대한대장항문학회지제 21 권제 4 호 J Korean Soc Coloproctol Vol. 21, No. 4, 2005 종설 원위부직장암의복회음절제술을위한임상해부학적지식및술기 연세대학교의과대학외과학교실, 세브란스병원대장암클리닉 김남규 Sharp Pelvic Dissection for Abdominoperineal Resection for Distal Rectal Cancer Based on Anatomical and MRI Knowledge Nam Kyu Kim, M.D., Ph.D. Department of Surgery, Division of Colorectal Surgery Colorectal Special Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Even though sphincter saving surgery such as coloanal anastomosis or intersphincteric resection have been popular in era of Total Mesorectal Excision (TME) in distal rectal cancer, unreasonable sphincter saving surgery might cause a couple of troublesome complications in terms of oncologic or functional outcomes. Since preoperative staging work up recently have been developed with MRI or MDCT, it is important to assess whether rectal cancer invaded into surrounding sphincter or levator ani muscle based on MRI or MDCT coronal image study. If tumor is located at a very close distance or has invaded the adjacent sphincter muscle, the need of abdominoperineal resection is definite without any hesitation for curative resection. But, the actual number of cases of APR have been decreased in favor of sphincter preserving surgery even APR remains an important therapeutic option in the surgical treatment of low rectal cancer. Indication case for APR have become a intersphincteric resection or ultralow anterior resection and coloanal anastomosis. Even patients who showed invasion of sphincter underwent sphincter saving surgery, lately proven safe in terms of recurrence and defecation functions. On practical view points on operative techniques, abdominal phase are same as TME techniques. Sharp pelvic dissection must be carried out along the visceral fascia enveloping the mesorectum to the levator ani muscle with preservation of pelvic autonomic nerve. Perineal phase dissection is a key process in APR. During perineal dissection, inadequate resection margin and blunt tissue dissection along the nonanatomical plane encourage implantation of a malignant cell and local recurrence. Moreever, it could lead to serious complications such as prostatic urethral injury, vaginal wall perforation, perineal sinus and fistula. Massive bleeding from pelvic side wall major vessels injury. Especially in males with very narrow pelvis, pelvic dissection is very difficult due to deep narrow and blunt sacral curvature of the pelvis. It is nearly impossible to reach the levator ani muscle and result in perineal dissections performed on excessively high levels. For colorectal surgeons with insufficient experience, it is difficult to dissect the rectum from the perineum upto the seminal vesicle level. In the classic pattern, anterior and lateral dissection from the prostate or vagina after the completion of posterior dissection. The