대한외상학회지 Vol. 24, No. 2, December, 2011 원 저 다발성외상환자에서췌장손상치료경험 연세대학교의과대학외과학교실 장현아 심홍진 차성환 이재길 Abstract Management of Traumatic Pancreas Injury in Multiple Trauma - Single Center Experience Hyuna Jang, M.D., Hong Jin Shim, M.D., Sung Whan Cha, M.D., Jae Gil Lee, M.D., Ph.D. Department of Surgery, Yonsei University College of Medicine Purposes: Pancreatic injury is rare in abdominal trauma patients (3%~12%). but it could result in significant morbidity and even mortality. Early and adequate decision making are very important in the management of patients with traumatic pancreatic injury. The purpose of this study was to assess the kinds of management and outcome through the review of our experience of pancreatic injury with multiple trauma. Methods: We reviewed 17 patients with traumatic pancreas injury via electronic medical records from Jan. 2002 and April. 2011. We collected demographic findings; the type, location and grade of pancreas injury, the treatment modality, and patient s outcomes, such as complications, length of hospital stay (LOS), and mortality. Results: Total 17 patients were reviewed, and man was 13 (88%). Traffic accident was the most common cause of injury. Pancreas neck was the most common injured site, and occured in 5 patients. Ductal injury was detected in 7 cases. Eleven patients were treated by surgical procedure, and in this group, 3 patients underwent the endoscopic retrograde pancreas drainage procedure coincidently. ERPD was tried in 8 patients, and failed in 2 patients. The major complications were post-traumatic fluid collection and abscess which accounted for 70 % of all patients. The hospital stay was 35.9 days, and it was longer in patient with ductal injury (38.0±18.56 vs. 34.5±33.68 days). Only one patient was died due to septic shock associated with an uncontrolled retroperitoneal abscess. Conclusion: Early diagnosis is the most important factor to apply the adequate treatment option and to manage the traumatic pancreas injury. Aggressive treatment should be considered in patients with a post-operative abscess. (J Korean Soc Traumatol 2011;24:111-117) Key Words: Pancreas injury, Trauma Address for Correspondence : Jae Gil Lee, M.D., Ph.D. Division of Surgical Critical Care and Trauma, Department of Surgery, Yonsei University College of Medicine 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea Tel : 82-2-2228-2127, Fax : 82-2-313-8289, E-mail : jakii@yuhs.ac 접수일 : 2011 년 10 월 5 일, 심사일 : 2011 년 10 월 6 일, 수정일 : 2011 년 11 월 1 일, 승인일 : 2011 년 11 월 11 일 본논문의요지는 2011 년대한외상학회춘계학회에서포스터전시되었음. 본연구는 2008 년연세대학교신임교원정착금 (6-2008-0024) 지원에의해수행되었음. 111
