대한내과학회지 : 제 83 권제 2 호 2012 http://dx.doi.org/10.3904/kjm.2012.83.2.221 박리성올가미결찰을이용하여내시경적으로제거한대장지방종 1예 연세대학교의과대학강남세브란스병원내과 정다현 윤영훈 허철웅 윤지현 김우정 김지현 이상인 Case of a Giant Colonic Lipoma That Was Endoscopically Removed by Strangulation with Repetitive Endoloop Ligation Da Hyun Jung, Young Hoon Yoon, Cheal Wung Huh, Ji Hyun Yoon, Woo Jeung Kim, Jie-Hyun Kim, and Sang In Lee Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Colonic lipomas are the most common tumors of mesenchymal origin in the large intestine. These tumors are typically found in the colon, but are also discovered in the small bowel, stomach, and esophagus. Most gastrointestinal lipomas are asymptomatic and are discovered incidentally during endoscopy or surgery. Large lipomas can cause abdominal pain, gastrointestinal bleeding, obstruction, and intussusceptions and therefore require resection. Surgical resection is typically only considered for the removal of giant lipomas > 2 cm because of concerns regarding the high complication risk of endoscopic resection. New techniques that use endoscopic snare polypectomy with endoloops or endoscopic resection with an endoloop after an unroofing technique have recently been reported. We herein report a case of a 7-cm giant colonic lipoma that was removed by an endoscopic unroofing technique and repetitive endoloop ligation and strangulation. (Korean J Med 2012;83:221-225) Keywords: Colon; Endoscopic resection; Lipoma 서론대장지방종은대장에서가장흔한간엽조직종양으로소장, 위, 식도에서도발생할수있다. 대부분의경우증상이없어대장내시경이나수술을통해우연히발견되는경우가많으며, 크기가크지않은경우특별한치료를필요로하지않는다. 증상또는합병증이발생하거나악성종양과감별을 요하는경우절제해야하는데, 2 cm가넘는지방종의경우올가미를통한내시경적절제를시도할경우지방조직의특성상절제가잘되지않고, 이로인한장천공등의합병증발생의우려가있다. 따라서이전에는 2 cm 이상의지방종인경우수술적제거가권장되었다 [1]. 최근유경성의폴립인경우 stalk의크기에따라내시경적절제술이조심스럽게행해지고있다. 내시경적용종절제술이나, unroofing 기법 Received: 2011. 4. 26 Revised: 2011. 7. 28 ccepted: 2011. 9. 30 Correspondence to Young Hoon Yoon, M.D. Department of Internal Medicine, Gangnam Severance Hospital, 712 Eonju-ro, Gangnam-gu, Seoul 135-720, Korea Tel: +82-2-2019-3453, Fax: +82-2-3463-3882, E-mail: dryoun@yuhs.ac - 221 -
- The Korean Journal of Medicine: Vol. 83, No. 2, 2012 - 및박리성올가미를반복적으로이용하여단계적으로지방종을제거한예가보고된바있으며점막하박리술을이용하여성공적으로절제한경우도보고되었다 [2]. 저자들은 7 cm 크기의거대대장지방종을 unroofing 기법과박리성올가미를사용하여반복적교액을통해단계적으로크기를줄여내시경적으로제거한 1예를경험하였기에보고한다. 증례 85세여자가 10일동안지속된복통과혈변을주소로타병원내원하여시행한대장내시경에서구불결장의거대종양이발견되어본원에전원되었다. 과거력이나가족력에는특이사항은없었다. 내원당시혈압은 149/72 mmhg, 맥박 은분당 90회, 체온은 36.1, 호흡수는분당 18회이었다. 의식은명료하였고결막은창백하지않았다. 복부는부드러웠으나, 복부종괴는만져지지않았으며, 압통이나반사통은없었고, 장음은정상이었다. 직장수지검사에서혈흔은없었으며그외특이소견은보이지않았다. 말초혈액검사에서백혈구 8,160/mm 3, 혈색소 9.8 g/dl, 혈소판 470,000/mm 3 이었고, 혈액응고검사는정상이었다. 혈청생화학검사에서 UN/Cr 20.7/0.42 mg/dl, 총단백 5.4 g/dl, 알부민 3.1 g/dl, ST 17 IU/L, LT 12 IU/L, 총빌리루빈 0.8 mg/dl이었고, 대변잠혈검사에서양성소견을보였다. CE 5.4 ng/ml, C 19-9 10.4 U/mL 로종양표지자검사는 CE가약간증가하였다. 