dissected proximal colon was delivered outward through the perineal wound and with traction of the delivered portion of the colon, anterior dissection was performed. However, in patients with narrow pelvis, such delivery of the proximal colon through perineal wound can result in fractured tumor and local recurrence due to limited operation field. Therefore, it is mandatory that specimen must be delivered in situ after posterior, anterior and lateral dissection. During posterior dissection, gluteus muscle must be observed and removal of the ischiorectal fat tissue should be accomplished. In lateral dissection, levator ani muscle must be divided near the bony insertion. Finally, during anterior dissection, seminal vesicle and prostate gland must be exposed and neurovascular bundle observed at the 10 and 2 o'clock direction. In addition to TME on abdominal phase, Sharp Anatomical Perineal Dissection (SAPD) empowered by 3D concept based on MRI is a key process for prevention of local recurrence in APR. J Korean Soc Coloproctol 2005;21:258-267 Key Words: Abdominoperineal resection, Rectal cancer, Total mesorectal excision, Sharp anatomical perineal dissection, Pelvic magnetic resonance image 복화음절제술, 직장암, 전직장간막절제술, 정확한해부학적회음부절제술, 골반자기공명영상 책임저자 : 김남규, 120-752, 서울시서대문구신촌동 134 연세대학교의과대학대장항문외과 Tel: 02-2228-2117, Fax: 02-313-8289 E-mail: namkyuk@yumc.yonsei.ac.kr 본종설의요지는 2005 년제 60 회일본소화기외과학회 International Rectal Cancer Surgery Symposium (7 월 22 일 Tokyo, Japan) 에서발표되었음. Correspondence to: Nam Kyu Kim, Department of Surgery, Division of Colorectal Surgery, Yonsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul 120-752, Korea. Tel: +82-02-2228-2117, Fax: +82-313-8289 E-mail: namkyuk@yumc.yonsei.ac.kr 258
김남규 : 원위부직장암의복회음절제술을위한임상해부학적지식및술기 259 서론복회음절제술은원위부직장암을치료하는수술방법으로 1883년 Czerny가처음시행하였고이후여러의사가시행하였지만 1908년 Miles가처음으로체계적으로기술하여보고하였다. 1 당시 Miles는환자부검예를통하여직장암은항문에서의위치에관계없이주로세방향으로전이가진행된다는것을관찰하였다. 즉상방향 (upward) 으로는직장간막 (mesorectum) 내상직장, 하직장동맥을따라진행되어복부대동맥쪽으로진행된다고하여에스상결장및결장간막전체를모두절제해야한다고하였다. 측방향 (lateral) 으로는골반측방벽, 내장골동맥림프절전이가발생한다고하였고특히복막내직장암 (intraperitoneal rectal cancer) 보다복막외직장암 (extraperitoneal rectal cancer) 일때전이가잘된다고하였다. 내장골동맥림프절을제거한경우재발과생존율에서차이가없다는연구가이루어졌으나 2 이것은나중에일본의사들이주장하는골반측방림프절절제술 (lateral pelvic lymph node dissection) 의종양학적이점과도연관이되는부분이다. 3 하방향 (downward) 으로는항문괄약근, 항문거근 (levator ani muscle) 을지나항문주위피부, 좌골직장지방조직 (ischiorectal fat), 서혜부림프절등으로전이되는경우이다. 따라서 Miles는직장암의근치적수술을위해서는직장암의항문에서위치에관계없이전직장, 항문주위괄약근, 항문거근및좌골직장지방조직, 에스상결장및장간막, 골반복막등이포함되어절제되어야한다고주장하였다. 이후 Goligher와 Duke는 4 복회음절제병리조직, 1,500예를분석조사한결과하향으로전이된예는극히적은것을보고하였다. 대개는종양하연 6 mm 이내에암세포가위치하고 2% 만이 20 mm 이상아래로전이가되는것을발견하였다. 이러한관찰이후항문괄약근보존수술의안전성이강조되었고항문괄약근보존술이점차확산되었다. 지속적인병리조직검사에서직장암은세포분화가좋은경우에원위부전이가 1 cm 미만이라는결과가확인되었고 5-7 자동문합기가개발되면서항문괄약근보존술이보편화되었다. 그러나항문괄약근보존술이보편화되고있고, 강조되고있어도원위부직장암에서복회음절제술은최근에이르기까지중요한술식으로여겨지고있다. 일반적으로복회음절제술의빈도는전체수술의 18~27% 차지하고있다. 