대한내시경복강경외과학회지 Vol.. No., 00 단일기관에서경험한복강경췌장수술 원저 연세대학교의과대학외과학교실 김동현ㆍ강창무ㆍ최새별ㆍ최기홍ㆍ김경식ㆍ최진섭ㆍ이우정 The Current Status of Laparoscopic Pancreatic Surgery: Experiences at a Single Institution Dong-Hyun Kim, M.D., Chang-Moo Kang, M.D., Sae-Byeol Choi, M.D., Ki-Hong Choi, M.D., Kyung-Sik Kim, M.D., Jin-Sub Choi, M.D., Woo-Jung Lee, M.D. Department of Surgery, Yonsei University College of Medicine, Seoul, Korea Purpose: This study aimed to access the characteristics of laparoscopic pancreas surgery and to compare the results between laparoscopy and conventional open surgery. Furthermore, we plan to offer guidance for performing laparoscopic pancreas surgery in the future. Methods: From March 004 to September 007, 7 patients underwent laparoscopic pancreas surgery (LP), including Da Vinci robotic surgeries, at the Department of Surgery, Yonsei University College of Medicine. We reviewed the clinicopathologic characteristics of these cases and we compared the results to open surgery (OP) for treating low-grade solid pseudopapillary neoplasm (SPN) as a control group. Results: The locations of tumor were 3 at the head, at the body and 3 at the tail. The postoperative pathologic diagnoses revealed 6 cases as benign disease and as malignant disease. Sixteen of these cases underwent distal pancreatectomy, including 6 spleen-preserving procedures, of which 3 cases also had preservation of the splenic vessels, and the others had enucleation performed. There was no perioperative transfusion and 0 minor complications were seen, without any mortality. The mean amount of blood loss, the day of starting the diet and the length of the hospital stay were significantly less for the cases of laparoscopic surgery. There was no difference in the postoperative complications (p=0.537). Conclusion: In fact, laparoscopic pancreas surgery is feasible and safe even if it does present some challenges. So if possible, it could also be applied to various kinds of pancreatic surgeries, including those for