본원에서시행한대장내시경검사에서구불결장에관강전체를메우고있으며표면점막의부분적괴사가동반된 7 cm 크기의거 C D Figure 1. Initial colonoscopic findings. () giant subepithelial lesion was seen in the sigmoid colon with luminal obstruction. Its surface was covered with exudates. () The roof of the lipoma was dissected with a needle knife (unroofing technique). (C) Yellowish adipose tissue was exposed. (D) n endoloop was applied to the mass. - 222 -
- Da Hyun Jung, et al. Colonic lipoma removed endoscopically - Figure 2. bdominal computed tomography (CT) findings. () 7-cm low-attenuation lesion with obstruction was present in the sigmoid colon. () round target-shaped mass was present in the left abdomen. 대종괴가관찰되었다 (Fig. 1). 복부컴퓨터단층촬영에서이종괴는 3.8 7.0 cm의균일한저밀도의음영을보여, 구불결장에발생한거대지방종으로판단되었고 (Fig. 2), 그로인한장중첩증소견및장폐색소견이관찰되었다 (Fig. 2). 수술적치료를고려하였으나고령으로인해환자의전신상태가좋지않았기때문에수술적치료보다는내시경적절제를계획하였고, 종양의크기가커서 unroofing 기법과박리성올가미교액술을통한단계적절제술을시도하기로하였다. 침형절개도 (needle knife) 로점막표면을절개하여 (Fig. 1) unroofing 하자내부의지방조직이노출되어지방종을확인할수있었고 (Fig. 1C) 조직검사를시행하였다. 박리성올가미를사용하여종양의기시부를조여교액하고자하였으나, 종양의크기가너무커서기시부의교액이어려웠고, 1차적으로약 40% 를포획하여결찰하고혈행을차단하였다 (Fig. 1D). 조직검사결과지방조직을확인할수있었다. 1개월후시행한대장내시경검사에서종양의크기는 50% 정도감소하였고이전에걸어놓은박리성올가미는탈락되어관찰되지않았다. 다시한번박리성올가미를사용하여종양의하단부를조이고혈행을차단하였다 (Fig. 3). 2개월후시행한대장내시경검사에서종양의크기는 75% 정도감소하였고, 이전 Figure 3. One-month follow-up colonoscopic findings. The lipoma had decreased to 50% of its original size after 1 month. The previous endoloop was dropped out, and a second endoloop was applied. 에시행한박리성올가미는남아있었다. 다시한번박리성올가미를이용하여종양의하단부를결찰하고교액하였다 (Fig. 4). 3개월후반복대장내시경검사를실시하였고종양의크기는줄어 1 cm 이하로감소하였다 (Fig. 5). 환자는더이상증상이없고, 지방종의크기가충분히감소되어추후 - 223 -
- 대한내과학회지 : 제 83 권제 2 호통권제 624 호 2012 - Figure 4. Two-month follow-up colonoscopic findings. () The lipoma had decreased to 25% of its original size after 2 months. () third endoloop was applied repetitively. Figure 5. Four-month follow-up colonoscopic findings. The lipoma had decreased to 10% of its original size after 4 months. 합병증발생가능성이없다고판단되어, 더이상의절제없이외래에서추적관찰중이다. 고 지방종의원인은명확히밝혀지지않았으나발생학적으로잘못위치한지방결체조직에서발생하는것으로알려져있다. 대장지방종의진단은대장내시경, 내시경초음파, 복부전산화단층촬영, 대장바륨조영술등으로확인할수있고, 조직검사로확진할수있다. 대장내시경검사에서는유연하고매끄러운점막을보이고황적색을띠며, 생검겸자로 찰 눌렀을때함입되는 cushion effect, 생검겸자로점막을잡아당기면쉽게당겨지는 tenting sign, 생검한부분으로지방조직이밀려나오는 naked fat sign 이특징적인소견이다. 복부전산화단층촬영검사에서는 -80 ~ -120 Housefield unit (HU) 밀도의균일하고경계가뚜렷한종괴양상을보인다 [3]. 대장지방종의경우대부분증상이없고, 크기가크지않으면이차적합병증발생률이낮아치료를필요로하지않는다. 하지만, 크기가큰경우이로인해복통, 장폐색, 장중첩증등의증상이발생할수있고출혈등도유발할수있다 [4]. 대장지방종은증상이없는경우악성화가능성이없어치료가불필요한경우가대부분으로정기적으로추적관찰만하면되고 [5], 합병증을동반한경우나악성종양과감별이필요한경우절제가필요하다. 대장에서원발성으로발생한악성지방종은극히드물고전세계적으로 10예의보고가있다 [6]. 크기가 2 cm 이상인경우천공이나출혈의합병증발생률이높아외과적절제가권고되고있으나최근내시경적제거술이시도되고있다. 내시경적절제술을시행하는경우, 지방조직의특성상전기전도율이낮아절제도중전기출력을올려고열이발생하고이로인해종양주위의대장벽에손상을주어천공이나출혈의가능성이높다 [7]. Unroofing 기법은 Mimura 등 [8] 이대장림프관종의내시경치료에서처음시도한방법이다. 지방종에서 unroofing 기법은종괴의상부를절개하여노출된틈으로지방의자연배출을유도하여지방종의크기를감소시키는방법이다. 박리성올가미를사용하여지방종을제거하는것은용종으로가는혈행을차 - 224 -
