부산대병원학술지통권제28 호, 2010 장루복원술이후경과 부산대학교의학전문대학원외과학교실 조홍재 The Clinical results after stoma repair Hong Jae Jo Department of Surgery, School of Medicine, Pusan National University Abstracts * Purpose : This study aimed to investigate the clinical results accompanying stoma repair and to evaluate the significant factors associated with complications and outcomes. Subjects and Methods : I reviewed 106 patients who underwent stoma repair in our hospital between January 2005 and June 2009. Data of all complications during this procedure, i.e., wound infection, prolonged ileus, anastomotic leakage, and death were collected with respect to patient- and operation-associated parameters. Results : Complications of stoma repair developed in 23 (21.7%) cases: 19(20.9%) cases in loop ileosotmy, 2(22.2%) cases in loop colostomy, and 2(33.3%) cases in Hartmann colostomy. The overall complication rate was significantly associated with the urgency of the primary operation (elective vs. emergency, 16.5% vs. 39.1%, * 본연구는 2009년도부산대학교병원임상연구비지원으로이루어졌음 - 131 -
조홍재 P=0.018), and with the operation time ( 60 min vs. >60 min, 15.8% vs. 36.6%, P=0.005). Prolonged ileus developed in 14 (13.2%) cases, wound infection in 5(4.7%) cases, anastomotic leakage in 2 (1.9%) cases, intraabdominal abscess in 1(0.9%) case, and death in 1(0.9%) case. Wound infection was related to the type of stoma between a loop ileostomy and a Hartmann colostomy (3.3% vs. 16.7%), but no other factors were associated with other complications. Conclusions : There was significant relation of overall complications to the type of the primary operation and the operation time, but there was no statistical difference in complications between a loop ileostomy and a loop colostomy repair groups. The accurate surgical technique and patient care is more important to reduce complications. Key words : Stoma repair 서론 최근장루조성술환자가점차적인증가추세에있다. 이에따라양성또는악성질환, 외상등으로근치적, 고식적술식으로시행되고있는장루조성술은기술적인면뿐만아니라재활에있어서도최근괄목할만한발전을이룩하였다. 고리형결장루복원술은술식의단순성에비해의외로합병증이많이동반된다. 이에반해고리형회장루는일시적으로원위부문합부를보호하기위한방법중하나로대변우회에효과적이면서도조성및복원술기면에서어렵지않아자주선택되는방법이다. 또한재건결장직장절제술이궤양성대장염이나가족성용종증과같은질환의표준수술이되고최근초저위전방절제술의 증가로일시적인우회성회장루의시행빈도는더욱높아지고있다 1. 이외에도게실염, 외상과같은응급상황시고리형결장루나하트만결장루를종종시행하게된다. 본연구는이러한여러가지형태의일시적장루의복원시발생할수있는합병증의빈도와이에관련된인자들을장루유형별로고찰하고분석하여복원술의선택및합병증예방에도움이되고자하였다. 방법 2005년 1월부터 2009년 6월까지본원에서장루복원술을시행한환자중 6개월이상추적이가능하였던환자를대상으로장루의종류에따라비교하였으며, 다른수술과동반된경우는제외하였다. 총 106명의대상환자를의무기록을토대로후향적으로분석 - 132 -
