대한안과학회지 2017 년제 58 권제 7 호 J Korean Ophthalmol Soc 2017;58(7):757-762 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2017.58.7.757 Original Article 내시경을이용한코경유눈물주머니코안연결술의수술시간관련예측인자 Prognostic Factors Associated with Surgical Time of Endonasal Dacryocystorhinostomy 박혜인 이강원 강성모 Hye In Park, MD, Kang Won Lee, MD, Sung Mo Kang, MD 인하대학교의과대학인하대학교병원안과학교실 Department of Ophthalmology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea Purpose: To determine the prognostic factors associated with surgical time of endonasal dacryocystorhinostomy (DCR). Methods: From April 2009 to June 2014, 66 eyes of 66 patients who underwent endonasal DCR for 5-year periods were retrospectively evaluated with regard to surgical time and several other factors. The factors were patient factors (age, sex), category of diagnosis (inflammation and non-inflammation), and systemic factors (diabetes mellitus [DM], hypertension [HTN], anticoagulant agents, sinusitis history). We divided the study period into three subperiods and compared their surgical time. The anatomical factor of thickness of the maxillary frontal process was evaluated by computed tomography (CT), as was the existence of symptom recurrence after surgery and reoperation according to surgical time. A total of 66 cases (right: 31, left: 35) were included. Any case with concurrent surgery, abnormal structure of the nasal cavity, or bilateral DCR was excluded. Results: Average surgical time was 49.95 minutes. Surgical time of endonasal DCR was short in inflammatory cases (p = 0.047), in the third surgical period (p = 0.001), and was correlated with thickness of the maxillary frontal process (p = 0.001). In addition, surgical time correlated with the existence of symptom recurrence after surgery and reoperation (p = 0.012). Conclusions: It is considered that surgeon skill affects surgical time, and the thickness of the maxillary frontal process by CT will aid in the prediction of surgical time and success rate of endonasal DCR. J Korean Ophthalmol Soc 2017;58(7):757-762 Keywords: Endonasal dacryocystorhinostomy (DCR), Prognostic factor, Success rate, Surgical time 내시경을이용한코경유눈물주머니코안연결술 (endonasal dacryocystorhinostomy) 은코눈물관막힘을진단받은환자들의치료로널리이용되고있으며, 초기에는피부경유연 Received: 2017. 3. 9. Revised: 2017. 5. 4. Accepted: 2017. 6. 22. Address reprint requests to Sung Mo Kang, MD Department of Ophthalmology, Inha University Hospital, #27 Inhang-ro, Jung-gu, Incheon 22332, Korea Tel: 82-32-890-2400, Fax: 82-32-890-2417 E-mail: ksm0724@inha.ac.kr * Conflicts of Interest: The authors have no conflicts to disclose. 결술과비교하여성공률이낮았으나내시경의발달과더불어피부흉터가남지않고술후회복이빠른장점덕택에선호도가높다. 1-10 내시경을이용한코경유눈물주머니코안연결술의수술결과에영향을미치는요인에대한보고를살펴보면술후비강뼈구멍의막힘, 유착, 공동눈물소관막힘등의합병증이수술실패의원인으로알려져있다. 11-14 하지만수술결과에관련된술전, 술중예측인자에대한연구는미미하며누낭, 그리고비강의해부학적구조가수술예후에영향을미친다는보고가있으나 15,16 수술시간을대상으로한연구는아직없다. c2017 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 757