- 정다현외 6 인. 내시경적으로제거한거대대장지방종 - 단하여내시경적으로크기감소를유발하는것으로굵은혈관이경내에분포하는경우에서도박리성올가미를통해지혈효과를얻어합병증을줄일수있다. 크기가커서박리성올가미에잘들어오지않는경우에는두통로 (two-channel) 대장내시경을이용하여움켜잡기겸자로종괴를움켜잡고박리성올가미를거는방법이도움이된다는보고도있다 [9]. 또다른경우에서는대장내시경을통해무경성거대지방종에고장생리식염수와에피네프린을주입하여인공용종을만들고올가미를이용하여용종을제거한후헤모클립을사용하고지혈한뒤지방종을제거한보고도있으며 [10], 대장내시경조직검사후에자발적으로거대지방종이제거된보고도있다. 저자들은대장내시경에서발견된구불결장의 7 cm의거대지방종을 unroofing기법과박리성올가미를이용하여반복적교액을통해크기를줄인뒤내시경적절제술을시행하여비수술적으로안전하게치료하였다. 거대지방종의절제에있어 unroofing기법과박리성올가미를반복적으로사용하는방법은안전한내시경적절제술이라고생각한다. 요약대장지방종은대장에서가장흔한간엽조직종양으로, 소장, 위, 식도에서도발생할수있다. 대부분의경우증상이없어치료가필요하지않고, 대장내시경이나수술을통해우연히발견되는경우가많지만, 크기가큰경우에는복통, 출혈, 폐색, 장중첩등과같은합병증을동반할수있어제거를고려하여야한다. 2 cm가넘는지방종의경우, 내시경절제시합병증발생률이높기때문에수술적제거가권장되고있으나최근내시경적용종절제술, unroofing 기법및박리성올가미를이용하여단계적으로지방종을내시경적으로제거한예가보고되었다. 저자들은 7 cm 크기의거대대장지 방종을 unroofing 기법과박리성올가미를사용하여반복적교액을통해단계적으로크기를줄여내시경적으로제거한 1 예를경험하였기에보고한다. 중심단어 : 대장 ; 지방종 ; 내시경적절제 REFERENCES 1. Shin EK, Kim KJ, Seo J, et al. case of giant colonic lipoma showing spontaneous resolution after endoscopic partial resection. Korean J Gastroenterol 2007;50:199-202. 2. Morimoto T, Fu KI, Konuma H, et al. Peeling a giant ileal lipoma with endoscopic unroofing and submucosal dissection. World J Gastroenterol 2010;16:1676-1679. 3. lberti D, Grazioli L, Orizio P, et al. symptomatic giant gastric lipoma: what to do? m J Gastroenterol 1999;94: 3634-3637. 4. Youk CM, Kim S, Park KC, et al. Lipoma of the transverse colon with intussusception: a case report. Korean J Med 2001;61:41-45. 5. Tascilar O, Cakmak GK, Gün D, et al. Clinical evaluation of submucosal colonic lipomas: decision making. World J Gastroenterol 2006;12:5075-5077. 6. Choi YY, Kim YJ, Jin SY. Primary liposarcoma of the ascending colon: a rare case of mixed type presenting as hemoperitoneum combined with other type of retroperitoneal liposarcoma. MC Cancer 2010;10:239. 7. Whang HC, Im DH, Oh JS, et al. case of a colonic giant lipoma removed by endoscopic resection. Korean J Gastrointest Endosc 2007;35:355-358. 8. Mimura T, Kuramoto S, Hashimoto M, et al. Unroofing for lymphangioma of the large intestine: a new approach to endoscopic treatment. Gastrointest Endosc 1997;46:259-263. 9. Shin YK, Kim EY, Jeon SW, et al. case of giant colonic lipoma endoscopically removed using an unroofing technique in phases. Korean J Gastrointest Endosc 2008;36:242-247. 10. Kim CY, andres D, Tio TL, enjamin S, l-kawas FH. Endoscopic removal of large colonic lipomas. Gastrointest Endosc 2002;55:929-931. - 225 -