외과적응급수술 연세대학교의과대학세브란스병원외과및간암전문클리닉 김경식 Surgical emergency Kyung Sik Kim Dept. of Surgery, Liver Cancer Special Clinics, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Recently Hepatitis A virus infections have been rapidly increased from 798 in 2005 to 7,889 in 2008 in Korea. The progression to fulminant hepatic failure has occasionally occurred. Although the only definite therapy is liver transplantation for fulminant hepatic failure, there is no definite consensus for an optimal patient selection program and the determination of the operation time. Cirrhotic patients may become candidates for emergency surgery. This may be due to conditions requiring emergency surgery such as acute cholecystitis, acute appendicitis, incarcerated hernia, and rupture of viscus, variceal bleeding, and so on. To achieve the better surgical results, the more sophisticated patient selection program and the choice of ideal operation time should be needed in liver transplantation. During the emergency operation, the extents of surgery have to be lessened to minimize the operation time and the amount of bleeding. Malnutrition, which is frequently encountered in cirrhotic patients, has been shown to have an important impact on the surgical risk. A poor nutrition status has also been associated with a higher risk of complications and mortality in patients undergoing liver transplantation. Because the nutrition therapy may improve the clinical outcome in cirrhotic patients undergoing general surgery and/or liver transplantation, the effective managements are recommended to enforce suitable nutritional supply. Key words: Liver Cirrhosis, Fulminant Hepatic Failure, Risk Factors, Postoperative Complications, Emergency operation 서론 최근들어우리나라에서는 A형간염이급격하게증가하여 2005 년 798 명에서 2008년 7,889명으로지속적인급증세를보이고있고 2009 년 1~3 월까지 A형간염신고건수는 1,668 건으로작년같은기간보다약 2.1 배증가한것으로나타났다 ( 그림 1). 1 드물지만전격성간부전 (fulminant hepatic failure) 이발생하고, 2 적극적인내과적치료에반응하지않아응급으로간이식수술이행해지고있는실정 3 으로급성간부전에대한관심이높아지고 82
김경식 외과적응급수술 Figure 1. 2009 년 1~3 월지역별 A 형간염발생건수. Figure 2. 2002 년미국에서의급성간부전환자의발생원인 5 있다. 하지만이런경우는매우제한적인경우로임상에서흔히보는대부분의경우는간경변이동반된환자에서응급수술이행해지는경우이다. 그러므로본난에서는전격성간부전에서의간이식은개괄적으로살펴보고, 주로간경변이동반된환자에서흔히경험하게되는외과적응급수술의종류를알아보고이에따른효율적인수술준비및수술후의예후등을살펴봄으로써보다효과적인치료적접근에도움을주고자한다. 전격성간부전에서의간이식 전격성간부전은기존의간질환이없는상태에서바이러스나약물등에의한급성의간손상으로간의기능이제대로이루어지지않아간성뇌증, 뇌부종, 순환기및신장장애, 혈액응고장애, 저혈당및각종감염으로인한 83
Table 1. 2006 년한국단일 3 차의료기관에서의전격간부전환자의발생원인 6 패혈증등여러합병증을동반함으로써사망률이높은치명적질환이다. 4 우리나라에서의전격성간부전의원인을살펴보면구미의보고 ( 그림 2) 5 에서와달리약물에의한것은비교적적고주로 B형간염에의한경우가 15.8% 였고 A형간염에의한경우도 3.3% 였다 ( 표 1). 6 그림 2에서보는바와같이특이약물반응, B형간염, 자가면역간염, 윌슨병, Budd-Chiari 증후군등이원인인경우는간이식수술없이단기간생존할가능성은 25% 미만으로 5 전격성간부전의가장중요한치료는간이식이지만일부환자에서는간이식없이도회복이가능하기때문에좋은예후를보이는환자를선별할수있는방법에대한연구가활발히진행되고있다. 전격성간부전환자들의예후에대한다변량분석을통하여간이식이필요한환자를선별하기위한여러가지기준이제안되었으나 ( 표 2) 아직정확한결과를보이는유용한검사로널리인정받은지표는없는실정이다. 최근대한간학회지에발표된전격성 A형간염환자에서는간성뇌증의정도가심하지않는경우에는자발생존이가능하다고보고하였다. 3 이식이지연되어환자의상태가악화되면이식을받아도회복하지못하거나신경학적후유증을남길수있으므로언제수술을시행해야할것인가를결정하는것은매우어렵다. 현재까지전격성간부전의치료방법으로 84