장루복원술이후경과 하였으며장루복원술후 30일내에유병률에영향을준것을합병증으로정의하고발생빈도를분석하였으며, 장루의종류에따라각각의연령, 성별, 체질량지수(Body mass index, BMI), 선행질환의종류, 응급수술여부, 복원까지의기간, 문합방법, 수술시간, 식이개시, 재원기간등을비교하였다. 또한장루복원후합병증의발생빈도와각각의합병증과관련된인자를분석하였다. 장폐쇄는술후 7일까지장음이약하고가스배출이안되거나, 복통으로식이개시를하지못하거나, 식이개시후오심, 구토등으로비위관을이용한감압이필요한경우로정의하였다. 창상감염은상처부위에서화농성삼출물이배액되는경우로하였다. 문합부누출은복막염소견이있거나장피부누공이있으며, 방사선검사시조영제누출소견시로정의하였다. 체질량지수는미국국립보건연구소의정의를따랐고, 수술시간은피부절개부터피부봉합까지의시간으로하였으며, 식이개시는물섭취를시작하는시점을기준으로하였다. 통계적유의성의검정에서장루의종류에따른비교는분산분석(ANOVA) 및 Kruskal Wallis 검정으로하였고, 합병증관련인자는 chi-square test로하였으며 P<0.05 시유의한것으로간주하였다. 결과 총 106예의환자에서평균연령은 62.3세였고, 장루의종류는고리형회장루가 91예 (85.8 %), 고리형결장루가 9 예(8.5%), 하 트만결장루가 6 예(5.7%) 였으며, 장루종류에따른비교에서성별, 동반질환, 연령에따른차이는없었으며, 체질량지수가하트만결장루에서유의하게높았다 (Table 1). 선행질환으로는고리형회장루에서종양성질환이다수를차지한데비해고리형결장루와하트만결장루에서는외상의빈도가높았으며이로인한응급수술의빈도또한높았다(P<0.002). 종양성질환에서는고리형회장루또는고리형결장루의시행빈도가비슷한반면, 비종양성질환에서는고리형결장루의빈도가높았다 (10.9% vs 55.4%. P<0.001). 복원시기는 86 예(81.1 %) 에서 12주이전에복원하였고평균 15.5 주후복원하였다. 장루형태에따른복원시기의차이는없었으며, 문합방법에있어서도고리형회장루와고리형결장루가비슷한소견을보였으나, 하트만결장루에서는문합기사용이많았다. 평균수술시간은 52.3±2.5 분으로고리형회장루, 고리형결장루, 하트만결장루순으로증가하였으나, 식이개시및재원기간에는차이가없었다. 식이개시는 2.2±0.7 일, 수술후평균재원기간은 6.2±1.2 일이었다(Table 2). 합병증은고리형회장루 19 예(20.9%), 고리형결장루 2 예(22.2%), 하트만결장루 2예 (33.3%) 에서합병증이발생하였으나, 각장루의종류에따른합병증의차이는없었다 (Table 3). 그러나선행된장루조성술이응급으로이루어진경우추후복원시전체합병증의빈도가높았고, 장루복원술의수술시간( 60 분) 이길수록합병증이많았다. 그외성별, 나이, 선행질환의종류, 복원 - 133 -
조홍재 시기, 문합방법과합병증사이에는유의한관계가없었다(Table 4). 장폐쇄의경우에는각장루술에따른차이가없었으며, 창상감염은보존적인치료로호전되었는데고리형회장루, 고리형결장루, 하트만결장루순으로창상감염이증가하였다 (Table 3). 각각의장루유형과관계된유의인자의비교에서는고리형회장루에서복원수술시간이길수록전체합병증의빈도가높았다. 고찰 일시적인장루형성술은주로일시적인감압이나대변의우회목적으로사용하는술식으로보통남자에서조금더많이시행되나본연구의경우에차이를발견할수없었으며, 악성종양, 염증성장질환, 외상성질환등에서다양하게시행된다. 복원을염두에둔일시적인장루는고리형회장루, 고리형결장루, 하트만결장루등여러가지형태로시행된다. 그중조성및복원술기면에서의간편함으로자주선택되는방법은고리형회장루이나일시적인배변우회술로서의고리형회장루와고리형결장루의우월성에대한보고는서로다르다. 무작위대조군임상연구의메타분석 2 에따르면고리형결장루에서는수술부위의감염빈도가높은경향이있고고리형회장루에서는장루복원후장폐쇄의빈도가높은경향이있음이보고되었다. 본원에서는술식의편리함과복원술시의간편함때문에고리형회장루를선호하는편이다. 장루복원후발생하는합병증의빈도는 5~39% 정도로알려져있고그중창상감염이 7 29% 로가장많은것으로보고되고있으나본연구에서는술후장폐쇄가가장많이발생하였다. 장폐쇄는보통 1.2 14% 정도로보고되는데, 본연구의경우 13.2% 로다소높은빈도를나타내었으나, 통계적으로유의하게장폐쇄와관련된인자는없었다. 다만응급으로고리형회장루를조성한경우에장루복원후장폐쇄가증가하였으나통계적인유의성은없었다 3-6. 합병증과관계된원인인자에대한보고는저자마다차이가있어장루의복원시생기는여러가지합병증을줄이기위한많은논의가있었다 7,8. 본연구에서는장루복원술후고리형회장루 19 예(20.9%), 고리형결장루 2 예(22.2%), 하트만결장루 2예 (33.3%) 에서합병증이발생하여전체합병증발생빈도는 21.7% 였으나, 이중사망 1 예가포함되어있었다. 장루조성시응급수술시와장루복원시수술시간이길수록전체합병증빈도가높았다. 이는선행수술이응급으로이루어진경우에문합부위의누출, 외상, 감염성장질환등이많은경우로복강내감염을유발할수있는인자의증가로인하여술후장유착이나장폐쇄가많아장루복원시에이로인한어려움을많이겪게되고, 수술시간의지연을가져오는것으로생각된다. 그러나창상감염을제외하고는장루의종류에따른합병증의차이는없었고전체합병증발생빈도와연령, 성별분포, 동반질환유무, 선행질환 의종류, 복원까지의기간, 문합방법등에 - 134 -