8,9 복회음절제후국소재발률은 4~33% 로보고되고있으며이는항문괄약근보존술식보다다소높다. 생존율도다소낮은것으로보고되고있으나원인에대해서는보고자에따라다르게제시되고있다. 10,11 원인에대한이유를분석한결과부적절한회음부박리로인한암세포의착상등주로수술과관련된인자들의보고가많다. 과거에는복회음절제술을시행하던원위부직장암을초저위전방절제술및수기대장항문문합술, 항문괄약근사이절제술 (Intersphincteric resection) 등의술기를적용하여괄약근을보존하고있으며수술전방사선치료의확대적용으로직장암의크기를감소시킨후항문괄약근보존술식을시도하고있다. 따라서점차로복회음절제술의빈도가감소하고있으며이로인한수술경험의부족등도치료성적의저하이유로거론되고있다. 본종설에서는복회음절제가필요한환자의선택이중요하고복회음절제술시주위해야할개념과구조들을살펴보기로한다. 최근들어이러한것을결정하거나수술절제면 (dissetion plane) 을판단하는데 MRI 영상이많은도움을주고있다. 즉수술전 MRI 영상 (Magnetic Resonance Image) 이보편화되면서과거 CT 나직장초음파검사영상보다해부학적구조를미리볼수있고종양의진행정도와주변구조와의관계를잘볼수있다. 본론 1) 복회음절제술후국소재발 Haward 등 12 은 1986년부터 1994년까지직장암수술한 3,521명대상으로조사한결과복회음절제술의경우, 항문괄약근보존술환자보다예후가나쁘다고보고하였다. 이러한보고에의하면복회음절제술시문제점이있거나원위부직장암이여러가지이유로예후가더나쁘다고생각할수있다. Heald 등 13 은복회음절제술은단지 7.5% 에만시행하였는데국소재발은 17% 로보고하였다. 그러나항문괄약근보존술에서는 5% 미만의국소재발률을보고하였다. 항문괄약근보존술식의경우원위부절제연은대개 1~2 cm 이며전직장간막절제술 (Total mesorectal excision) 이시행되었다고보고하였다. Heald는복회음절제술이보다국소재발률이높은이유를회음부절제시 (perineal dissection) 의종양세포의착상때문이라고하였다. Law 등 14 도복회음절제술이괄약근보존술에비해국소재발률이각각 23%, 10.2%, 5년생존율은각각
260 대한대장항문학회지제 21 권제 4 호 2005 60%, 74% 로모두통계적으로의의있게낮았다고보고하였는데이는회음절제가비해부학적절제면이며정확한절제면이없기때문이다. 따라서이로인한넓은회음절제후절제면 (raw surface) 으로암세포가착상이될가능성이보다높기때문일것이라고설명하고있다. Dehni 등 15 은복회음절제술후국소재발률을 3% 로보고하는데이렇게낮은국소재발률의이유를종양절제시종양과인접한항문거근과종양주위를넓게한덩어리로절제하기때문이라고주장하였다. 즉항문거근을가능한기시부에서절단하며종양이항문거근과가까우면종양과항문거근을무모하게박리하는것을피해부적절한종양세포의절제연으로의착상을피하려고한다고하였다. Heald도이러한부분을강조하여복회음절제표본은대개직장간막이끝나는부위와항문거근이잘린자리의경계가좁아져허리가생기는데이허리부위에암세포가노출이되어국소재발이될수도있다고하였다. 따라서광범위한항문거근및좌골직장지방절제로원주모양의한통으로조직이절제되어야한다고주장하였다. 이외에도복회음절제술시특히회음절제시직장벽의천공이생기는경우가드물지않게발생하는데특히후방절제 (posterior dissection) 시나전방절제 (anterior dissection) 시주변항문미골인대 (anococcygeal ligament) 를자르거나앞쪽에서질혹은전립선쪽과박리하다직장천공이발생한다. 이는적절한절제연을찾지못해서생기는일이다. 직장의후방과측방이박리된경우절단된에스상결장을회음부로꺼내어아래로당기면서직장의앞쪽을박리하는순서로수술을진행하는데특히좁은골반에서는에스상결장과박리된직장이쉽게회음부로나오지못할때직장이천공되는경우가있다. 혹은직장암이주로직장의전방에위치할때직장을뒤집어서회음부로뺄때직장이천공되기쉽고종양이파열되기쉽다. 이때는뒤집지말고그자리에서직장전방박리를시행하고그대로직장과에스상결장을회음부로빼는것이좋은방법이라고생각한다. Eriksen 등 16 은 54개병원에서수술한직장암환자분석한결과약 8.1% 의직장천공률이관찰되었고복회음절제술시천공률이높았다고하였다. 특히천공된경우대조군에비해 5년국소재발률이각각 28.8%, 9.9% 로의의있게높은것을관찰하였다. 이논문에서도강조되었지만직장암수술시천공은아주재발에큰위험요소이기때문에정확한해부학적박리를시 Fig. 1. Abdominopelvic CT shows local recurrence at right pelvic sidewall and presacral area after APR. 행하여천공이발생하지않도록해야한다. 복회음절제술후골반내국소재발은재수술이특히어려운것으로알려져있다. 실제로본교실에서직장암수술후국소골반재발의형태와예후를조사한결과에의하면일차수술이복회음절제술인경우는항문괄약근보존술에비교하였을때근치적절제율이각각 8.3%, 40.7% 이었다. 17 복회음절제술을시행하였던경우는대개골반측방벽이나천골앞쪽, 방광뒤등에서재발하기때문에수술이어렵게된다 (Fig. 1). 따라서복회음절제후재발은재수술이어렵기때문에일차수술시보다철저한수술이필요하다고생각한다. 복회음절제술을피하는이유중하나가장루조성때문인데삶의질이낮은이유가장루때문이라는보고도있지만 18 장루를피하는것이단지삶의질을높이는방법은아니라는점을지적한논문도있다. 19 즉초저위전방절제술, 다병합치료등의치료는환자의삶의질을많이떨어뜨릴수있다. 따라서복회음절제술을시행받은환자가항문괄약근보존술을시행받은환자에비하여삶의질은비슷하거나더높을수있다고하였다. 따라서원위부직장암에서복회음절제가필요한환자들에게는과감하게복회음절제술을시행하고장루재활치료를시행하는것이환자를위하는길이며복회음절제술시, 상기기술한충분한절제연을가진원통형표본 (cylindrical shape), 직장간막말단부의직경이작아지지않는표본 (No waist), 충분한항문거근절제, 천공없는직장절제등의수칙을지킨다면복회음절제로인한합병증이나국소재발은예방할수있을것으로생각한다.