대한외상학회지제 24 권제 2 호 I. 서론외상으로인한췌장의손상은드물게접하는질환으로복부외상환자에서약 3%~12% 정도로보고하고있다.(1) 하지만합병증이잘발생할수있고, 합병증이발생한경우에는사망률이 19%~40% 를차지하고있어, 췌장손상은전체사망률이 3%~70% 까지이르는치명적인손상중하나이다.(2-6) 최근교통사고의증가및진단장비등의발달로췌장손상의발생률이증가하고있어적절한치료가중요하다.(7) 외상성췌장손상은다발성장기손상과동반되어있는경우가많아서, 손상초기에정확한진단및치료가어려운경우가많다. 외국과달리우리나라에서는교통사고, 낙상에의한둔상이많은비율을차지하고있기때문에췌장은동반손상이더많고증상이모호한경우가많다. 또한췌장은후복막에위치하고있어임상양상이비특이적으로나타나서조기에진단하는것이어렵다.(8-11) 최근에췌장손상에대한치료방법으로수술외에도췌장손상의정도에따라내시경적치료등다양한시도가이루어지고있다. 내시경을이용한췌관조영술은췌관의손상유무와정도를확인할수있으며, 췌장배액을위한췌관내스텐트를삽입할수있어진단과치료목적으로사용될수있다. 또한췌장주위농양이나가성낭종에서내시경적경위배액술이나위낭종문합술등을시도하기도한다. 하지만외상성췌장손상환자에서수술이나내시경적치료또는보존적치료를선택하는데있어명확한기준이정해져있지는않다. 따라서본연구에서는외상성췌장손상환자에서진단과치료방법에대해알아보고결과를평가해보고자하였다. II. 대상및방법세브란스병원에서다발성외상으로내원한환자를대상으로의무기록을통해 2002년 01월부터 2011년 04월까지입원치료를받은외상성췌장손상환자를선택하여후향적으로분석하였다. 사고의종류, 췌장손상부위, 췌관의손상유무, 췌장의손상정도, 동반손상장기및내원당시혈청아밀라제, 치료의종류, 치료결과, 합병증, 재원기간을조사하였다. 췌장의손상정도는미국외상학회 (AAST) 의기준을따라서평가하였다. III. 결과전체환자는 17명이었고남자15명 (88%) 여자2명 (12%) 이었고, 평균연령은 37.2(±22.3) 세였다. 소아환자 1예를제외한 16명의환자가응급실내원직후시행한복부검퓨터 단층촬영으로진단되었다. 교통사고가 9예로가장많았고폭행으로인한손상이 4예있었다. 췌장손상부위는경부 5예 (29%) 로가장많았고두부 4 예 (24%), 체부 3예 (18%), 미부 3예 (18%) 순이었다. 췌관손상은전체 7예 (41%) 에서관찰되었으며, 내시경적췌관조영술이나자기공명영상을이용한췌관조영술에서 6예발견되었으며수술중에확인된경우가 1예있었다. 5명의환자는경증의췌장손상으로복부 CT 에서췌관의손상을의심할만한소견이보이지않아추가적인검사를시행하지않았다. 2명은췌관의손상을확인하기위해자기공명영상췌담관조영술을시행하였으며, 췌관손상이없음을진단하였다. 그외 3예는수술실에서췌관손상이없음이확인되었다. 혈청아밀라제수치는응급실내원직후결과를전원온환자는전병원의초기결과를기준으로하였으며평균혈청아밀라제는 448.5(±684.7) U/L이었다. 리파아제는검사가시행되지않는경우가많아분석에서제외하였다 (Table 1). 내시경적췌관조영술은 5예에서시행하였으며초기평가뿐만아니라수술후합병증의원인을파악하거나혈역학적으로안정된이후에도시행하였다. 대부분치료초기에시행하는내시경은주췌관의손상유무을확인하고, 췌액의분비가잘이루어지도록내시경적췌장조영술과, 괄약근절개술 (5명) 또는췌장배액관및스텐트삽입술 (2명) Table 1. Clinical characteristics of the patients Variable Results (%) Age (year) 37±22.3 Gender Male 15 (88)0 Female 2 (12) Mechanism of injury Traffic accidents 9 Assault 4 Stab injury 2 Slip down 1 Crushing 1 Site of pancreas injured Head 4 (24) Neck 5 (29) Body 3 (18) Tail 3 (18) Whole contusion 2 (11) Serum amylase (U/L) 448.5±684.7 MRCP performed 5 (30) Surgery performed 11 (65)0 Ductal injury 7 (41) Mortality.1 (5.8) 112