장루복원술이후경과 서통계적으로유의한차이는없었다. 장루 의복원시기에있어서는보통장부종이없 어지고 섬유성유착이 감소되는 2 3개월 (12 주) 후에장루를복원해야합병증발생이 적다는보고가있는반면, 복원시기와무 관하다는보고도있다 9-11. 본연구경우에 복원시기가평균 15.5주로다른보고와유 사한소견을보였으며, 장루술식에따른 차이는없었으며, 복원시기에따른합병증 의차이는찾을수없었다. 각장루의문합 방법에있어서자동봉합기의사용은합병 증에는영향을주지않아다른보고들과일 치한결과를나타내었다 3,4. 자동봉합기의 사용으로수술시간을줄일수있었다. 창 상감염은고리형회장루, 고리형결장루, 하트만결장루순으로증가하였는데, 창상 감염은고리형회장루에서 2.8 14.2%, 고 리형결장루에서 2 40% 정도로보고된 다. 본연구의경우전체창상감염의빈도 는 5,6,12-16 4.7% 로보고되었다. 창상의지연 봉합시창상감염률을낮출수있다는보고 들이있으나그결과에있어아직이견이 있는것으로알려져있다 7,17,18. 창상감염과 관계되는 인자로 고리형 회장루에서 자동 문합기를사용시감소하였으나통계학적유 의성은없었고체질량지수에따른차이도 없었다. 문합부누출은 0 7% 로보고되는 데 5,6,13,15 본연구의경우 1.9% 의빈도를보 였으며, 다른보고에서와같이문합방법 등과는유의한관계를찾을수없었다 2,5-7. 복강내농양은수술시오염의결과로생겨 나게되는데통상 1% 정도의빈도를나타내며 본조사의경우도 1 예(0.9%) 에서있었다. 각각의장루종류에따라복원후생길수있는합병증및관련인자에대한다양한보고가있다. 고리형회장루복원술후생기는합병증으로는장폐색, 창상감염, 문합부누출, 복강내농양, 출혈등이있을수있으며빈도는 10 27% 로보고되고있으며합병증발생과관계된유의한인자는없는것으로알려져있다 6,10,13,20,21. 본연구에서는이전수술및수술시간의증가로인한합병증발생빈도의증가는장유착등으로인한것으로생각된다. 하트만결장루복원후합병증은 10 50% 로보고되고있으며, 그중창상감염은 10 38%, 문합부누출은 1.5 21% 까지보고되고있는데이는질환의진행정도및봉합방법, 외과의의숙련도에따라차이가있는것으로보고되었다 22-24. 본연구에서는하트만결장루복원시고리형회장루에비해창상감염이많은소견을보였으며, 장루의종류에따른합병증의차이는발견할수없었다. 현재, 고리형회장루가조성및복원술기면에서의간편함으로선호되고있지만고리형결장루와고리형회장루모두배변우회에효과적인술식으로어느한술식이다른술식보다절대적인우위를보이지는않는다. 고리형회장루는고리형결장루에비해조성및복원시수술시간이짧고창상감염및장루탈출이적으며장루의크기가크지않은장점이있으며, 단점으로지적되는고배액량과전해질불균형은일정기간의적응기간을거치면서배액량이감소하는것으로알려져있다 25. 따라서일시적인장루의선택은집도하는외과의의경험과숙련도그리고선 - 135 -
조홍재 호도에따라결정될수있을것으로생각하며다만선행장루조성이응급으로이루어진경우장루복원시합병증이발생하지않도록노력해야할것으로생각한다. 또한세부적으로고리형회장루의복원시에는복원후장폐쇄의가능성을염두에두고유착박리및안전한장문합에신경을써야할것이며결장루의복원시에는특히창상감염에유의해야할것으로생각한다. 결론 장루복원술후에발생하는합병증은장루조성술시의응급수술여부와장루복원술시의수술시간과밀접한관련을보였다. 창상감염의경우장루의종류에따른차이를보였으나, 다른합병증의빈도는차이가없었다. 집도하는외과의의선호도와숙련도에따라장루의종류를결정할수있으나, 장루의종류에따라복원후장폐쇄와창상감염의가능성을염두에두어야하며, 장루복원술시합병증을줄이기위하여보다세심한수술및환자처치가이루어져야할것으로생각된다. REFERENCES 1. Williams NS. Restorative proctocolectomy is the firstchoice elective surgical treatment for ulcerative colitis.br J Surg 1989;76:1109-10. 2. Lertsithichai P, Rattanapichart P. Temporary ileostomyversus temporary colostomy: a meta-analysis of complications. Asian J Surg 2004; 27:202-10. 3. Hasegawa H, Radley S, Morton DG, Keighley MR. Stapled versus sutured closure of loop ileostomy. A randomized controlled trial. Ann Surg 2000;231:202-4. 4. Hull TL, Kobe I, Fazio VW. Comparison of handsewn with stapled loop ileostomy closures. Dis Colon Rectum 1996;39:1086-9. 5. Feinberg SM, McLeod RS, Cohen Z. Complications of loop ileostomy. Am JSurg1987;153:102-7. 6. Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD, Gemlo BT. Techniques and complications of ileostomy takedown. Am J Surg 1999;177:463-6. 7. Hackam DJ, Rotstein OD. Stoma closure and wound infection:an evaluation of risk factors. Can J Surg1995;38:144-8. 8. Pokorny RM, Heniford T, Allen JW, Tuckson WB,Galandiuk S. Limited utility of preoperative studies in preparation for colostomy closure. Am Surg 1999;65:338-40. 9. Shellito PC. Complications of abdominal stoma surgery.dis Colon Rectum 1998;41:1562-72. 10. Freund HR, Raniel J, Muggia-Sulam - 136 -