malignancy. However, the surgeons need accumulated skill and experience, and careful selection of the patients for laparoscopic pancreas surgery is required to achieve better results. Key words: Pancreas, Laparoscopy, Enucleation, Pancreatectomy 중심단어 : 췌장, 복강경, 단순핵절제술, 췌장절제술 서 최근복강경수술에대한경험과기구및장비의발달로간단한수술외에도개복수술로만가능해보였던종류의수술들이복강경수술로가능해지고있다. 이런이유에서복강경췌장수술에있어서도이전보다는많은종류의수술들이행해지고있고, 복강경유문보존췌십이지장절제술과같은기술적으로어려운수술들이몇몇기관에서시도는되고있으나아직보편화되지는않았다. 췌장에대한복강경적접근은 9년 John Hopkins 대학에 B.M. Bernheim에의해처음언급되었고, 994년 Soper 등 은처음으로돼지에서복강경적췌장미부절제를보고하였다. 이 통신저자 : 이우정, 서울시서대문구신촌동 34 번지우편번호 :0-75 연세대학교의과대학외과학교실 Tel:0--0, Fax:0-33-9 E-mail:wjlee@yuhs.ac 007 년대한내시경복강경학회추계학술대회에서구연발표하였음. 론 후 996년 Gagner 등 이인슐린종에대해비장보존췌장미부절제를보고하였으며, 우리나라에서는 003년 Choi 등, 3 그리고 005년 Han 등 4 이췌장체부과미부에생긴다양한양성혹은경계성종양에대해기술적으로어려운복강경비장및비장혈관보존원위부췌장절제술에대한증례들을보고한적이있다. 지금까지, 우리나라뿐아니라여러나라의많은기관에서췌장질환에대한복강경수술을많이보고하고있으며, 또한, 다른질환에비해췌장질환에있어서는한기관에서복강경수술예가많지않아유럽에서는여러기관이함께자료를모아복강경수술에대한안정성과효용성을보고하기도하였다. 5 복강경췌장수술에있어서현재많은빈도로시행되고있는수술종류로는원위부췌장절제술또는단순핵절제술이있고, 원위부췌장절제의경우아직은췌장미부에위치한고형또는낭종성종양인경우가대표적인적응증이라고할수있다. 6 본저자들은췌장의체부혹은미부에생긴병변에대해복강경수술을한 7예를분석하여그특징들을알아보았고, 진단명은상이하나병변의위치에따른수술적범위가동일하면서개복하에수술한고형가성 30
김동현외 6 인 : 단일기관에서경험한복강경췌장수술 3 유두상종양 예와비교분석하였다. 이에그차이점을알아보고복강경적췌장수술의향후방향에대해알아보고자한다. ) 대상환자 대상및방법 004년 3월부터 007년 9월까지연세대학교세브란스병원에서양성혹은경계성종양의췌장병변으로, da Vinci 로봇수술 예를포함하여복강경적췌장수술을시행받은 7명의환자를대상으로하였다. 저자들은임상적, 병리학적결과를분석하여복강경췌장수술의특성을알아보았고, 췌장병변중고형가성유두상종양 (solid pseudopapillary neoplasm, SPN) 으로개복수술로절제범위가같았던 명의환자를비교군으로하여비교분석하였다. ) 수술적방법 수술은전신마취를하였고복강경수술에서환자의자세는수술자의경험에따라옆누움자세 (lateral decubitus position) 혹은바로누운자세 (supine position) 를취하였으며개복수술에서는바로누운자세를취하였다. 췌장절제는 Endo-GIA 봉합기를사용하였는데보통은 blue cartilage (45 mm, 3.5 mm) 또는 yellow cartilage (45 mm, 3.6 mm) 을사용하였으나굵기가굵은경우는 green cartilage (45 mm, 4. mm) 를사용하였다. 하지만, 췌장의두께가두꺼워제대로자동봉합이되지않은경우는절제된단면을단일미세섬유흡수사 (PDS 3-0; Ethicon, Inc) 를사용하여복강경기구로다시 U자봉합을하였다. 3) 통계처리 SPSS.0 통계프로그램을사용하였으며, student t-test, 상관분석을적용하여 p value 0.05 이하인경우를통계학적으로의미있는것으로하였다. 결 과 장오래걸렸다. 수술중수혈한예는없었고합병증은 0예 (37.0%) 에서있었으며사망예는없었다 (Table ). 