김남규 : 원위부직장암의복회음절제술을위한임상해부학적지식및술기 261 2) 수술방법복회음절제술은복강내수술시의전직장간막절제술 (Total mesorectal excision) 과회음절제시의정확한해부학적회음부절제술 (Sharp Antomical Perineal Dissection, SAPD) 로구성되었다고할수있다. 어떻게해야전직장간막절제술과정확한해부학적회음부절제술를할수있는가? 전직장간막절제술개념이란직장간막을싸고있는직장고유근막을따라서정교한해부학적골반박리를하는것으로이절제면으로항문거근까지박리를하다보면직장의원통형근육층만나오게된다. 항문거근약 1~2 cm 상방에서는직장간막이없어진다 (Fig. 2). 대개직장벽이얇은항문거근과가볍게붙어있어박리해야만거근을볼수있다. 단직장암이이근처에있을때는박리를피해야한다 (Fig. 2). Abdominal approach (Total Mesorectal Excision) Rectum Mesorectum Tapered mesorectum near the level of levator ani muscle Perineal Dissection (SAPD) Fig. 2. Mesorectum was tapered down near the level of levator ani muscle. APR component consist of TME (abdominal phase) plus sharp anatomical perineal dissection (perineal phase). A Metastatic lymph node B Mesorectum Rectal cancer Internal obturator muscle Ischial spine Ischirectal fat Levator ani muscle Fig. 3. Axial T2 weighted image shows fine linear hypodense structure along the visceral pelvic fascia enveloping mesorectum (A). Coronal image shows metastatic lymph node was located at close to the imaginary dissection line especially the level of levator ani muscle insertion site (B).
262 대한대장항문학회지제 21 권제 4 호 2005 회음부를절제하기전에가능한골반쪽박리가항문거근까지내려가는것이편하다. 만일골반이좁아서골반박리가항문거근까지못내려간경우회음부절제시상당수준까지박리가올라가야하므로이때는초심자들은특히주위장기손상이안되도록조심해야한다. MRI상에서전직장간막절제술의절제면은 Axial T2 weighted fast spin echo image상 fine linear hypodense structure가보이는데이것이직장고유근막이다 (Fig. 3A). 이면으로박리하는것이다. 관상영상 (coronal image) 상직장암이내폐쇄근에가까이위치하고있고좌골직장지방과항문거근직상방에서끝나는직장간막과의사이에잘룩한부분이보인다. 복부로의절제시 TME도정확히진행되어야하지만회음절제도가능한절제연을넓게확보하여수술하는것이중요하다 (Fig. 3B). 가상의박리선 (Imaginary dissection line) 근처에전이림프절이존재하는것을볼수있다 (Fig. 3B). Heald는직장간막후방에주행하는상직장동맥및정맥주변에따라림프절들이존재하고있어특히이것들을싸고있는지방층이다치지않도록정교하고정확한골반박리를해야한다고강조하고있다. 전이림프절이골반박리 plane에서단지 1~2 mm 떨어져있어서이 plane이지켜지지않으면전이림프절을다치기쉬어암세포의파종이생기기쉽다. 회음부절제시에도전이림프절이계획된절제연에가깝게위치하고있으므로부정확한박리는부적절한전직장 간막절제술과마찬가지로암세포의파종을발생시키기쉽다. 회음부에서는회음섬유근성 (perineal body) 에있는천혹은심부횡회음부근육 (superificial and deep perineal muscle) 과천골앞에있는항문미골인대 (anococcygeal ligament) 를중요한전방및후방경계표지이다. 회음부박리시주요혈관은내음부혈관에서나오는하직장혈관들이다 (Fig. 4). 항문거근이측방으로기시부부위부터잘려야되며종양이항문거근이나항문괄약근과가까우면골반박리시종양근처까지박리하는것은의도하지않은암세포수술창상의착상을유발할수있기때문에피하는것이좋다. 