대흉외지 2008;41:724-728 임상연구 원발기흉수술후재발의위험인자 유재근 * ㆍ이석기 * ㆍ서홍주 * ㆍ서민범 * Risk Factors for Recurrent Pneumothorax after Primary Spontaneous Pneumothorax Jai Kun Yu, M.D.*, Seog-Ki Lee, M.D.*, Hong Joo Seo, M.D.*, Min Bum Seo, M.D.* Background: The purpose of this study was to identify factors associated with recurrent pneumothorax after wedge resection in primary spontaneous pneumothorax in our hospital. Material and Method: Two hundred thirty-five consecutive patient (98% males; mean age, 23.9±4.5 years) who had undergone video-assisted thoracoscopic surgery (VATS) were reviewed retrospectively. The two groups were divided as follows: group A, non-recurrent patients (225 patients [96%]); and group B, recurrent group (10 patients [4%]); the risk factors were compared between the two groups. The single and multiple factors that influenced the recurrence rate were analyzed using Cox's proportional hazard model. Result: There were no significant differences between the recurrent and non-recurrent groups in terms of gender, smoking, site of recurrence, degree of collapse, operative time, and number or weight of resected bullae. The recurrence rate was significantly more common in the following: younger ages, increased height/weight ratio, longer initial air leakage period, and shorter duration of chest drainage. Early aggressive exercise (<30 days) of patients after wedge resection increased the tendency for recurrence. Conclusion: Thoracoscopic wedge resection does not have a higher recurrence rate than open thoracotomy. However, young age, height/weight ratio, continuous air, and duration of chest tube placement were risk factors for a recurrent pneumothorax. Key words: 1. Pneumothorax 2. Risk factors (Korean J Thorac Cardiovasc Surg 2008;41:724-728) 서론자발성기흉에대한외과적치료는 1990년대이후로급격하게발전을해서현재는흉강경을이용한폐기포절제술이보편화되어있으며, 자발성기흉에대한흉강경을이용한폐기포절제술후재발률은 3.9 13.7% 이고 [1,2], 부가적인흉막유착술을시행하여재발율을 0 3.6% 으로감소시킨결과를보고하고있다 [3]. Lippert 등은기존의폐질환이없는환자에서재발성기흉에대한독립인자는폐실질섬유화, 60세이상나이, 키 / 몸무게비및흡연여부라고하였다 [4]. 저자들은폐쐐기 절제술후재발에관여되는인자를알고자, 이에대한위험인자를분석비교하여보았다. 대상및방법 2002년 1월부터 2005년 12월까지본원흉부외과에서흉강경을이용하여흉막유착술없이폐기포절제술만을시행한 235명을대상으로하였다. 퇴원후외래추적관찰중에재발이없었던 A군 (225명: 96%), 재발이있었던 B군 (10명: 4%) 으로나누어서후향적조사를통하여재발위험인자에대하여알고자하였다. * 조선대학교의과대학부속병원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Chosun University Hospital, Chosun University College of Medicine 논문접수일 :2008 년 6 월 9 일, 심사통과일 :2008 년 9 월 16 일책임저자 : 이석기 (501-717) 광주시동구서석동 588 번지, 조선대학교병원흉부외과 (Tel) 062-220-3160, (Fax) 062-232-5723, E-mail: chcs@chosun.ac.kr 본논문의저작권및전자매체의지적소유권은대한흉부외과학회에있다. 724