평균나이는 46.5 (5 76) 세로남자가 예, 여자가 9예였으며, 이중 6예 (59.3%) 에서는우연이발견된병변이었다 (Table ). 전체병변의위치는췌장두부에 3예, 체부에 예, 미부에 3 예였고, 핵절제술은두부에 3예, 체부에 7예, 미부에 예에서시행하였다. 이중 예는로봇수술로시행하였는데가성낭종으로핵절제술이 예, 장액낭성종양으로비장보존췌장원위부절제술이 예에서있었다. 최종보고된병리학적진단을보면장액낭성종양이 6예로가장많았고고형가성유두상종양이 5예, 점액낭성종양이 4예, 림프상피낭종이 예, 관내유두상점액성종양이 예, 가성낭종이 예, 기능않는내분비성종양이 예였으며, 그외에췌장염으로인한양성협착, 인슐린종, 관주위섬유화, 관샘암종이각각 예씩으로다양한췌장질환에대해복강경수술을시행하였다 (Table 3). 관샘암종의경우는췌장미부에위치한 3 cm 크기로수술전방사선학적평가에서양전자방사단층촬영 (positron emission tomography, PET) 상명확히악성이의심되지를않았고자기공명단층촬영 (magnetic resonance imaging, MRI) 을추가로시행한결과섬세포종양 (islet cell tumor) 또는고형가성유두상종양 (solid pseudopapillary neoplasm, SPN) 으로판명되어수술한예였다. 수술은복강경췌장원위부절 Table. Surgical outcomes Surgery type Enucleation Distal pancreatctomy Spleen-preserving Adrenalectomy Operation time (min) Bleeding (ml) Transfusion Complication Mortality 6 6 75 (0 50) 4 (trivial 500) 9 복강경적췌장수술로핵절제술이 예 (40.7%), 원위부췌장절제술이 6예 (59.3%) 로모두 7예였고비장보존술식이 6예에서있었는데그중 3예에서는비장혈관도같이보존하였다. 그러나, 비장혈관을결찰하면서비장을보존한 3예중 예에서는수술후복부전산단층촬영 (computerized tomography, CT) 에서비장아래 /3 부위에허혈소견을보였었으나최근검사한복부전산단층촬영에서는정상소견을보였다. 그리고, 부신피질샘종으로동시절제가 예에서있었으며개복술로전환된예는없었다. 평균수술시간은 75분 (0 50) 으로복강경핵절제술이제일짧았고, da Vinci 로봇수술로비장보존술식을같이한예에서가 Table. General characteristics Age Gender Male Female Symptoms Incidental detection Abdominal discomfort Neuroglycopenic 46.5 (5 76) 9 6 3
3 대한내시경복강경외과학회지제 권제 호 00 Table 3. Pathologic characteristics Table 5. Open vs laparoscopic surgery Open Lapa p value Tumor size (cm) Pathology Serous cystic tumor Solid pseudopapillary neoplasm Mucinous cystic tumor Lymphoepithelial cyst IPMT* Pseudocyst Non-functioning endocrine tumor Benign stricture duct d/t pancreatitis Insulinoma Periductal fibrosis Ductal adenocarcinoma 3. (0.9 7.5) 6 5 4 Gender Male:Female Age Tumor size (cm) Operation type Distal pancreatectomy Enucleation Operation time (min) Bleeding (ml) Diet start (POD*) Hospital stay (day) Complication Yes/No 4: 30.±0. 6.±3.6 7 5 66.0±4. 55.0±364. 6.5±3.7 3.6±9.6 6/6 :9 46.5±5.5 3.±.5 75.±79.9 4.±45.4.7±0.9 9.3±4.7 0/7 0.354 <0.00 0.00 0. 