장현아외 : 다발성외상환자에서췌장손상치료경험 Table 2. Demographics of the patients Case Mode of Age Sex No. injury Grade Amylase Combined injury Procedure Complication HS 1 19 M Assault 2 2786 none ECG, with stent Pseudocyst 010 2 18 M Assault 4 0983 Kidney contusion DPS Abscess 059 Brain hemorrhage 2nd op: **I&D 3 13 M BA 2 Hemoperitonium DPS Abscess 053 SD 4 61 M *TA 3 0080 Hemoperitonium S/P ligation of SMA Pseudocyst 051 Kidney contusion **I&D Abscess Wound seroma 5 63 F slip 3 0267 Hemoperitonium DPS No 016 Spleen laceration 6 6 M BA 1 0092 Liver contusion No No 008 7 3 M Crushing 3 0695 Liver contusion Pancreaticojejunostomy No 013 Spleen contusion 8 20 M Stab 2 0042 Hemoperitonium Observation No 006 Retroperitoneal hematoma 9 55 M Assault 2 0220 Hematoma in Observation Fluid collection 023 pancreas ERPD failed Fluid collection 10 17 M Assault 3 0288 Hemoperitonium EST and Fluid collection 045 Fluid collection ERPD drain insertion Stenosis of PD 11 35 M *TA 2 0153 Brain hemorrhage Primary repair of duodenum Fluid collection 052 Multiple rib ***Fx. -> tube duodenostomy Abscess Perforation of Pyloric exclusion Incisional hernia duodenum& T-colon Cholecystectomy Liver laceration Gastrojejunostomy ligation of liver parenchyma 12 45 M *TA 2 0129 Liver laceration Primary repair of duodenum Fluid collection 042 Duodenal perforation Cholecystectomy Wound infection Kidney injury Gastrojejunostomy incisional hernia Hemoperitonium Nephrectomy **I&D 13 49 M Stab 3 0072 Spleen laceration DPS Fluid collection 011 Hemothorax Open thoracotomy Hemoperitonium 14 73 M *TA 3 0337 Gall bladder stone SD Fluid collection 033 Multiple rib ***Fx. DPS Abscess Hemothorax Cholecystectomy **I&D 15 43 M *TA 2 0031 DPS Fluid collection 022 16 56 M *TA 5 0784 Rib ***Fx. Pancreticoduodenectomy Abscess 116 duodenal perforation Roux-en-Y HJ Colon perforation 113
대한외상학회지제 24 권제 2 호 Table 2. Demographics of the patients continue Case Mode of Age Sex No. injury Grade Amylase Combined injury Procedure Complication HS Retroperitoneal abscess Abscess drainage Intraabdominal Bleeding Septic shock, DIC 17 57 F *TA 3 0218 Liver laceration PTGBD, SD Abscess 051 Multiple ***Fx. EGC, Gall bladder empyema Hemoperitonium Laparoscopic cholecystectomy Pseudocyst ERPD Postop bile leakage *TA: Traffic accident, BA : Bicycle accident, PTGBD: