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1 J Korean Surg Soc 2010;79: DOI: /jkss 원 저 고도비만환자에서복강경하위소매절제술의초기경험 순천향대학교의과대학외과학교실 노정호ㆍ김지선ㆍ김용진ㆍ조성우ㆍ최동호ㆍ허경열ㆍ김재준 Initial Experience of Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients Jung Ho No, M.D., Zisun Kim, M.D., Yong Jin Kim, M.D., Sung Woo Cho, M.D., Dong Ho Choi, M.D., Kyung Yul Hur, M.D., Jae Joon Kim, M.D. Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea Purpose: Laparoscopic sleeve gastrectomy (LSG) is rapidly gaining ground as one of the surgical procedures in bariatric surgery with emerging long-term follow-up data. The aim of the present study was to report our initial experience of LSG in morbidly obese patients. Methods: Sixty-four consecutive patients underwent LSG from April 2009 to July 2010 at our bariatric surgery center. Patients eligible for LSG were those with a body mass index (BMI) of >37 kg/m 2, and >32 kg/m 2 with co-morbidities. LSG was performed using 5 trocars and endo-staplers with guidance of 34 Fr bougie. Perioperative management was standardized. The clinical data were prospectively collected and retrospectively analyzed. Results: Among 64 patients, 19 were male and 45 were female, mean age was 35 years (range 20 57), mean preoperative BMI was 38.8 kg/m 2 (range 32 57), and mean preoperative body weight was 108 kg (range ). Mean operative time was 118 minutes (range ) and mean length of hospital stay was 3.4 days (range 1 82). Staple line leak occurred in 1 patient, kinking of the gastric tube occurred in 2 patients. There was no open conversion and no postoperative mortality. After 170 days of follow-up, 24.4 kg of body weight loss and 52.7% of excess weight loss (%EWL), on average, was noted. Conclusion: Though long-term follow-up is needed, our early operative outcome was satisfactory in terms of %EWL and safety of the procedure. LSG was a safe and effective treatment strategy for morbidly obese patients. (J Korean Surg Soc 2010;79: ) Key Words: Sleeve gastrectomy, Morbid obesity 중심단어 : 위소매절제술, 고도비만 서 베리아트릭수술은고도비만환자의장기적이고지속적인체중감량및비만관련질환의개선에있어유일하게 책임저자 : 김용진, 서울시용산구한남동 , 순천향대학교병원외과 Tel: , Fax: yjkim@hosp.schmc.ac.kr 접수일 :2010 년 9 월 7 일, 게재승인일 :2010 년 10 월 9 일 론 그효과가입증되고검증된치료방법이다.(1) 전체인구의 30% 이상이고도비만인미국을포함한서구의경우다양한베리아트릭수술이급속히증가하고있다. 한국도더이상예외가아니며, 2008년보건복지가족부산하질병관리본부에서시행한제 4기국민건강영양조사결과에따르면비만인구 ( 만 19세이상, 체질량지수 25 kg/m 2 이상 ) 유병율이 30% 를상회한것으로보고되었다.(2) 또한비만과동반하여고혈압, 당뇨, 고지혈증등의만성질환도상승하는추세로, 우리나라도비만을미용적인문제가아닌하나의질환 460