- 대한안과학회지 2017 년제 58 권제 7 호 - 이에저자들은수술관련요인중수술시간에영향을미칠것으로예상되는여러예측인자들을술자의숙련도, 해부학적구조, 수술전코눈물관막힘의세부진단, 환자의성별, 나이, 전신질환, 약물복용력등으로나누어, 실제내시경을이용한코경유눈물주머니코안연결술시행에있어서수술시간에영향을미치는예측인자를분석하고수술시간에따른술후증상재발, 재수술여부의상관관계에대해서도분석하였다. 대상과방법 2009년 4월부터 2014년 6월까지 5년에걸쳐코눈물관막힘을진단받고내시경을이용한코경유눈물주머니코안연결술을시행받은 66명 66안을대상으로기존에촬영한수술동영상을통해비강의구상돌기 (uncinate process) 에리도카인을주입한시점부터실리콘관을삽입하고결찰하기까지의수술시간을측정하고, 의무기록을통해환자의나이, 성별, 전신질환 ( 당뇨, 고혈압, 항응고제사용여부, 부비동염과거력 ) 을조사하였다. 코눈물관막힘의원인 ( 염증성 vs. 비염증성 ) 은, 술전증상을비롯한술중내시경적진단을통해눈물소관염이나눈물주머니염등눈물기관의염증소견을동반한경우를염증성, 그이외는비염증성으로분류하였다. 또한술전촬영한안와컴퓨터단층촬영을통해상악동의전두돌기두께를측정하였고 (Fig. 1) 각요인들과수술시간의관련성을분석하였다. 술자의숙련도는크게 2009년 4월부터 2011년 3월, 2011년 4월부터 2013 년 2월, 2014년 3월부터 2014년 6월, 세기간으로나누어평균수술시간을분석하는방법으로하였다. 또한수술시간을 20분이상 40분미만, 40분이상 60분미만, 60분이상 80분미만, 80분이상 100분미만, 100분이상의총 5군으로분류하여수술시간에따른증상재발이나재수술여부에유의한차이가있는지에대해서도후향적분석을시행하였다. 비정상적비강구조를가진경우, 다른수술을동반시행했거나코경유눈물주머니코안연결술을양측에동시에시행한경우는제외하였다. 본연구는본원의임상시험심사위원회로부터승인을받았다 ( 승인번호 : INHAUH 2017-02-011). 모든수술은한명의안과전문의에의해동일한방법으로시행되었다. 전신마취후비강내시경을이용하여눈물주머니와비강외벽을확인한뒤비강의구상돌기부위점막에 1:100,000으로희석한에피네프린과리도카인을주입하고 1:10,000으로희석한에피네프린을적신거즈를비강에채워넣어코점막을수축시켰다. 절개칼과골막거상기로마취부위점막을절개하고젖힌뒤론저를이용하여눈물주머니오목의앞쪽부분에구멍을내고눈물주머니오 목을형성하는눈물뼈 (lacrimal bone) 와위턱뼈 (maxillary bone) 를충분히제거하였다. 노출된눈물주머니의내측벽도절개를가하고벌집뼈집게를이용하여제거하였다. 위눈물점및아래눈물점을확장시킨뒤식염수를이용한눈물소관관류술및눈물길더듬자검사를시행하여폐쇄되었던눈물길이확보되었음을확인하였다. 하나의실리콘관양끝을각각위눈물점및아래눈물점으로삽입하여위눈물점및아래눈물점사이에적절한정도의긴장이생기도록조정하고코아래선반의외측에서실리콘관을묶어매듭부를코안에위치시킨뒤비강점막에 Triamcinolone 40 mg을주입하고 Nasopore (Stryker Canada, Hamilton, Canada) 를이용하여비강을패킹하였다. 통계학적분석은 SPSS ver. 19.0 (IBM Corp., Armonk, NY, USA) 을이용하였으며각요인들과수술시간의관련성을 Student T-test, Pearson test, Fisher s exact test, analysis of variance (ANOVA) 방법으로분석하였다. p-value가 0.05 미만인경우를통계적으로유의한것으로판정하였다. 결 과 연구대상이된환자는총 66 명으로평균연령 52.1 ± Figure 1. Measurement of the thickness of the maxillary frontal process by computed tomography scan. In axial view, we pointed the anterior lacrimal fossa (A) and maxillary-lacrimal suture line (B), and made parallel lines. At the center between two lines (mid-point of black line), thickness of frontal process was measured at medial side (double-headed arrow). 758