김경식 외과적응급수술 Table 2. Prognostic indices in fulminant hepatic failure Authors King s College Criteria (1989) 8 Harrison (1990) Clichy Criteria (1991) Pereira (1992) Madl (1994) Lee (1995) Itai (1997) Mitchell (1998) Obaid (2000) Rolando (2000) Schmidt (2002) Bernal (2002) Harry (2002) Yantorno (2004) Barshes (2006) Prognostic Index Acetaminophen ph <7.3 or all of followings (Encephalopathy GIII or IV, INR >6.5, Creatinine >3.4 mg/dl) Nonacetaminophen INR >6.5 or at least 3 of the followings (Age <10 or >40 yrs, Interval >7 days, undetermined etiology, INR >3.5, Bilirubin >17.5 mg/dl) serial prothrombin times Grade III or IV encephalopathy in association with Age<30, Factor V <20% or Age >30, Factor V <30% Factor VIII & Factor V ratio score sensory evoked potentials serum levels of Gc-globulin Assessment of liver size on CT APACHE score(the Acute physiology & Chronic Health Evaluation) Liver histology the severity of the SIRS Hyperphosphatemia Blood lactate level adrenal insufficiency MELD score Body mass index, serum creatinine, recipient age, history of life support 간이식이유일하기때문에급성간질환환자가심한혈액응고장애소견을보이기시작한다면, 간이식이필요하게될가능성을염두에두고치료에임해야할것이다. 7 간경변이동반된환자에서흔히경험하게되는외과적응급수술 우리나라에서간경변증을동반한환자에서시행되는외과적응급수술에관한체계적인보고가매우드문실정이다. 간경변증을동반한환자에서수술후의예후에관한인자를분석한논문을토대로외과적응급수술의빈도및특히응급수술이예후에미치는영향을알아보았다. 9-13 1. 간경변환자에서의외과적응급수술의빈도김등의보고에의하면 9 간경변을동반하여수술이시행되었던 223 예중위장관계응급수술은 35예가시행되었다. 가장많은빈도는담낭절제술 8예였고, 충수절제가 7예, 위절제 6예, 식도정맥류지혈을위한직달법 6예, 위장천공에의한단순봉합이 4예, 비장절제, 췌장미부절제, 항문주위농양배액이각각 1예씩있었다. 1946 년 7월 ~1957 년 5월까지미국 Cleveland 의재향군인병원에 Laennec 간경변을동반한 577 명의환자에서 18예의복강내급성복증으로진단되었다. 12 원인별로살펴보면소화성궤양의천공 5예, 췌장염 4예, 특별한원인이없던복막염환자 3예, 위벽괴사, 급성충수염, 상장간막동맥색전증, 대장폐색, 간암의괴사및파열, 85
Table 3. 간경변을동반한환자에서의급성복증의원인및시행되는수술의빈도 저자 Finlayson (1964) Kim (1991) Hoteit (2008) 대상기간 July, 1946~May 1957 Jan. 1979~Dec. 1988 Jan. 1999~Dec. 2004 대상환자 18/557 35/223 35/195 응급질환또는수술빈도 소화성궤양의천공 (5) 췌장염 (4) 특별한원인이없던복막염 (3) 위벽괴사 (1) 급성충수염 (1) 상장간막동맥색전증 (1) 대장폐색 (1) 간암의괴사및파열 (1) 복수천자후복막염 (1) 담낭절제술 (8) 충수절제술 (7) 위절제 (6) 식도정맥류지혈을위한직달법 (6) 위장천공에의한단순봉합 (4) 비장절제 (1) 췌장미부절제 (1) 항문주위농양배액 (1) 탈장고정술 (13) 담낭절제술 (6) 진단적개복술 (4) 대장절제 (3) 소장절제 (3) 소화성궤양천공단순봉합 (2) 농양배액술 (2) 치질결찰 (1) 충수절제술 (1) 복수천자후복막염각각 1예씩을보고하였다. 또한최근간경변을동반한환자 195 예중에서수술후의예후에관한예측을위한연구를살펴보면 35명의환자에서위장관관련응급수술이시행되었다. 13 가장많은빈도를보인경우는탈장고정술로 13예 (37.1%) 였다. 빈도별로살펴보면담낭절제술 6예, 진단적개복술 4예, 대장절제 3예, 소장절제 3예, 소화성궤양천공단순봉합 2예, 농양배액술 2예, 치질결찰 1예, 충수절제술 1예였다. 시대별지역별편차를고려해볼때영상의학적진단기술이보편화되지않았던 1960 년대에는주로사망률이매우높아 Finlayson 의보고에의하면 577 명의환자중에서병원에입원하는동안에 227 명이사망하였다. 12 우리나라 9 와미국 13 과의자료를비교해보면시기적인차이가있지만담낭절제술은지역적차이가없이많이시행되는수술이었다. 그러나우리나라에서는위절제, 충수절제, 식도정맥류의직달법등이흔하게시행되었지만미국에서는탈장수술, 대장, 소장수술이많이시행되어지역적질환의차이에의할것으로사료된다. 2. 간경변을동반한환자에서의응급수술후의예후간경변을동반한환자에서전신마취하의수술을시행하는것은수술및마취와관련된합병증의위험도를증가시키는것으로알려져있다. 14 즉기존의간기능장애는출혈및감염을쉽게일으키게되고, 15 전신마취는간으로의혈류감소를유발함으로써보다허혈성손상을많이받게하며수술후사용되는약물에의해서도간독성을일으키게된다. 16 그러므로수술전평가와수술을위한적절한환자선택을위해서여러가지모델들이제안되어임상에서흔히 Child-Turcotte-Pugh 점수와 MELD score 를많이사용하고있다. 13 하지만응급수술의경우에는환자의생명이우선되는상황에서적절한선택을하는데에는많은제약이있을수있다. 특히응급수술의경우선택수술 (elective surgery) 보다약 4배이상의사망및간의비보상 (hepatic decompensation) 이발생하고, 13 수술후재원기간에영향을미치는단독인자이기 17 때문에더욱세심한수술전후의관리가필요하다. 수술전 MELD score 가 11점이하이거나 Child 점수가 7점이하인경우에는응급수술후사망이나간의비보상예를경험하지못했다는보고도있지만대부분의환자들이이들점수보다더나쁘기때문에, 13 수술의중증도점수 (severity score) 가높을수록, 수술시저혈압이생긴경우에예후가나빠질수있고, 18 수술시간이 2시간이상길어진경우에는사망률이높아져, 11 응급수술의경우에는가능한적은범위의수술을진행하 86