2 Jung Ho No, et al:laparoscopic Sleeve Gastrectomy 461 으로인식하고적극적으로치료해야할시점에도달했다고하겠다. 복강경도입후베리아트릭수술은급격히발달하여고도비만을치료하기위한다양한수술방법이시도되었다. 순수하게식이를제한하는형태의수술중하나인복강경하위소매절제술은 1999년초고도비만환자에서췌담도우회술을시행하기전단계로체중감소를유도하기위한목적으로시행되었으며,(3) 이후수술의안정성및장기적인효과가발표되면서부분적으로일차수술의한방법으로인정받고있다.(4) 복강경하위소매절제술시행후 3년추적검사결과평균초과체중감소율은약 60 70% 로보고되었으며,(5) 계통고찰결과관찰기간 (3 60개월) 중평균초과체중감소율은 55.4% ( ) 인것으로보고되었다.(6) 최근발표결과에따르면수술후 6년이상지난시점에서평균초과체중감소율이 50% 이상으로유지되어, 복강경하위소매절제술을장기적인체중감량및유지를위한치료방법의한가지로서고려해볼수있음이밝혀졌다.(7) 이에저자들은본원에서시행한복강경하위소매절제술의초기경험을보고하고자하였다. 방법 1) 환자선택및수술준비 본원임상윤리위원회의승인 ( 승인번호 # ) 을거쳐 2009년 4월부터 2010년 7월까지 64명의환자에서복강경하위소매절제술을시행하였다. 아시아-태평양비만수술기준 (8) 에근거하여체질량지수 37 kg/m 2 이상인경우, 체질량지수 32 kg/m 2 이상이면서당뇨가동반된경우, 또는체질량지수 32 kg/m 2 이상이고고혈압, 고지혈증, 관절병증, 수면무호흡증등의비만관련동반합병증중두가지이상이있는환자를대상으로하였으며, 수술전영양사면담을통하여지방간으로인한간비대를줄이고환자들에게수술에대한동기를부여하기위한목적으로 2주간고단백식이를하도록교육하였고, 수술전기본검사로혈액검사 ( 일반적인수술전검사와동일 ), 흉부엑스선촬영, 심전도, 폐기능검사, 위내시경, 복부전산화단층촬영, 정신과면담을시행하였으며, 필요할경우갑상선기능검사 ( 갑상선기능이상으로치료받은병력이있는경우 ), 수면검사및이비인후과검진 ( 수면무호흡증의병력이있는경우 ), 당화혈색소, basal insulin level, basal C-peptide level 등의혈액검사 ( 당뇨를진단받았거나치료중인경우 ), 그리고산부인과검진 ( 월경장애가있는경우 ) 등을시행하였다. 수술시작시점부터전향적으로수집한환자의임상자료를바탕으로수술전후의체중, 초과체중및체질량지수의변화, 동반합병증의변화, 수술관련합병증및사망등에대하여분석하였다. 2) 수술방법 수술 12시간전에심부정맥혈전증예방을위한저용량헤파린을주사하였고, 마취유도전예방적항생제를투여하였다. 전신마취하에양팔을벌리고앙와위에서역트렌델렌버그 (reverse-trendelenberg) 자세를취하였고, 환자의안전을위해발받침대를사용하였다. 간견인을위하여검상돌기왼쪽하방에 11 mm 투관침 (ENDOPATH R XCEL TM Bladeless Trocar, Ethicon Endo-Surgery, Cincinnati, OH, USA) 과 0 o 카메라를이용해복강내로진입후기복 (12 15 mmhg) 을형성하고시야를확보하였다. 이후카메라삽입을위한 11 mm 투관침을좌상복부에, 수술자를위해한개의 12 mm 투관침 (ENDOPATH R XCEL TM Bladeless Trocar, Ethicon Endo-Surgery, Cincinnati, OH, USA) 과한개의 5 mm 투관침 (ENDOPATH R XCEL TM Bladeless Trocar, Ethicon Endo-Surgery, Cincinnati, OH, USA) 을우상복부에, 그리고조수를위한 5 mm 투관침을좌상복부에위치시켰다 (Fig. 1). 유문륜 4 cm 상부의대만부위에서시작하여위-식도경계부위까지초음파절삭기 (Ultrasonic HARMONIC R Devices, Ethicon Endo-Surgery, Cincinnati, OH, USA) 를이용하여가능한위에붙여서대망을분리하였다. 위후벽은횡격막의 Fig. 1. Laparoscpic sleeve gastrectomy was performed using 5 trocars. The position and size of trocars are illustrated.