0.006 <0.00 0.00 0.046 0.537 *IPMT = intraductal papillary mucinous tumor. *POD = postoperative day. Table 4. Complicaiton Mortality Morbidity Pancreas fistula* Grade I (enucleation/distal pancreatectomy) Grade II (enucleation/distal pancreatectomy) Grade III Herniation through mesenteric defect frequency 5 (/3) 4 (/) 0 *Proposed by the International Study Group on Pancreatic Fistula. 제및비장절제술을시행하였고, 병기는 T3NM0, stage IIb (AJCC 6 th ) 로합병증없이수술후 9일째퇴원하여현재 6차례의 gencitabine 항암약물치료후재발없이외래경과관찰중이다. 수술과관련된합병증은 0예로, ISGPF (the International Study Group on Pancreatic Fistula) 에따라분류하였을때, 7 5예에서는 grade I이었고, 4예에서는 grade II로췌장액누출로배액술을시행하였고, 그중핵절제술을한 예에서는배액양이줄지않아내시경역행췌담관조영술을시행하여췌장관에관을삽입하여감압시키는추가치료로호전되었다. 그리고다른한예의경우는췌장및비장박리과정에서생긴대장장간막결손부위로탈장이생겨탈장교정술을시행받았다 (Table 4). 복강경수술의경우개복수술과비교하였을때, 통계학적으로의미있는결과를보인것은입원기간이평균 9.3일로개복수술의 3.6일보다짧았고 (p=0.046), 식이시작일은평균.7일로개복수술의 6.5일보다빨랐으며 (p=0.00), 출혈량에서는평균 4. cc로개복수술의 55.0 cc보다확연 히적었다 (p<0.00). 물론, 두군간에수술범위인췌장원위부절제와핵절제간의빈도에서는차이를보이지않았다 (p=0.). 하지만, 수술시간에서는개복수술의경우가평균 66.0분으로복강경수술의 75.분보다짧았고통계학적으로도의미있는결과를보였다 (p=0.006). 수술관련합병증에서는복강경수술이 0예 (37.0%), 개복수술이 6예 (.6%) 로복강경수술에서더많았으나두군간에통계학적차이를보이지는않았다 (p=0.537) (Table 5). 고찰췌장수술은해부학적위치상후복막장기로깊이가깊은데다가주위장기들과인접해있어기존의개복수술에서는절개창이컸고, 그로인한수술후통증, 창상감염, 오랜입원기간그리고미용적인효과가적은단점들이있었다. 최근들어사회활동이활발한젊은사람들이건강검진에서췌장질환이발견되어췌장수술을받는경우가늘어나게됨으로써이러한단점들을극복하여정상활동으로빨리복귀하게하는복강경수술이외과영역에서점차늘어가고있다. 하지만, 췌장절제후에생길수있는여러합병증들중제일중요한것은췌장루로서이것은악화되어농양, 패혈증또는치명적인동맥출혈을야기하여환자에게는치명적인결과를가져올수가있다.,9 췌장루에대한정의는여러가지로정의되고있으나, 0, ISGPF에따르면배액양과는상관없이수술후 3일부터배액관에서측정되는 amylase 수치가혈청 amylase 수치의 3배이상으로정의하고있고임상양상의정도에따라 A, B, C로나누고있다. 7 췌장절제시췌액이새는것을막는표준방법으로는췌장의잘린끝부분의주췌관을결찰하고절단면을봉합하는것이다. 그러나, 절단면에는주췌관과연결된작
김동현외 6 인 : 단일기관에서경험한복강경췌장수술 33 은췌관들이있는데평균 개로없는경우부터 5개까지로보고하고있다. 3 이런이유에서주췌관만결찰하고절단면을봉합하는것은근본적인방법이될수없다. Kunio 등 9 은 Endo-GIA 봉합기를이용한췌장절제가주췌관을결찰하고절단면을봉합하는방법보다수술후에췌관루가의미있게더적게생길뿐아니라간편하고빠르다는장점을보고하였다. 이외에초음파절단기를이용한췌장절제가있는데, Suzuki 등은이러한방법으로비섬유성췌장에서췌장루발생이현저히감소하였다고보고하였으나, 4 이것또한, 절제면의모든췌관을결찰하는과정이필요하므로봉합기를사용하는것이더효율적이라볼수있겠다. 췌장질환의복강경수술에있어서환자의자세는수술자의경험에의존하지만각각장단점들이있다. 