김경식 외과적응급수술 여수술시간을줄이고특히출혈에조심하여야할것이다. 수술후영양불량은합병증이더욱많이발생하는요인이므로적극적인영양공급에힘써야할것이다. 19 맺는말 최근들어 A형간염에의한전격성간부전이증가에의하여응급간이식이빈번히시행되고있고간경변증이동반된환자에서의수술의경험이축적되면서외과적응급수술이적극적으로확대되고있는실정으로보다좋은수술의결과를얻기위해서응급간이식시에는보다세심한환자의선택및시기의결정이필요하고응급수술의경우에는가능한적은범위의수술을진행하여수술시간을줄이고출혈을최대한적게하고적절한영양공급을시행하여보다효과적인환자의관리가권장된다. 참고문헌 1. 이수아. 질병관리본부 A형간염, 조심하세요. [cited; Available from: http://www.datanews.co.kr/site/ datanews/dtwork.asp?itemidt=1002000&aid=20090402095137500 2. Lemon SM, Shapiro CN. The value of immunization against hepatitis A. Infectious agents and disease 1994;3:38-49. 3. Kim JM, Lee YS, Lee JH, Kim W, Lim KS. [Clinical outcomes and predictive factors of spontaneous survival in patients with fulminant hepatitis A]. Korean Journal of Hepatology 2008;14:474-82. 4. Trey C, Davidson CS. The management of fluminant hepatic failure. New York: Grun & Stratton 1970. 5. Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Annals of internal medicine 2002;137:947-54. 6. Heo NY, Lim YS, Kang JM, Oh SI, Park CS, Jung SW, et al. [Clinical features of fulminant hepatic failure in a tertiary hospital with a liver transplant center in Korea]. Korean Journal of Hepatology 2006;12:82-92. 7. Suh KS, Kim JH. Indications for liver transplantation in acute liver failure. Korean Journal of HBP surgery 2009;13:25-30. 8. O Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology 1989;97:439-45. 9. Kim HD, Kim NK, Kim BR, Lee KS. An analysis of risk factors affecting opertive morbidity and mortality in cirrhotic patients. Korean Journal of surgery 1991;40:480-91. 10. Park YH, Shin JH, Kim YS, Pae WK. Analysis of risk factors affecting postoperative mortality and morbidity for celiotomy in cirrhotic patients. Korean Journal of surgery 1995;48:518-23. 11. Son SH, Suh GJ, Seong SY, Ju JS, Lee HS, Lee SK. Factors influencing the mortality in patients with hepatic cirrhosis undergoing major abdominal operations. Korean Journal of surgery 1997;53:697-706. 12. Finlayson G, Roth H. acute abdominal emergencies in patients with cirrhosis. Archives of surgery 1964;88: 947-54. 13. Hoteit MA, Ghazale AH, Bain AJ, Rosenberg ES, Easley KA, Anania FA, et al. Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis. World J Gastroenterol 2008;14:1774-80. 14. Friedman LS. The risk of surgery in patients with liver disease. Hepatology 1999;29:1617-23. 15. Gholson CF, Provenza JM, Bacon BR. Hepatologic considerations in patients with parenchymal liver disease undergoing surgery. Am J Gastroenterol 1990;85:487-96. 87
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