34 Fr 부지 (bougie) 를삽입하여십이지장으로넘겨둔후처음박리하였던대만부위에서위각방향으로복강경용선형절단기 (ECHELON ENDOPATH TM Staplers 45 mm, Ethicon Endo-Surgery, Cincinnati, OH, USA) 를이용하여위-식도경계부위까지부지를따라위를절단하였다.

3 462 J Korean Surg Soc. Vol. 79, No. 6 Fig. 2. Resected gastric specimen (A) and water-soluble contrast swallow study on postoperative day 1 (B) were shown. The greater curvature and the posterior wall of stomach were properly removed (B). 좌각근육이노출되도록박리하였다. 34 Fr 부지 (bougie) 를삽입하여십이지장으로넘겨둔후처음박리하였던대만부위에서위각방향으로복강경용선형절단기 (ECHELON ENDOPATH TM Staplers 45 mm, Ethicon Endo-Surgery, Cincinnati, OH, USA) 를이용하여위-식도경계부위까지부지를따라위를절단하였다. 위절단면의경우초기 30명은스테이플이겹치는부위와출혈부위만선택적보강봉합을시행하였으며, 이후 34명은절단면전체에연속보강봉합을시행하였다. 절단면누출여부를확인하기위하여염색액 (Methylene blue) 과공기를이용하였다. 절제된위표본은우상복부의 12 mm 투관침부위를확장하여제거하고수술을종료하였으며, 비위관이나배액관은사용하지않았다 (Fig. 2A). 3) 수술후관리심부정맥혈전증을예방하기위하여저용량헤파린을 2 주간투여하였으며, 입원기간동안하지정맥압박술 (pneumatic pump) 을시행하였다. 수술후제 1일에수용성조영제 (gastrografin) 를이용한위장관조영술을통해누출여부를평가하였고 (Fig. 2B), 누출이없는경우바로식이를진행하였다. 식이진행의경우수술후 3일동안은미음 (clear liquid), 수술후 3주까지는죽 (soft diet), 그리고그이후부터는서서히정상식이 (solid diet) 를하도록지도하였다. 위식도역류예방을위해수술후 2개월간항궤양제 (proton pump inhibitor) 를투약하였고, 급격한체중감소로인한담석증예방을위해 ursodeoxycholic acid (300 mg/day, 우루사, 대웅제약, Seoul, Korea) 를 6개월간처방하였다. 수술후 1주일, 1개월, 3개월, 6개월, 그리고 12개월에외래추적을시행하였다. Table 1. Summary of preoperative patient characteristics Parameter Value (range) Total number of patients 64 Male:Female 19:45 Mean age (year) 35±9.4 (20 57) Mean body weight (kg) 108±20.3 (75 164) Mean body mass index (kg/m 2 ) 38.8±5.0 (32 55) Mean excess weight loss (kg) 47±16.8 (21 95) Mean number of co-morbidity* 1.4±1.2 (0 4) Mean follow-up (day) 170±118 (34 497) *Co-morbidity = diabetes, hypertension, hyperlipidemia, sleep apnea, degenerative joint disease. 4) 통계분석 수집한임상자료는 SPSS version 14.0을이용하여분석하였고, 결과는평균 ± 표준편차또는평균 ± 범위로표시하였다. 결 64명환자중남자는 19명, 여자는 45명이었고, 평균연령은 35세 ( 범위 20 57) 였으며, 수술전평균체중은 108 kg ( 범위 ), 그리고평균체질량지수는 38.8 kg/m 2 였다. 수술전당뇨, 고혈압, 고지혈증, 수면무호흡증및관절병증등의동반합병증이세가지이상인경우는 12명 (18.8%), 두가지인환자는 15명 (23.4%), 하나의합병증만있는환자는 20명 (31.3%), 그리고합병증이없는환자는 17명 (26.6%) 이었다 (Table 1). 평균수술시간은 118 분 ( 범위 ) 이었다. 개복으로 과