실제로수술전 MRI로원위부직장암인에서항문거근, 내괄약근과외괄약근과의관계를축방향혹은관상영상으로종양이근접해있거나침범한경우를미리예측할수있기때문에종양근처의박리를피할수있다고생각한다. 20 항문거근은복회음절제술시이근육의붙는자리에서자르게되는데이근육은얇은근육 (membranous sheet like structure) 이다. 간혹직장간막을싸는근막과붙어있게된다. 이얇은근막은회음부박리시골반벽에서가까운곳에서절단한다 (Fig. 5). 항문관주위로발달한항문괄약근을보여준다. 직장을 U형으로감싸고치골로가서붙는직장치골근이보이고옆으로넓게존재하는항문거근이보이고있다. 회음부박리시이근육을같이포함하여절제하게 Superficial transverse perineal muscle Internal pudendal artery Inferior rectal artery Anococcygeal ligament Fig. 4. Perineum in male and female. superficial and deep transverse perineal muscle was located at the perineal body, which is important landmark as well as coccyx.
김남규 : 원위부직장암의복회음절제술을위한임상해부학적지식및술기 263 Mesorectum and fascia Levator ani m. Levator ani m. coccyx Fig. 5. Levator ani muscle is inserted to the pelvic sidewall, which is like membranous sheet and sometimes to adhesed to the rectal proper fascia enveloping the mesorectum. Puborectalis muscle Rectum Levator ani muscle Fig. 6. Anal sphincter muscle was shown around the anal canal. U shaped puborectalis muscle was clearly seen and surrounding levator ani muscle was also seen. These membranous sheet structure must be cut off from its insertion site. 된다 (Fig. 6). 이때중요한골반표지자는양쪽좌골극 (ischial spine) 이고뒤쪽으로는미골이다. 항문거근위치에서는골반벽에가깝게항문거근을잘라내야한다. 3) 수술전직장 MRI 중요소견과해부학적구조수술전 MRI 영상과해부학적구조와의상관관계를살펴보면보다수술시정확한절제면에대한자신감이생길수있다. 시상영상 (sagittal view) 에서 S3, 4 경계에서직장후벽으로주행하는 low signal intensity가있는데이것이직장천골근막 (rectosacral fascia) 이다. 이는직장후강을박리할때 coccyx 근처까지박리시반드시절단해야하는근막이다. 관상영상 (coronal view) 에서는항문거근이잘보이고있고내폐쇄근도잘보이고있다. 원위부직장암시주변항문괄약근과종양과의상관관계를더잘알아보는것이다. 특히항문거근과의종
264 대한대장항문학회지제 21 권제 4 호 2005 Rectosacral fascia Levator ani m. Internal obturator m. Fig. 7. Rectosacral fascia was seen as low signal intensity band structure at the S3, 4 level which was continuous with the rectal wall. Levator ani muscle was also clearly seen at coronal image, which was hanging down to the anal sphincter muscle. Fig. 8. Pelvic MRI shows rectal cancer directly invaded into the surrounding sphincter muscle and APR was performed. Gross finding revealed that cancer invaded to the surrounding anal sphincter muscle. 양과의관계, 즉종양의내괄약근의침범등을수술전에찾아보는것이중요하다 (Fig. 7). Fig. 8은종양이내괄약근을침범한소견을보여복회음절제술을진행하였다. 