Percutaneous trans-gall bladder drainage, HS: Hospital stay (day) EGC: Endoscopic gastrocystostomy, DPS: Distal pancreatectomy with splenectomy, **I&D: Irrigation and drainage SD: Simple drainage, HJ: Hepaticojejunostomy, EST: Endoscopic sphincterotomy, ERPD: Endoscopic retrograde pancreatic drainage, ***Fx.: Fracture, PD: Pancreatic duct, DIC: Disseminated intravascular coagulopathy Table 3. Management of the pancreatic injuries according to AAST injury scale II Grading *No Procedure performed (No. of pts.) LOS (days) Grade I 01 No pancreatic-specific surgery performed (1) 8.0±0.0 Grade II 07 No pancreatic-specific surgery performed (4) 19.14±19.34 Endoscopic cystogastrostomy (1) Distal pancreatectomy with splenectomy (2) Grade III 07 Distal pancreatectomy with spelenectomy (3) 0.027±18.01 Pancreaticojejunostomy (1) Endoscopic gastrocystostomy (1) Irrigation and drainage of peripancreatic abscess S/P ligation of mesentery artery (1) ERPD with stent insertion (1) Grade IV 01 Distal pancreatectomy with splenectomy (1).59±0.0 Grade V 01 Pancreaticoduodenectomy Roux-en Y hepaticojejunostomy (1) 116±0.0. 17 29.76±29.45 *No: number, LOS: length of stay, ERPD: endoscopic retrograde pancreatic drainage. Table 4. Organ injury associated with pancreatic injuries. No. Intraabdominal organ Liver 5 Duodenum 3 Spleen 3 Kidney 3 Others 2 Extra-abdominal organ Bone 4 Brain 2 Lung 2 에서시행하였다. 또한내시경적췌관조영술외에도가성낭종및농양합병증을치료하기위해내시경적위낭종배액술및스텐트삽입술을 2예에서시행하였다. 수술은 11 예에서시행하였으며, 내시경적췌관조영술을같이시행한환자가 3예있었다. 내시경이후췌관의손상이나십이지장의손상이발견되어수술을시행한환자는 3예가있었다 (Table 2). 동반손상된복강내장기는간이 5예로가장많았고, 십이지장과비장, 신장이각각 3예씩있었으며, 복부외장기는골절이 4예있었다 (Table 3). 손상정도 (AAST) 에따라시행된치료방법이달라졌으며, 치료결과는 Table 4와같다. 치료의합병증은 13예에서발생하였으며복강내체액저류가 7예로가장많았다. 전체환자중 1명이지속적인후복막농양에의한패혈증 114
장현아외 : 다발성외상환자에서췌장손상치료경험 및다발성장기부전으로사망하였다. 환자는수술전복부컴퓨터단층촬영에서췌장경부의손상이의심되어, 내시경적췌관조영술을시도하려하였으나십이지장손상이동반되어있어췌두부절제술을시행하였다 (Fig. 1). IV. 고찰외상성췌장손상은 3%~12% 정도의빈도로나타나지만결과는치명적인성적을보이고있다.(1) 췌장손상이있는경우사망과직접적인연관성이 19%~40% 이고, 이에따라사망률도 3%~70% 로예후가좋지않다.(2-6) 최근사고의증가및자살의증가등으로인한복부둔상이흔하게발생하면서, 이와더불어췌장손상의발생률이증가하고있어, 이에대한적절한진단및치료가더욱중요한현실이다.(7) 미국에서는관통상이전체외상의 70% 를차지하지만우리나라의경우는둔상이전체의 92% 를차지하고있어, 복부손상에의한췌장손상의발생가능성이더높다.(8-11) 췌장은주변중요장기들에의해둘러싸여있어동반손상이잘발생할수있고척추뼈에기대고있어충격에의한손상이발생할수있다. 그러나복부둔상의경우손상부위가광범위하게나타나고, 동반손상을수반하는경우가많아췌장손상에의한증상이늦게나타나게되며, 췌장은후복막에위치하고있어환자가느끼는증상이모호하고의료진이쉽게간과할수있어진단이쉽지않다.