- 박혜인외 : 눈물주머니코안연결술의시간관련인자 - 12.1세였으며남자 21명, 여자 45명으로여자가더많았다. 당뇨 8명, 고혈압 17명, 부비동염과거력 4명, 항응고제를복용하는환자는 5명이었고코눈물관막힘의원인으로는염증성원인이비염증성원인보다많은수가포함되었다 (Table 1). 평균수술시간은 49.95분이었다. 각요인들과평균수술시간과의연관성을분석한결과, 원인분류에서염증소견을보인경우가평균수술시간이유의하게짧은것으로나타났으며 (p=0.047) 수술시기에따른평균수술시간도최근마지막시기 (2014년 3월부터 2014년 6월까지 ) 가유의하게가장짧은것으로나타났다 (p=0.001). 또한해부학적측면에서, 술전안와컴퓨터단층촬영을통해측정한상악동 (maxilla) 의전두돌기 (frontal process) 평균두께는 1.595 mm였으며상악동의전두돌기두께가얇을수록평균수술시간도유의하게짧은결과를보였다 (p=0.001). 그밖에나이, 성별, 당뇨, 고혈압, 부비동 Table 1. Demographics of the patients Characteristics Value Age (years) 52.1 ± 12.1 Gender (patients, %) 66 Male 21 (31.8) Female 45 (68.2) Diabetes Mellitus (patients, %) 8 (12.1) Hypertension (patients, %) 17 (25.8) Sinusitis (patients, %) 4 (6.1) Anticoagulant History (patients, %) 5 (7.6) Disease category Inflammation 43 (65.2) Non-inflammation 23 (34.8) Values are presented as mean ± SD unless otherwise indicated. 염과거력, 항응고제복용력등은수술시간과유의한연관성이없었다 (Fig. 2). 다변량분석결과, 수술시기, 즉술자의숙련도, 상악동의전두돌기두께와평균수술시간과의관련성을증명하였으나 (p=0.000), 염증성소견을가진코눈물관막힘과수술시간과의관련성은없었다 (Table 2). 또한수술시간을 5군으로나누어증상재발, 재수술여부를분석한결과수술시간이긴군일수록증상재발혹은재수술을한환자수가상대적으로많았으며이는통계학적으로유의한결과로나타났다 (Table 3). 고찰 코눈물관막힘의일차적치료는수술이다. 초기에는피부절개를통한눈물주머니코안연결술이주로이루어졌으나내시경의발달로합병증이적어지고많은장점들이보고됨에따라내시경을이용한코경유눈물주머니코안연결술이코눈물관막힘의대표적인치료법으로자리잡았다. 현재까지수술실패의원인에대해서는술후추적관찰결과비강측누공의육아종, 반흔조직에의한막힘등의합병증이가장흔한원인으로알려져있으며, 14 Ha et al 17 은실패율을줄이기위한방법으로지속적인액체의흐름을통한압력이필요하다는측면에서술후정기적인코눈물관세척이도움이된다고하였다. 수술결과에관련된술전예측인자에대해서는술전누낭, 비강등의해부학적구조가수술예후에영향을미친다는보고가있으나 15,16 내시경을이용한코경유눈물주머니코안연결술의수술시간 Table 2. Factors associated surgical time Unstandardized Standardized coefficients coefficients (Beta) p-value * Age 0.063 0.056 0.630 Sex 1.767 0.057 0.631 Inflammation vs. Non-inflammation -5.316-0.176 0.121 Period -10.548-0.475 0.000 Thickness of maxillary frontal process 9.145 0.578 0.000 * Multivariate analysis. Table 3. Results of endonasal DCR related to surgical time Success (patients, %) Failure (patients, %) p-value * Group 1 (20-40 min) 9 (19.6) 2 (10.0) 0.012 Group 2 (40-60 min) 25 (54.3) 7 (35.0) Group 3 (60-80 min) 12 (26.1) 6 (30.0) Group 4 (80-100 min) 0 (0.0) 3 (15.0) Group 5 (over 100 min) 0 (0.0) 2 (10.0) Total 46 (100.0) 20 (100.0) DCR = dacryocystorhinostomy. Fisher s exact test. 759
- 대한안과학회지 2017 년제 58 권제 7 호 - A B C D E F G H I Figure 2. Factors associated surgical time. Age (A), sex (B). Inflammation vs. non-inflammation (C). Period (D). Systemic factors (E-H). Thickness of maxillary frontal process (I). There were statistically significant differences with disease category (Inflammation vs. non-inflammation; p = 0.047), period (p = 0.027. 0.001), thickness of maxillary frontal process (Pearson correlation coefficient = 0.886, p = 0.001). The average of thickness of frontal process of maxillary bone was 1.595 mm. But, there were no statistically significant differences with age (p = 0.443), sex (p = 0.515), and systemic factors (DM; p = 0.925, HTN; p = 0.791, anticoagulant history; p = 0.129, sinusitis history; p = 0.791). ANOVA = analysis of variance; DM = diabetes mellitus; HTN = hypertension; Hx = history. 760