유재근외 Risk Factors for Recurrent Pneumothorax Table 1. Patients' characteristics Age, years (mean) Gender (M:F) Height/weight ratio Smoking history Site (Right/Left) Right Left Both Degree of lung collapse Mild Moderate Severe *p<0.05. Table 2. Surgical results Data Group A Group B 28.3±14.4 221:4 3.2±0.3 103 (45.8%) 105 (46.7%) 122 (54.2%) 3 (1.3%) 24 (10.7%) 106 (47.1%) 95 (42.2%) 19.6±7.17 9:1 3.3±0.4 3 (30%) 6 (60%) 4 (40%) 2 (20%) 6 (60%) 2 (20%) Data Group A Group B No. of resection Weight of resection tissue (g) Duration of air leakage (days) Duration of chest tube (days) Duration of chest tube (days) after no air leakage Duration of admission (days) Follow up (months) *p<0.05. 1.6±0.8 4.3±2.5 0.3±1.1 4.6±1.6 4.3±1.3 6.7±1.9 33.0±13.8 1.4±0.6 4.1±0.6 1.9±3.2* 6.0±4.1* 2.8±3.5* 8.9±4.3 30.0±16.3 단순흉부방사선검사및 HRCT으로진단을하였고, 수술적응증은 2회이상재발, 전폐가허탈된경우, 고해상도전산화단층촬영 (High resonase computed tomography, HRCT) 상에폐기포가발견된경우및재발에대하여걱정이있는경우이었다. 기존폐질환으로발생한이차성기흉은제외하였다. 수술은전신마취하에이중내관기관삽관을이용한일측폐환기로병변반대측와위자세로중액와선 7 혹은 8 늑간에 10 mm 흉강경 (Asculap, Germerny) 투관침 (trochar), 전액와선 5 혹은 6 늑간과후액와선 6 혹은 7 늑간에기구투관침 (trochar) 을설치하고, 흉막유착이있는경우는단극전기소작기 (monopolar electrocautery, Mizuho Inc., Tokyo, Japan) 로박리를하였으며, 폐기포를내시경용자동봉합기 (Endo-GIA, Tyco, Norwalk, CT, USA) 을사용하여폐쐐기절제술을시행하였다. 공기누출여부는기도압 25 cmh 2O Table 3. Postoperative data Postoperative bleeding Wound infection Increased ALT/AST Aggressive exercise<30 days Interval of recurrence (months) Group A 2 (0.8%) 3 (1.3%) 15 (6.7%) Unknown Group B 1 (10%) 4 (40%) 10.2±8.5 Table 4. Significant single independent risk factors for recurrence after wedge resection Factors Age Duration of air leakage Hight/Weight ratio Duration of chest tube Degree of collapse Smoking history No. of resection Gender Weight of resection Site Duration of admission Analysis based upon Cox's proportional hazard model. p value 0.0032 0.0056 0.0063 0.0065 0.0953 0.2853 0.4596 0.6324 0.6587 0.7262 0.7512 이상에서시행하였으며, 절개부위는흡수성망상 (oxidized cellulose: Surgicel R ) 위에 Fibrin Glue (Greenplast R ) 를도포하여수술을마치었다. 28Fr 흉관한개를넣은후폐가완전히팽창한다음수술을마치었다. 흉관제거는공기누출이없으며, 하루배액량이 50 ml 미만, 폐허탈이없는것을확인하고시행하였다. 추적관찰은퇴원후 1주일, 한달그리고 6개월간격으로외래에서단순흉부방사선검사를시행하였으며, 호흡곤란이나흉통이발생시에는즉시병원으로오도록하였으며, 재발에대한진단은단순흉부방사선검사로하였다. χ 2 test와 Cox's proportional hazard model을이용하여통계처리를하였으며, p-value 0.05이하를통계적유의수준으로하였다. 결 각군의평균나이는재발되는군에서 19.6±7.17세로더어렸으며 (p<0.05), 각군남녀비는남자가많았으나, 통계학적의의는없었다 (Table 1). 흡연력, 병변부위및폐허 과 725
