endoscopic submucosal dissection and their managements. Clin Endosc. 2014;47: Schepers NJ, van Buuren HR. Pneumothorax following ERCP: report of four cases and review of the literature. Dig Dis Sci 2012;57: Schmidt G, Börsch G, Wegener M. Subcutaneous emphysema and pneumothorax complicating diagnostic colonoscopy. Dis Colon Rectum 1986;29: Pourmand A, Shokoohi H. Tension pneumothorax, pneumoperitoneum, and cervical emphysema following a diagnostic colonoscopy. Case Rep Emerg Med 2013;2013: Cerfolio RJ, Bryant AS. Efficacy of video-assisted thoraco

6 - Yu Rim Lee, et al. Pneumothorax following gastric ESD - scopic surgery with talc pleurodesis for porous diaphragm syndrome in patients with refractory hepatic hydrothorax. Ann Thorac Surg 2006;82: Doğan ÜB, Keskin MB, Söker G, Akın MS, Yalaki S. Endoscopic closure of an endoscope-related duodenal perforation using the over-the-scope clip. Turk J Gastroenterol 2013;24: Vincent M, Smith LE. Management of perforation due to colonoscopy. Dis Colon Rectum 1983;26: MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British thoracic society pleural disease guideline Thorax 2010;65(Suppl 2):ii

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±è¹ÎÁö 531 김민지 외: 미숙아에 발생한 의인성 식도천공과 기종격증 및 종격동염 A B C D E F Fig. 1. Chest radiographs and CT scans of a premature infant. Chest radiograph at 6 days after birth (A) shows left paravertebral radiolucency at the