- 박혜인외 : 눈물주머니코안연결술의시간관련인자 - 에관련된연구는아직없다. 하지만술전해부학적구조가영향을미친다는기존보고가있는만큼, 수술시간이길어지면서발생하는염증이나부종등다른요인에따라수술합병증이나성공률의차이가존재하기때문에수술시간과수술예후, 합병증의관련성을예상해볼수있다. 더군다나이수술은경험이적고숙련이안된의사가수술에익숙해지기까지오랜시간이걸리는, 즉러닝커브 (learning curve) 가길며어려운수술이다. 모든수술에서경험과숙련도가수술시간에영향을미칠것이라는것은짐작가능하나이수술처럼러닝커브가긴수술의경우에는술자의숙련도가수술시간을비롯한예후에더큰영향을미칠것이다. 이에저자들은수술시간을예측하는것이수술을계획하고결과와회복을예측하는데에도움이될것이라는판단하에수술시간에영향을미치는요인들을크게술자의숙련도, 해부학적구조, 수술전코눈물관막힘의세부진단과환자의성별, 나이, 전신질환, 약물복용력등으로나누어수술시간에영향을미치는예측인자와더불어, 술후증상이재발한경우나재수술을한경우와그렇지않은경우를구분하여수술시간에따른수술성공률의차이를분석했다. 본연구결과, 내시경을이용한코경유눈물주머니코안연결술의시행에있어서수술시기가최근인케이스, 즉술자의경험이많고숙련도가높을것으로예상된경우, 염증이코눈물관막힘의원인인경우, 상악동의전두돌기두께가얇은경우에짧은수술시간이소요됨을확인했다. 또한수술시간에따른수술성공률을분석한결과수술시간이짧을수록수술의성공률이높다는결론을얻을수있었다. 기존연구중유병기간이오래된눈물기관의염증으로인한코눈물관막힘의경우수술성공률이낮았고이중누낭염증이큰비율을차지했다는보고는있으나 18 염증소견을보인경우와그렇지않은경우를구분하여수술성공률을비교한연구는아직없다. Kim et al 8 은내시경을이용한코경유눈물주머니코안연결술의경우비강의해부학적구조를자세히볼수있음으로써막힌위치에따라비강연결부위를잘맞도록하여수술성공률을높이며술후합병증도적을뿐아니라눈물관폐쇄의원인을평가하는데에큰도움이된다고하였다. 예후와관련하여, 이보고에서는술중내시경을이용한해부학적구조파악에초점을맞춘반면, 본저자들은수술시간을중점으로분석한결과안와컴퓨터단층촬영을통해측정한상악동의전두돌기두께가얇은경우에짧은수술시간이소요된다는결론을얻었고, 따라서수술전에미리안와컴퓨터단층촬영이라는비침습적인진단도구로수술시간을예측할수있으며더나아가수술결과예상의가능성도확인했다. 본연구의한계점으로는, 후향적으로이루어졌으며대상환자수가적었다는점을들수있다. 특히단변량분석에서는수술시간과유의한관련성이증명되었던염증성코눈물관막힘이다변량분석에서는의미있는결과를얻지못했다. 추후저자들은더많은환자를대상으로신뢰도높은분석을시행할계획이다. 이연구의결과를바탕으로하여술전코눈물관막힘의원인파악과안와컴퓨터단층촬영을통한상악동의전두돌기두께측정을통한수술시간을예측하고증상재발이나재수술여부등을예상하여수술계획을세우거나수술후관리에신중을기해야할것으로생각된다. 또한저자들은내시경을통한코경유눈물주머니코안연결술이러닝커브가긴수술이라는것도다시한번확인할수있었다. REFERENCES 1) Park JD, Kim YI, Shin SG. The factors related to surgical success rate of endonasal dacryocystorhinostomy. J Korean Ophthalmol Soc 1998;12:2848-53. 2) Rice DH. Endoscopic intranasal dacryocystorhinostomy results in four patients. Arch Otolaryngol Head Neck Surg 1990;116:1061. 3) Javate RM, Campomanes BS Jr, Co ND, et al. The endoscope and the radiofrequency unit in DCR surgery. Ophthal Plast Reconstr Surg 1995;11:54-8. 4) Lee HC, Chung WS. Success rate of endonasal dacryocystorhinostomy. J Korean Ophthalmol Soc 1996;37:211-8. 5) Boush GA, Lemke BN, Dortzbach RK. Results of endonasal laser-assisted dacryocystorhinostomy. Ophthalmology 1994;101: 955-9. 6) Weidenbecher M, Hosemann W, Buhr W. Endoscopic endonasal dacryocystorhinostomy: results in 56 patients. Ann Otol Rhinol Laryngol 1994;103(5 Pt 1):363-7. 