4 Jung Ho No, et al:laparoscopic Sleeve Gastrectomy 463 의전환은없었으며, 4예에서합병절제 ( 담낭 3예, 자궁근종 1예 ) 를시행하였다. 한명에서절단면최상부에누출이발생했으며, 2차례의추가수술 ( 일차봉합및배액술 ) 을시행하였다. 두명에서꼬임 (kinking) 이발생했으며, 1명은 4일간의금식후저절로호전되었으며, 다른 1명은 3주간의금식이필요하였다. 수술관련사망은없었다 (Table 2). 170일의평균추적기간동안초과체중감소율은 52.7% 였고, 평균 24.4 kg의체중감량이이루어졌다. 수술후 1개월, 3개월, 6개월, 및 12개월에각각 10.8 kg, 21.1 kg, 27.3 kg, 및 29.0 kg의평균체중감소가이루어졌다 (Table 3, Fig. 3). 당뇨가동반되었던 20명 (30%) 중 19명에서혈당강하제투약이필요없었으며, 현재인슐린투여중인한예는수술전체질량지수 32.3 kg/m 2, 당화혈색소 10.1%, basal C-peptide 2.08 ng/ml였다. 고혈압이동반되었던 20명중추적기간이 6개월이넘은 7명의경우모두투약을중지하였으나, 남은 13명은현재추적중이다. 환자병력상수면무호흡증이뚜렷하였던 4명은모두증상이소실되었다 (Table 4). 소량의위만남도록하는술식을말한다. 위소매절제술의체중감소와동반합병증완화의기전은식이제한, 그리고여러신경-호르몬적요소에의한것이라고알려져있다.(4) 복강경하위소매절제술의주요장점으로비교적술식이간단하며, 기존의다른우회술식 (Laparoscopic Roux-en-Y gastric bypass, bilio-pancreatic diversion) 에비하여위험성이낮다는점과,(9,10) 위입구를협착시켜정상적인식사를제한하고체내에이물질을남기는조절형위밴드술에비해우월한체중감량효과를보인다는점등을들수있다.(11,12) 또한위소매절제술을루와이위우회술식이나조절형위밴드술과직접비교한연구결과에따르면다른술식에서는발견되지않은호르몬 (ghrelin) 의유의한억제및감소로장기적인식욕감소의효과가나타났다.(13,14) 복강경하위소매절제술은그동안체중감소와관련하여장기적인결과가부족하다는단점이있었다. 그러나최근장기결과들이보고되었고,(15) 미국비만대사수술학회 (The American Society for Metabolic and Bariatric Surgery) 에 고 찰 베리아트릭수술중하나인위소매절제술은위의소만을따라위체부와기저부를포함한위를절제하여관형태의 Table 2. Parameters related to the operation Value (range) Mean operative time (minute) 118±45 (65 340) Median number of stapler cartridge 7 (5 8) Mean hospital stay (day) 3.4±10.0 (1 82) Complication 3 (4.7%) Leak 1 Kinking 2 Fig. 3. Evolution of percentage of excess weight loss and body mass index after laparoscopic sleeve gastrectomy. Table 3. Weight loss outcomes after laparoscopic sleeve gastrectomy Parameter Preoperative 1 month 3 month 6 month 12 month Follow-up number of patients Mean weight (kg) 108± ± ± ± ±17.9 Mean body mass index (kg/m 2 ) 38.8± ± ± ± ±4.6 Mean %EWL* (%) NA 24.3± ± ± ±11.4 Mean %EBMIL (%) NA 30.7± ± ± ±17.3 Mean weight loss (kg) NA 10.8± ± ± ±11.0 Loss in body mass index (kg/m 2 ) NA 3.9± ± ± ±3.5 *%EWL = percentage of excess weight loss; NA = not applicable; %EBMIL = percentage of excess body weight index loss; %EBMIL = (preoperative BMI current BMI)/(preoperative BMI 25) 100.