종양의괄약근침범정도를수술전 MRI로비교적정확히예측할수있다. 괄약근침범원위부직장암의무리한항문괄약근보존술식을피할수있게한다 (Fig. 8). 4) 도식화된복회음절제술의그림청색선이복회음절제술이진행되는박리면이다. 즉복부에서는 visceral plevic fascia (rectal proper fascia) 의박리면으로항문거근위치까지박리가진행되고난후회음부박리는충분한좌골직장지방조직 (ischiorectal fat) 을포함하고대둔근근막과내패쇄근을노출하면서항문거근은골반벽에가깝게절단한다 (Fig. 9). 회음부박리시타원형피부절개 (elliptical skin incision) 를항문에서 2~3 cm 피부포함하여절개하고 ( 양쪽좌골극이표지자 ) 좌골직장지방 (ischiorectal fat) 을박리한다. 미골이기준이되어항문미골인대를자르면서복부에서박리하던면과교통한다. 양옆으로항문거근이붙는부위를골반벽에가깝게자른다. 항문거근까지들어가는데하직장혈관을결찰하게된다. 뒤와옆이박리가되면직장의앞쪽과회음부와붙은부분을잘박리해야한다. 이경우골반이넓거나직장암이전방에만없으면절단된에스상결장을회음부절개창으로뽑아내서당기면서전립선이나질과직장을
김남규 : 원위부직장암의복회음절제술을위한임상해부학적지식및술기 265 박리한다. 이과정에서주변전립선이나질혹은직장의천공이생길수있으니각별한주의가요구된다. 5) 육안적소견 Levator ani muscle Internal and external anal sphincter Ischiorectal fat Internal obturator muscle Ischial spine Fig. 9. Blue line represent the dissection line at the time of APR. In Abdominal phase, dissection line should be followed along the rectal proper fascia plane. In perineal phase, dissection continued to the levator ani muscle and cut it off at the bony insertion site as can as possible. En-bloc resection must be included a wide excision of the levator ani muscle and ischiorectal fat. 절제된조직의육안적소견과절단면의병리조직학적검사를해야한다. 복회음절제된육안적소견인데원주형형태여야하며생체에서항문거근이붙어있던자리는잘려진후근육이위축되어자연허리가형성이되나가능한사진처럼허리가없게원통형으로나와야한다. 물론천공된부위는없어여하며사진은종양이수술전 MRI상에서항문거근침윤이의심된환자로항문거근을골반벽에아주근접하여절제하여절제연을확보하였다. 아울러충분한좌골직장지방조직을제거하여야한다 (Fig. 9, 10). 정확한 SAPD (Sharp Anatomical Perineal Dissection) 이이루어지지않으면종양과가깝게절제가이루어 APR specimen Levator ani muscle invasion by tumor Fig. 10. Macroscopic assessment of APR specimen shows cylindrical shaped specimen without waist. Rectal cancer directly invaded into the levator ani muscle and wide margin was obtained (right). Table 1. Oncologic outcomes following curative abdominoperineal resection for rectal cancer Group Patients (n) Radiotherapy Chemotherapy Local Five-year recurrence (%) survival (%) Nissan et al 8 (2001) 282 188 (94) NA 6.4 58 Heald et al 13 (1997) 15 None None 33 47 Law et al 14 (2004) 69 31 (45) 28 (41) 23 60 Heo et al 21 (2004) 110 29 (81) 100 (10) 23.6 58.1 Enker et al 22 (1995) 148 NA NA 13 60.2 YUMC (2005) 256 193 (63) 175 (81) 12.6 67 NA = not applicable.