대흉외지 2008;41:724-728 Table 5. Significant multiple risk factors for recurrence after wedge resection Factors Coefficient Stander error p-value Age Height/Weight ratio Duration of air leakage Duration of chest tube 0.4366 0.3584 0.3269 0.4276 0.1321 0.1268 0.1452 0.2135 Using Cox's proportional hazard model. 0.0042 0.0053 0.0073 0.0095 Hazard ratio 2.485 0.4253 2.123 0.3256 탈정도는양군사이에유의한차이는없었다. 수술적요인에대한것으로술후공기누출기간길수록, 공기누출기간을제외하고공기누출이완전히멈춘후흉관거치기간이짧을수록재발가능성이더높았으며 (p<0.05), 흉강경으로확인한폐기포개수및절제된조직무게에서는두군간의차이를확인할수없었다 (Table 2). 술후합병증으로는두군간의빈도차이는없었고, 평균재발기간은 10.2±8.5개월 (0.6 22개월) 이었다 (Table 3). 재발된군중 4명은술후한달동안충분한준비운동없는과격한운동 ( 농구등 ) 을했던경험이었다 (Table 3). 술후재발에영향을주는변수를알아보고자시행했던 Cox's proportional hazard model에서단일변수는수술시나이, 공기누출기간, 키 / 몸무게비및흉관유지기간 (Table 4) 이었다. 다중변수에의한위험인자는수술시나이, 신장 / 몸무게비, 공기누출및흉관유지기간순이었다 (Table 5). 고 지난 4년간시행했던 235명에대한후향적조사에서자발성기흉환자에서폐쐐기절제술을시행하고퇴원후재발율 4% 정도는다른저자들의재발율 3.9 13.7% 과큰차이가없었음을알수있었다 [1-3]. Guo 등은수술하지않은자발성기흉에서재발위험인자로큰신장, 가벼운몸무게, 기존폐질환및화학적흉막유착술을제시하였는데 [5], 수술후재발위험인자로저자들이제시한수술당시나이, 신장 / 몸무게비, 공기누출여부및흉관유지기간등과는차이를보여주고있다. 이는수술적요인이포함되지않아서발생하는차이로생각된다. 찰 수술을시행하지않은재발성자발성기흉에서폐기포형성기전은폐포벽에작용하는공기압변화가폐기포형성과폐기포파열에중요한역할을하여, 폐포벽에대한국소적인표면장력와구조적인변화-폐섬유화-를발생하키는것으로알려져있다 [6]. 그러나, 흉강경수술후재발하는원인으로 Umemoto 등은흉강경의제한적시야및렌즈구면수차로인한정확한영상을얻을수없어서놓치는경우와절제부분혹은다른곳에새로생기는경우로지적하였다 [6]. 본연구에는재발된환자나이가평균 19.6±7.2세로재발하지않은환자인 28.3±14.4세보다통계학적의의가있을정도로어렸다. 이는앞으로성장할가능성있는환자의폐는성장함으로서절제부위및다른부위에폐포벽에작용하는공기압변화로폐기포형성이촉진이될수있을것이다. 수술하지않은환자에서 HRCT상에서첫번째기흉환자에는 56%, 재발된기흉환자는 64% 에서폐기포를발견할수있었으나 [7], 수술후에관찰한 HRCT상에서는약 71% 에서만폐기포를발견할수있으며, 새로운술후 fibrocystic과정이진행이되어서, 폐기포를형성하여, 수술적절제로도폐기포형성을막지못하지만 [8], 폐기포자체가재발성기흉을예측할수있는인자가아니다고하였다 [7]. 술후직후발생하는공기누출은수술당시에불완전한기포절제와관련이있을것으로사료되며, 폐절제부위가충분히치유되는기간동안흉관을유지하는것이술후재발을감소시키는도움을줄수있을것으로사료되며, 통계학적으로공기누출이멈춘후흉관유지기간이의의가있었다. 흡연과재발하는자발성기흉의관계는인종간차이가있다고하였다. Bense 등 [9] 과 Jansveld 등 [10] 은서구인들을대상으로한연구에서는상관관계가있다고하였지만, Yim 등은동양인에서는상관관계가없다고하였는데 [11], 본연구에서도수술후재발에관여한인자로흡연과는통계학적의의가없음을알수있었다. 재발은대부분첫발병이있는후 2년이내에발병하는것으로보고되고있는데 [4], 저자들의경우에도수술후재발하는평균기간은 10.2±8.5개월로대부분이 2년이내에재발되었다. 결론자발성기흉에서흉강경을이용한폐기포절제술은재 726