저자들은옆누움자세 (lateral decubitus position) 혹은바로누운자세 (supine position) 를취하였는데, 옆누움자세의경우는무엇보다복강내장기들이중력의존의특성으로췌장미부주위의시야확보가바로누운자세보다잘되고또한, 췌장미부주위장기들을박리할때분리가잘된다는장점이있다. 하지만준비과정이오래걸리고항상있을수있는개복전환시어려움이따르는단점이있다. 또한, 비장보존및비장혈관보존술식을할경우, 비장에눌려비장혈관노출이어렵게되므로혈관주위를박리하는수술적조작에는어려움이있게된다. 6 이에반해바로누운자세는주위장기및조직들에의해옆누운자세보다췌장미부주위의시야확보가어렵고, 주위장기들과의분리가어려운반면, 반대로비장보존및비장혈관보존술식에서는비장혈관노출이용이한장점이있다. 비장을보존하는방법으로우회하는짧은위혈관과비장큰창자인대를이용해비장혈관을결찰할수도있겠지만, 5- 이런경우남아있는비장의정상적인기능에대한증거가없고농양이나괴사가생길가능성이더많게되므로가능한한비장혈관들을보존하는것이바람직하다. 6,9 췌장질환중저자들이경험한양성, 경계성종양의수술적치료로서복강경수술은개복수술과비교하였을때많은장점들을보여주고있고, 그효용성과안정성에서가치가있다고볼수있겠다. 이는, 확대된시야에서수술자가섬세한접근을가능하게함으로써, 출혈이나다른불필요한절제를줄일수있기때문이다. 그러나어느거리이상의투관침사이간격이필요한데다가제한된복강경기구의수로 5자유도의움직임만으로는주위조직및장기들과서로분리를하고혈관주위를박리하기는쉽지않다. 또한, 촉감적감지저하그리고수술시간의장기화라는근본적인문제점들로인해, 기술적으로어려운췌장질환의수술에서는이를극복하기위한어느수준이상의경험의축적과과학기술이바탕이된도구의개발을필요로하고있다. 후자의예로써, 이전에는소설이나영화에서나읽고보던로봇이최근몇년전부터는의료분야에서도수술적도구 로서개발되어실용화되어복강경수술이가지고있는한계를보완하고있고이제는국내에서도여러학회나심포지엄을통해로봇수술이새로운외과영역을차지하고있는것을볼수있다. 하지만, 로봇수술이 7자유도와 3차원의화면을제공해줌으로써이러한한계를극복하는발판을제시하고는있으나, 0, 이것또한아직까지는촉감적인감각과강도를못느낀다는제한점, 적절한환자를선택해야하는제한된적응증그리고고가의가격이라는또다른한계점을가지고있다. 0 이와같이복강경췌장절제술은아직해결해야할과제들을가지고는있으나, 세계여러기관들이그안정성과효용성뿐만이아니라기술적인가능성들을보고하고있다. 6,-4 한편, 지금까지는복강경시술에서양성혹은경계성췌장질환에대해서안전성과효용성을주로보고하고있으나, 최근 Melotti 등 6 은 5예의췌장관샘암종에대해복강경수술을시행하였는데절제면종양세포는음성이었고발췌한림프절의개수는평균 3개로, 아직경과관찰기간은짧지만수술후좋은경과를보고하였다. 저자들의경우도 예에서췌장미부관샘암종에대해복강경시술을하였고, 절제면종양세포는음성이었고발췌한림프절은 4개로개복수술과큰차이가없었고종양학적인관점에부합되는소견이었다. 오히려소위 no touch technique 에서는개복수술보다나은점을보였다. 이렇게볼때, 악성췌장질환에대한복강경수술도그적응증이개복수술보다는좁겠지만수술적가능성을볼수있겠고이에대한보다더많은연구가필요하겠다. 결 양성혹은경계성췌장질환에적용된복강경췌장수술은안정성과효용성을가지고있으나, 그수술적범위는아직한계가있고어느수준이상의경험을필요로하는것이사실이다. 그러나, 현재가지고있는복강경수술의한계점들을하나씩극복함으로써, 췌장질환에있어서복강경수술은제한된범위의수술에서악성질환의수술적치료로써까지확대적용될수있을것이다. 예를들어, 로봇수술이기술적인면에서는기여할수있을것이라예상되고, 또한이러한한계점들의극복은결국환자의삶의질의향상뿐만이아니라질병률, 생존률에긍정적결과를가져올수있을것으로생각한다. 론 참고문헌 ) Soper NJ, Brunt LM, Dunnegan DL, Meininger TA. Laparoscopic distal pancreatectomy in the porcine model. Surg Endosc 994;:57-60. ) Gagner M, Pomp A, Herrera MF. Early experience with
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