266 대한대장항문학회지제 21 권제 4 호 2005 져종양세포의수술부위착상등이발생하여이로인한국소재발등이발생하며또는주변장기손상, 질손상, 질회음부누공, 전립선요도손상등의합병증을유발할수있다. 6) 치료성적 직장암으로근치적복회음절제술후국소재발률은 6.4% 에서 23.6%, 생존율은 47% 에서 67% 으로다양하게보고되고있다 (Table 1). 본교실에서 1986년부터 2002년까지직장암으로근치적복회음절제술이시행되었던 256명을분석한결과국소재발률은 12.6%, 5 년생존율은 67% 였다. 결 항문괄약근보존술시대에원위부직장암수술에서아직중요한위치를차지하고있는복회음절제술의빈도가점차로줄고있는것이사실이다. 무리한항문괄약근보존술은조기국소재발이나항문협착, 변실금등의문제로삶의질이저하될수있는위험이있다. 따라서원위부직장암인경우수술전 MRI 검사로항문괄약근의침범유무를알고또환자의여러인자, 즉연령, 암세포분화도등을고려하여세심하고과감한결정을내려야할것이다. 복회음절제가결정되면전직장간막절제술과정확한해부학적회음부절제술 (Total Mesorectal Excision plus Sharp Anstomical Perineal Dissection) 의정확한해부학적박리를시행하여야할것이다. 론 감사의글 사진촬영에도움을주신외과백승혁선생님과그림제작을도와주신윤관현선생님께감사드립니다. REFERENCES 1. Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 1908;2:1812. 2. Deddish MR, Stearns MW. Anterior resection for carcinoma of the rectum and rectosigmoid area. Ann Surg 1961;154: 961-6. 3. Moriya Y, Sugihara K, Akasu T, Fujita S. Importance of extended lymphadenectomy with lateral node dissection for advanced lower rectal cancer. World J Surg 1997;21:728-32. 4. Goligher JC, Dukes CE, Bussey HJR. Local recurrence after sphincter saving excision for carcinoma of the rectum and rectosigmoid. Br J Surg 1951;39:199-205. 5. Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 cm rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patient's survival. Br J Surgery 1983;70:150-4. 6. Madsen PM, Christiansen J. Distal intramural spread of rectal carcinomas. Dis Colon Rectum 1986;29:279-82. 7. Moore HG, Riedel E, Minsky BD, Saltz L, Paty P, Wong D, et al. Accuracy of 1 cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined modality therapy. Ann Surg Oncol 2003;10:80-5. 8. Nissan A, Guillem JG, Paty PB, Douglas WW, Minsky B, Saltz L, et al. Abdominoperineal resection for rectal cancer at a speciality center. Dis Colon Rectum 2001;44:27-36. 9. Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B. Effect of a surgical training programme on outcome of rectal cancer in the county of Stockholm, Stockholm colorectal cancer study group, Basingstoke bowel cancer research project. Lancet 2000;356:93-6. 10. Zaheer S, Pemberton JH, Farouk R, Dozois RR, Wolff BG, Ilstrup D. Surgical treatment of adenocacrinoma of the rectum. Ann Surg 1998;227:800-11. 11. Heald RJ, Smedh RK, Kald A, Sexton R, Moran BJ. Abdominoperineal excision of the rectum--an endangered operation. Dis Colon Rectum 1997;40:747-51. 12. Haward RA, Morris E, Monson JRJ, Johnston C, Forman D. European J Surg Oncol 2005;31:22-8. 13. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997. Arch Surg 1998;133:894-8. 14. Law WL, Chu KW. Abdominoperineal resection is associated with poor oncological outcomes. Br J Surg 2004;91: 1493-9. 15. Dehni N, McFadden N, McNamara DA, Guiguet M, Tiret E, Parc R. Oncologic results following abdominoperienal resection for adenocarcinoma of the low rectum. Dis Colon Rectum 2003;46:867-74. 16. Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN on behalf of the Norwegian Rectal Cancer Group and the Norwegian Gastrointestinal Cancer Group. Inadvertent perforation during rectal cancer resection in Norway. Br J Surg 2004;91: 210-6. 17. Park JK, Kim NK, Baik SH, Lee KY, Sohn SK, CHO CH. Local pelvic recurrence after curative resection of the rectal cancer: classification and prognosis. J Korean Soc Coloproctol 2005;21:82-8. 18. Grumann MM, Noack EM, Hoffmann IA, Schlag PM. Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal
김남규 : 원위부직장암의복회음절제술을위한임상해부학적지식및술기 267 cancer. Ann Surg 2001;233;149-56. 19. Renner K, Rosen HR, Novi G, Holbling N, Schiessel R. Quality of life after surgery for rectal cancer: dose still need a permanent colostomy? Dis Colon Rectum 1999;42:1160-7. 20. Akasu T, Iinuma G, Fujita T, Muramatsu Y, Tateishi U, Miyakawa K, et al. Thin-section MRI with a phase-array coil for preoperative evaluation of pelvic anatomy and tumor extent in patients with rectal cancer. Am J Radiology 2005;184:531-8. 21. Heo YJ, Cho HM, Kim JG, Won YS, Jun KH, Chin HN, et al. Factors influencing the oncologic results after abdominoperineal resection: does the introduction of laparoscopic procedures influence the oncologic results? J Korean Soc Coloproctol 2004;20:311-8. 22. Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectum excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 1995;181:335-46.