7) Lee SH, Chung WS. Long term surgical efficacy of endonasal dacryocystorhinostomy. J Korean Ophthalmol Soc 2000;41:307-13. 8) Kim C, Kacker A, Levine B, Lelli GJ. Lacrimal system endoscopy assisted endonasal dacryocystorhinostomy. Orbit 2013;32:156-60. 9) Yakopson VS, Flanagan JC, Ahn D, Luo BP. Dacryocystorhinostomy: History, evolution and future directions. Saudi J Ophthalmol 2011;25:37-49. 10) Tripathi A, Lesser TH, O Donnell NP, White S. Local anaesthetic endonasal endoscopic laser dacryocystorhinostomy: analysis of patients acceptability and various factors affecting the success of this proce-dure. Eye (Lond) 2002;16:146-9. 11) Kim JH, Shin JC. Clinical evaluation of endoscopic transnasal dacryocyocystorhinostomy. J Korean Ophthalmol Soc 1997;38: 1706-11. 12) Zolli CL, Shannon GM. Dacryocystorhinostomy: a review of 119 cases. Ophthalmic Surg 1982;13:905-10. 13) McLachlan DL, Shannon GM, Flanagan JC. Results of dacryocystorhinostomy: analysis of the reoperations. Ophthalmic Surg 1980;11:427-30. 14) Kong YT, Kim TI, Kong BW. A report of 131 cases of endoscopic 761
- 대한안과학회지 2017 년제 58 권제 7 호 - laser lacrimal surgery. Ophthalmology 1994;101:1793-800. 15) Mannor GE, Millman AL. The prognostic value of preoperative dacryocystography in endoscopic intranasal dacryocystorhinostomy. Am J Ophthalmol 1992;113:134-7. 16) Woo KI, Maeng HS, Kim YD. Characteristics of intranasal structures for endonasal dacryocy storhinostomy in Asians. Am J Ophthalmol 2011;152:491-8.e1. 17) Ha TS, Na KS, Chi NC. Effectiveness of washing nasolacrimal duct as an additional therapy after dacryocystorhinostomy. J Korean Ophthalmol Soc 2000;41:2308-12. 18) Ozer O, Eskiizmir G, Unlü H, et al. Chronic inflammation: A poor prognostic factor for endoscopic dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2012;269:839-45. = 국문초록 = 내시경을이용한코경유눈물주머니코안연결술의수술시간관련예측인자 목적 : 내시경을이용한코경유눈물주머니코안연결술시행에있어서수술시간에영향을미치는예측인자에대해분석하고자한다. 대상과방법 : 2009 년 4 월부터 2014 년 6 월까지 5 년에걸쳐내시경을이용한코경유눈물주머니코안연결술을받은 66 명 66 안을대상으로수술시간을측정하고, 환자의나이, 성별, 질환의분류 ( 염증성 vs. 비염증성 ), 전신질환 ( 당뇨, 고혈압, 항응고제사용여부, 부비동염과거력 ), 술전안와컴퓨터단층사진을통해측정한상악동의전두돌기두께등각요인들과수술시간의관련성, 수술시간과증상재발혹은재수술여부의상관관계에대하여후향적분석을시행하였다. 비정상적비강구조를가진경우, 다른수술을동반시행했거나코경유눈물주머니코안연결술을양측에동시에시행한경우는제외하였다. 결과 : 평균수술시간은 49.95 분이었다. 또한코눈물길막힘의원인을분류했을때비염증성보다염증성의경우 (p=0.047) 에서술전안와컴퓨터단층촬영을통해측정한상악동의전두돌기두께가얇을수록평균수술시간이더짧았다 (p=0.001). 또한연구기간인 5 년을크게세시기로나누어분석했을때최근마지막시기의수술시간이가장짧은것으로나타났다 (p=0.001). 또한수술시간이길수록증상이재발했거나재수술을한빈도가높은것으로나타났다 (p=0.012). 결론 : 술자의숙련도와코눈물관막힘의원인을분석하고술전안와컴퓨터단층사진을통한상악동의전두돌기두께측정을통해내시경을통한코경유눈물주머니코안연결술의소요시간을예측가능하며이는수술예후와도관련성이있다. < 대한안과학회지 2017;58(7):757-762 > 762