장루복원술이후경과 M. Factors affecting the morbidity of colostomy closure: a retrospective study. Dis Colon Rectum 1982;25: 712-5. 11. Moon JS, Jun SH, Whang IW. Factors influencing the morbidity of colostomy closure. J Korean Surg Soc 1986;30:618-23. 12. Amin SN, Memon MA, Armitage NC, Scholefield JH. Defunctioning loop ileostomy and stapled side-to-side closure has low morbidity. Ann R Coll Surg Engl 2001;83:246-9. 13. van de Pavoordt HD, Fazio VW, Jagelman DG, Lavery IC, Weakley FL. The outcome of loop ileostomy closure in 293 cases. Int J Colorectal Dis 1987;2:214-7. 14. Khoo RE, Cohen MM, Chapman GM, Jenken DA, Langevin JM. Loop ileostomy for temporary fecal diversion. Am J Surg 1994;167: 519-22. 15. Metcalf AM, Dozois RR, Beart RW Jr, Kelly KA, Wolff BG. Temporary ileostomy for ileal pouch-anal anastomosis. Function and complications. Dis Colon Rectum 1986;29: 300-3. 16. Senapati A, Nicholls RJ, Ritchie JK, Tibbs CJ, Hawley PR. Temporary loop ileostomy for restorative proctocolectomy. Br J Surg 1993;80: 628-30. 17. Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD,Gemlo BT. Techniques and complications of ileostomy takedown. Am J Surg 1999;177:463-6. 18. Lahat G, Tulchinsky H, Goldman G, Klauzner JM, Rabau M. Wound infection after ileostomy closure: a prospective randomized study comparing primary vs. delayed primary closure techniques. Tech Coloproctol 2005;9: 206-8. 19. Hallbook O, Matthiessen P, Leinskold T, Nystrom PO, Sjodahl R. Safety of the temporary loop ileostomy. Colorectal Dis 2002;4:361-4. 20. Reisener KP, Lehnen W, Hofer M, Kasperk R, Braun JC, Schumpelick V. Morbidity of ileostomy and colostomy closure: impact of surgical techniqueandperioperativetreatment. World J Surg 1997;21:103-8. 21. Paredes JP, Cainzos M, Garcia J, Parada P, Fernandez E, Paulos A, et al. Colostomy closure: is it an intervention without risk? Rev Esp Enferm Dig 1994;86: 733-7. 22. Oomen JL, Cuesta MA, Engel AF. Reversal of Hartmann s procedure after surgery for complications of diverticular disease of the sigmoid colon is safe and possible in most patients. Dig Surg 2005;22:419-25. 23. Salem L, Flum DR. Primary - 137 -