5 464 J Korean Surg Soc. Vol. 79, No. 6 Table 4. Resolution and improvement of co-morbidities after laparoscopic sleeve gastrectomy Incidence (%) Resolved+ Improved (%) Unchanged on follow-up (%) Type 2 diabetes 20 (30%) 19 (95%) 1 (5%) mellitus Hypertension 20 (30%) 7 (35%) 13 (65%) Hyperlipidemia 29 (45%) 14 (48%) 15 (52%) Sleep apnea 4 (6%) 4 (100%) 0 (0%) Joint disease 16 (25%) 14 (88%) 2 (12%) 서도합의를거쳐일차수술로고려해볼만한가능성이충분히있다는내용의성명을발표하였다.(4) Himpens 등 (7) 이최근발표한위소매절제술의장기결과를살펴보면, 수술 6년후평균초과체중감소율이 50% 이상으로비교적만족스러운것으로나타났다. 그러나평균초과체중감소율은수술 3년추적시점에서는 77.5% 였다가, 6년추적시점에서는 53.3% 로수술후 3년에서 6년사이에체중증가가관찰되었고 26% 의환자에서위우회술식으로의전환이필요했다고하여, 현재로서는장기결과에대한추가연구가필요한것이사실이다. 국내에서는 Han과 Kim(16) 이위소매절제술의결과를발표하였는데, 1년, 2년, 3년평균초과체중감소율이각각 72.4%, 69.5%, 66.8% 로나타나비교적좋은성적을보였으나현재까지다른국내보고는없는실정이다. 저자들의결과는 1년추적시 59.4% 의초과체중감소율을보여비록국내보고보다는약간떨어지는결과를보였으나, 이는추적환자수가 8명인것이한가지원인이될것으로생각하며, 향후지속적인결과축적이필요할것이다. 장기결과에관한명확한자료가확인되기전까지는체중증가의방지를위해조절형위밴드술에대한연구 (17,18) 에서제시한것처럼정기적지속적추적관찰이필요할것으로판단한다. 비만관련동반질환의개선에있어, Han과 Kim(16) 은당뇨, 고혈압, 고지혈증, 수면무호흡증및관절병증의완치율 을각각 100%, 93%, 45%, 100% 및 76% 로보고하여, 고혈압을제외하고는저자들과유사한결과를보였다. 그러나본연구에서도추적기간이 6개월이상된환자에서는모두고혈압이호전되어투약을중지할수있었던것으로미루어장기추적이이루어지면향상된결과를보일것으로판단하였다. 당뇨의호전에있어저자들의결과 1예에서고혈당의완화가없었는데, 이는 Lee 등 (19) 의연구결과와일치하는소견으로, Lee 등은위소매절제후당뇨호전을예측 하는데있어잔여췌장기능을반영하는 basal C-peptide 농도가가장중요한인자라고하였다. 저자들의증례역시 basal C-peptide 농도가 2.08 ng/ml로잔여췌장기능이떨어진것이고혈당완화를보이지않은한원인이된다고판단하였으며, 동시에향후환자선택및수술방법의선택에있어세심한수술전검사가필요하다고판단하였다. 위소매절제술시사용하는부지의크기에대해서는아직까지합의가이루어지지않은실정이다. 보고된바에의하면사용하는부지의크기는 32 Fr에서 60 Fr까지다양하였고,(20-22) 현재까지의일반적인추세는직경이작은부지를선호하는것으로나타났다.(4) 지금까지의근거들을바탕으로저자들은절제된위의용적이장기간의체중감소와연관이있고시간이지나면서위가늘어나게되는것이체중감소유지실패의원인이될것이라고생각하여 34 Fr의부지를사용했으며,(23) 수술중에도되도록위-식도경계부위에가깝게위절제를하려고노력하였다. 비록짧은추적기간이기는하나수술후환자들이적절한체중감소를유지할수있었고협착발생도없었던것으로미루어 34 Fr 정도의부지크기면위소매절제술에적합하다고판단하였다. 보강봉합과관련하여 Dapri 등 (24) 의무작위연구를포함하여대부분의연구가누출예방에도움이되지못함을보고하고있다.(25,26) 그러나반대로 Ser 등 (27) 은보강봉합을시행하지않은초기 40명환자중 4명에서누출이발생했으나, 이후 78명에서보강봉합을시행하여누출이없었음을근거로보강봉합이누출예방에중요함을강조하였다. 저자들은초기에는스테이플이겹치는부위에만선택적봉합을시행하다가, 2명에서스테이플과주변조직의유착에의해발생한것으로판단되는기능적폐쇄를경험한후, 모든절단면에보강봉합을시행하였고그이후로는이와관련된합병증이발생하지않았다. 따라서보강봉합이누출예방에어떤영향을미치는지는명확하지않지만, 최소한절단면의출혈예방및유착으로인한기능적폐쇄에는도움이될것으로판단하였다. 위절단에사용하는스테이플의두께와관련하여다양한카트리지가사용되고있으나, 저자들은위벽이비교적두꺼운위하부의경우는 3.8 mm 골드카트리지를사용하였고, 상부쪽으로진행하면서비교적위벽이얇은부위는 3.5 mm 블루카트리지를이용하였다. 물론스테이플의선택에는수술자의개인적인경험및선호도도영향을미치겠으나절단면이긴위소매절제술의특성을고려했을때, 수술의안정성을위해서는적절한두께의스테이플선택도중