유재근외 Risk Factors for Recurrent Pneumothorax 발율이개흉술에비하여높지않고미용적으로좋아서많이시행하고있지만, 원발기흉수술후재발위험인자로나이가젊거나, 큰신장 / 몸무게비, 지속적인공기누출이있거나공기누출기간을제외하고공기누출이완전히멈춘후짧은흉관유지기간이었다. 참고문헌 1. Bertrand PC, Regnard JF, Spaggiari L, et al. Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS. Ann Thorac Surg 1996;61: 1641-5. 2. Inderbitzi RG, Leiser A, Furrer M, Althaus U. Three years' experience in video-assisted thoracic surgery (VATS) for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1994; 107:1410-5. 3. Horio H, Nomori H, Fuyuno G, Kobayashi R, Suemasu K. Limited axillary thoracotomy vs video-assisted thoracoscopic surgery for spontaneous pneumothorax. Surg Endosc 1998; 12:1155-8. 4. Lippert HL, Lund O, Blegvad S, Larsen HV. Independent risk factors for cumulative recurrence rate after first spontaneous pneumothorax. Eur Respir J 1991;4:324-31. 5. Guo Y, Xie C, Rodriguez RM, Light RW. Factors related to recurrence of spontaneous pneumothorax. Respirology 2005; 10:378-84. 6. Shamji F. Classification of cystic and bullous lung disease. Chest Surg Clin North Am 1995;5:701-16. 7. Smit HJ, Wienk MA, Schreurs AJ, Schramel FM, Postmus PE. Do bullae indicate a predisposition to recurrent pneumothorax? Br J Radiol 2000;73:356-9. 8. Fackeldey V, Schoneich R, Otto A, et al. Structural anomalies in lung apices after pneumothorax operation. Chirurg 2002;73:348-52. 9. Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest 1987; 92:1009-12. 10. Jansveld CAF, Dijkman JH. Primary spontaneous pneumothorax and smoking. Br Med J 1975;4:559-60. 11. Yim AP, Ho JK, Lai CK, Chan HS. Primary spontaneous pneumothorax treated by video assisted thoracoscopic surgeryresults of intermediate follow up. Aust N Z J Med 1995;25: 146-50. 12. Gomez-Caro A, Moradiellos FJ, Larru E, et al. Effectiveness and complications of video-assisted surgery for primary spontaneous pneumothorax. Arch Bronconeumol 2006;42:57-61. 727
대흉외지 2008;41:724-728 = 국문초록 = 배경 : 본원에서자발성기흉으로흉강경을이용폐쐐기절제술후퇴원한환자가운데재발로수술을다시받은환자에서기흉의재발에관한위험인자에대해연구하였다. 대상및방법 : 2002 년 1 월부터 2005 년 12 월까지본원흉부외과에서흉강경을이용하여흉막유착술없이폐쐐기절제술만을시행한 235 명을대상으로하였다. 퇴원후외래추적관찰중에재발이없었던 A 군 (225 명 : 96%), 재발이있었던 B 군 (10 명 : 4%) 으로나누어서후향적조사를통하여재발위험인자에대하여알고자하였다. 결과 : 각군의평균나이는재발되는군에서 19.6±7.17 세로더어렸으며 (p<0.05), 각군남녀비는남자가많았으나, 통계학적의의는없었다. 흡연력, 병변부위및폐허탈정도는양군사이에유의한차이는없었다. 수술적요인에대한것으로술후공기누출기간이길수록, 흉관거치기간이짧을수록재발가능성이더높았으며 (p<0.05), 평균재발기간은 10.2±8.5 개월 (0.6 22 개월 ) 이었다. 재발된군중 4 명은술후한달동안충분한준비운동없는과격한운동 ( 농구등 ) 을했던경험이었다. 술후재발에영향을주는단일변수는수술시나이, 공기누출기간, 키 / 몸무게비및흉관유지기간이었으며, 다중변수에의한위험인자는수술시나이, 신장 / 몸무게비, 공기누출및흉관유지기간순이었다. 결론 : 자발성기흉에서흉강경을이용한폐기포절제술은재발율이개흉술에비하여높지않아서시행할수있지만, 재발위험인자로나이가젊거나, 큰신장 / 몸무게비, 지속적인공기누출있거나짧은흉관유지기간이었으며, 퇴원후너무나빠른심한운동은폐기포절제술후기흉재발의원인이될수있다. 중심단어 :1. 기흉 2. 위험인자 728