조홍재 anastomosis or Hartmann s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Recum 2004;47:1953 64. 24. Aydin HN, Remzi FH, Tekkis PP, Fazio VW. Hartmann s reversal is associated with high postoperative adverse events. Dis Colon Rectum 2005;48:2117-26. 25. Hill GL, Millward SF, King RF, Smith RC. Normal ileostomy output: close relation to body size. Br Med J 1979;2:831-2. Table 1. Demographic characteristics of patients Loop ileostomy (n=91, %) Loop colostomy (n=9, %) Hartmann colostomy (n=6, %) Total (n=106, %) P-value Sex Male 46(50.5) 4(44.4) 4(66.7) 54(50.9) Female 45(49.5) 5(55.6) 2(33.3) 52(48.1) 0.432 Age (year) <65 48(52.7) 5(55.6) 3(50.0) 56(52.8) 65 43(47.3) 4(44.4) 3(50.0) 50(47.2) 0.046 Body mass index*(kg/m2) Normal 42(46.1) 4(44.4) 2(33.3) 48(45.2) Obesity 49(53.9) 5(55.6) 4(66.7) 58(54.8) 0.016 *Body mass index = normal (18.5 24.9), obesity (25.0 39.9) - 138 -
장루복원술이후경과 Table 2. Clinical characteristics of patients Loop ileostomy (n=91, %) Loop colostomy (n=9, %) Hartmann colostomy (n=6, %) Total (n=106, %) Tumor 68(74.7) 5(55.6) 2(33.3) 75(70.7) Preceding disease Trauma 10(10.9) 4(55.4) 4(66.7) 18(16.9) IBD* 7(7.6) 0 0 7(6.6) Infectious Disease 4(4.4) 0 0 4(3.8) Fistula 2(2.2) 0 0 2(1.9) Urgency of 1st operation Interval of stoma repair Elective 77(84.6) 6(66.7) 2(33.3) 85(80.2) Emergency 14(15.4) 3(33.3) 4(66.7) 21(18.8) Early ( <12wks) 75(82.4) 6(66.7) 5(83.3) 86(81.1) Late ( >12 wks) 16(17.6) 3(33.3) 1(16.7) 20(18.9) Mean 15.3 16.2 14.1 15.5 Anastomotic type Stapled 48(52.7) 4(44.4) 5(83.3) 57(53.8) Handsewn 43(47.3) 5(55.6) 1(16.7) 49(46.2) Mean operation time (min) 47±2.0 65±3.0 120±2.4 56.3±2.5 Mean hospital stay (day) 6.0±1.0 6.3±1.2 7.0±1.3 6.2±1.2 Mean diet start (day) 2.0±0.5 2.3±0.7 3.1±1.1 2.2±0.7 *IBD = inflammatory bowel disease Table 3. Complications of stoma repair Loop ileostomy (n=91, %) Loop colotomy (n=9, %) Hartmann colostomy (n=6, %) Total (n=106, %) Ileus 12(13.2) 1(11.1) 1(16.7) 14(13.2) Wound infection 3(3.3) 1(11.1) 1(16.7) 5(4.7) Anastomotic leakage 2(2.2) 0 0 2(1.9) Intraabdominal abscess 1(1.1) 0 0 1(0.9) Death 1(1.1) 0 0 1(0.9) Total 19(20.9) 2(22.2) 2(33.3) 23(21.7) - 139 -
조홍재 Table 4. Associated factors with complications of stoma repair No complication (n=83, %) Complication (n=23, %) Sex Male 43(51.8) 11(47.8) P-value Female 40(48.2) 12(52.2) 0.401 Age <65 yrs 44(53.0) 12(52.2) 65 yrs 39(47.0) 11(47.8) 0.356 Body mass index <25 kg/m2 40(48.2) 8(34.8) 25 kg/m2 43(51.8) 15(65.2) 0.063 Comorbidity Present 21(25.3) 5(21.7) Absent 62(74.7) 18(78.3) 0.230 Proceding disease Benign 24(28.9) 7(30.4) Malignant 59(71.1) 16(69.6) 0.201 1st operation Elective 71(85.5) 14(60.9) Emergency 12(14.5) 9(39.1) 0.018 Interval of stoma repair Early 79(95.2) 10(43.5) Late 4(4.8) 13(56.5) 0.502 Anastomotic type Stapled 45(54.2) 12(52.2) Hand-sewn 38(45.8) 11(47.8) 0.277 Operation time <60 min 64(77.1) 12(52.2) 60 min 19(22.9) 11(47.8) 0.005-140 -