6 Jung Ho No, et al:laparoscopic Sleeve Gastrectomy 465 요하다고할수있겠다. 위소매절제술후발생가능한합병증으로현재까지발표된 36개의연구결과를살펴보면, 총 2,367명의환자중누출 53예 (22%), 출혈 28예 (1.2%), 협착 15예 (0.6%), 그리고사망 5예 (0.19%) 가량으로보고되었다.(4) 이중가장치명적인합병증은누출로, 발생하게되면입원기간이길어지고환자의치료에어려움을겪게된다. 저자들역시 1예에서누출이발생하여 82일의긴입원이필요하였고, 재수술및다양한비수술적치료방법이이용되었다. 누출발생의위험인자로는남자, 50세이상, 및심한당뇨가동반된경우등이있으며, 지금까지가장적절한치료방법은스텐트삽입으로알려져있다.(28,29) 마지막으로위식도역류증상의경우빈도가 6.5% 로보고되었는데, 그원인을위소매절제술후위-식도경계부의해부학적구조가일자형태의관상구조로바뀌게되고, 하부식도괄약근의기능이약해지면서위식도역류증상이발생또는악화한다는기전으로설명하고있다.(30) 그러나이부분역시위소매절제술이역류증상을초래한다는입장과오히려수술이역류치료에도움이된다는입장으로나누어져있어,(31) 아직까지합일화된의견은없는실정이며지속적인추가연구가필요한문제라고할수있겠다. 결 본원의복강경하위소매절제술은개복으로의전환없이기술적으로용이하며안전하였다. 또한비록추적기간이짧기는하나수술후 1년추적결과, 59.6% 의초과체중감소율을보여만족스러운체중감량결과를보였다. 향후장기추적결과가필요하겠으나복강경하위소매절제술은국내고도비만환자에게비교적안전하고효과적으로시행할수있을것으로판단한다. 론 REFERENCES 1) American Society for Metabolic and Bariatric Surgery. Bariatric Surgery Society Takes on New Name, New Mission and New Surgery [Internet]. [updated 2007 Aug 22 cited 2010 Aug 12]. Available from: 2) Korean National Health & Nutrition Examination Survey [Internet]. [cited 2010 Aug 12]. Available from: cdc.go.kr/data/data0802.jsp 3) Gumbs AA, Gagner M, Dakin G, Pomp A. Sleeve gastrectomy for morbid obesity. Obes Surg 2007;17: ) Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis 2010;6:1-5. 5)Deitel M, Crosby RD, Gagner M. The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, Obes Surg 2008;18: ) Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis 2009;5: ) Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252: ) WHO Regional Office for the Western Pacific/International Association for the Study of Obesity/International Obesity Task Force. The Asia-Pacific perspective: redefining obesity and its treatment. Sydney: Health Communications Australia; ) Akkary E, Duffy A, Bell R. Deciphering the sleeve: technique, indications, efficacy, and safety of sleeve gastrectomy. Obes Surg 2008;18: ) Cottam D, Qureshi FG, Mattar SG, Sharma S, Holover S, Bonanomi G, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006;20: ) Langer FB, Reza Hoda MA, Bohdjalian A, Felberbauer FX, Zacherl J, Wenzl E, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005;15: ) Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16: ) Wang Y, Liu J. Plasma ghrelin modulation in gastric band operation and sleeve gastrectomy. Obes Surg 2009;19: ) Sammour T, Hill AG, Singh P, Ranasinghe A, Babor R, Rahman H. Laparoscopic sleeve gastrectomy as a single-stage bariatric procedure. Obes Surg 2010;20: ) Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, Gfrerer L, Ludvik B, Zacherl J, et al. Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin. Obes Surg 2010;20: ) Han SM, Kim WW. The 3-year results of laparoscopic sleeve gastrectomy for the treatment of Korean morbid obesity. J Korean Surg Soc 2007;73: ) Dixon JB, Laurie CP, Anderson ML, Hayden MJ, Dixon ME, O'Brien PE. Motivation, readiness to change, and weight loss following adjustable gastric band surgery. Obesity (Silver Spring) 2009;17: ) Chevallier JM, Paita M, Rodde-Dunet MH, Marty M, Nogues F, Slim K, et al. Predictive factors of outcome after gastric

7 466 J Korean Surg Soc. Vol. 79, No. 6 banding: a nationwide survey on the role of center activity and patients behavior. Ann Surg 2007;246: ) Lee WJ, Ser KH, Chong K, Lee YC, Chen SC, Tsou JJ, et al. Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion. Surgery 2010;147: ) Baltasar A, Serra C, Pérez N, Bou R, Bengochea M, Ferri L. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg 2005;15: ) Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg 2003;13: ) Moon HS, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 2005;15: ) Weiner RA, Weiner S, Pomhoff I, Jacobi C, Makarewicz W, Weigand G. Laparoscopic sleeve gastrectomy--influence of sleeve size and resected gastric volume. Obes Surg 2007;17: ) Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg 2010;20: ) Chen B, Kiriakopoulos A, Tsakayannis D, Wachtel MS, Linos D, Frezza EE. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences. Obes Surg 2009;19: ) Kasalicky M, Michalsky D, Housova J, Haluzik M, Housa D, Haluzikova D, et al. Laparoscopic sleeve gastrectomy without an over-sewing of the staple line. Obes Surg 2008;18: ) Ser KH, Lee WJ, Lee YC, Chen JC, Su YH, Chen SC. Experience in laparoscopic sleeve gastrectomy for morbidly obese Taiwanese: staple-line reinforcement is important for preventing leakage. Surg Endosc 2010;24: ) Oshiro T, Kasama K, Umezawa A, Kanehira E, Kurokawa Y. Successful management of refractory staple line leakage at the esophagogastric junction after a sleeve gastrectomy using the HANAROSTENT. Obes Surg 2010;20: ) Tan JT, Kariyawasam S, Wijeratne T, Chandraratna HS. Diagnosis and management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg 2010;20: ) Gagner M, Deitel M, Kalberer TL, Erickson AL, Crosby RD. The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, Surg Obes Relat Dis 2009; 5: ) Braghetto I, Lanzarini E, Korn O, Valladares H, Molina JC, Henriquez A. Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg 2010;20:

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