(11) 하지만명확한진단적도구가없어적절한진단이이루어지지않고치료의시점을놓치게되는경우가많다. 현재임상에서사용하고있는혈액의아밀라아제수치는민감도와특이도가낮으며수치의절대값이손상의중등도와관련이적다고알려져있다.(12) 본연구에있어서도 초기아밀라아제수치와췌장손상정도와의상관관계는없었다 (p=0.964). 초기환자평가시보편적으로시행하는컴퓨터단층촬영은비침습적이면서도쉽게시행할수있는장점이있으나수상후 24시간이전의촬영은주췌관의손상여부를알기가어렵고췌장손상의정도를반영하기에는한계가있다.(1) 본연구에서도대부분의환자에서복부컴퓨터단층촬영을시행하였으나수술전진단되지않고수술중진단되는환자도 3예있어, 복부컴퓨터단층촬영으로췌관손상을명확히진단하는것은어렵다고할수있다. 췌장의손상에서는주췌관의손상유무와정도를아는것이중요하다. 주췌관손상에대한진단은혈액학적인방법, 컴퓨터단층촬영이나자기공명영상을이용한영상학적인방법, 내시경을이용한조영술, 수술시직접확인하는방법이있으나현재췌관조영술이가장정확한것으로알려져있다.(13) 치료는췌장괄약근의감압이나췌관스텐트삽입으로췌액을원할하게배액하여역류하는것을막거나수술적인교정을하는방법이있으나현재까지명확히정립된바는없고주췌관손상여부에따라최종적인치료방법을결정하는것이중요하다. 주췌관의손상은동반합병증과상관관계가있으며손상의정도 (AAST) 가췌장합병증과사망을예견할수있는독립지표로서유용성이대두되었다.(9,14,15) 하지만주췌관의손상정도는유병률과사망률에연관성을고려할때수혈의정도, 염기부족, GCS (Glasgow Coma Scale) 점수및 RTS (Revised Trauma Score) 점수등을같이고려해야한다는지적도있다.(11) 본연구에서는손상정도가높아짐에따라평균재원기간이증가하였지만통계적으로손상정도와사망률및재원기간등과의연관성을찾기는어려웠다. 재원기간의증 A B Fig. 1. (A) CT finding: Fluid collection and pancreatic head injury were seen but duodenal injury was not detected. (B) In endoscopic finding, it was impossible to canulate of the ampulla of Vater because of duodenal necrosis. 115
대한외상학회지제 24 권제 2 호 가된이유는손상정도가증가함에따라수술적치료가시행된환자가많아, 수술후합병증및회복에시간이소요된것으로추정되었다. 내시경적시술이수술을대체할수있는도구로서인식되는것은부적절하다. 왜냐하면대부분의내시경적시술은혈역학적으로불안정한경우에는시행하기어렵고환자가이전에수술을시행하였거나해부학적변형이있는경우에접근의제한성때문에시행이어렵기때문이다.(2) 하지만주췌관의손상을확인함으로써보다적극적인치료를계획할수있고심하지않은경우라면스텐트삽입및위낭종배액술등이진단과동시에이루어질수있으므로불필요한수술을막을수있다는장점이있다.(1) 수술에있어서는췌관손상이없는경우대개국소적배액술이나괴사조직제거등으로안전하고효과적인치료를할수있으며 (16,17) 손상정도가 3이상에서는원위부췌장절제술을시행하는데주췌관의손상유무를파악하여결정해야한다.(18) 손상정도가 4인경우환자의임상적상태에따라원위부췌장절제술및국소배액술을시행하는등복합적인수술이필요할수있다. 췌장의절단은 80% 정도이상되었을때당뇨의발생을높이므로위험성이있는환자는이점을고려하여내적배액술을시행하거나루와이공장문합술등에의한췌장보존술을고려할수도있다.(19) 본연구에서는십이지장동반손상이 3예있었는데 2예에서일차봉합술을시행하였다. 십이지장손상이있는경우에단순배액이나일차봉합과같은간단한술식및손상교정수술을시행하는것이췌장절제보다결과가좋다는주장이있고유문공치술은잘시행하지않으며환자가혈역학적으로안정적이고복합적인손상이있는경우에췌십이지장절제술을시행해볼수있다.(20-24) 외상환자는다발성손상으로내원하는경우가많다. 외상환자의예후에있어서출혈, 산알칼리증, 체온저하, 호흡부전, 순환장애등여러가지가중요하다. 환자가췌장에손상이있다고하여치료를췌장에만국한하지말아야한다. 본연구에서 17예중 9예에서혈복강및혈흉과같은출혈이동반되었으며그중에는뇌출혈과같은증상을동반한경우도 2예있었다. 최근에는환자의수혈이나염기부족등이환자의사망률과연관이있다고알려져있으며빠른교정이췌장손상환자의생존율을높일수있다고주장하면서전체적인치료의중요성이강조되고있다. (25,26) 따라서환자의혈역학적생체징후가우선되어야하며이러한문제가안정적으로되었을때적절한적응증을가지고진단및치료적접근을하는것이중요하다. V. 결론현재외상성췌장손상에대한진단과치료에적립된 바가없으나진단시동반된외상의정도와혈역학적상태에대한평가후치료방법을결정하여야하겠다. 뿐만아니라손상부위, 손상정도, 동반질환및동반손상을고려하여적절히치료방법을고려하여야한다. 내시경적췌관조영술은진단및치료에유용성이있어수술적방법에보조적으로역할이증대되고있다. 외상성췌장손상은동반손상이많고복합적이기때문에여러가지다양한방법을이용하여각각의경우에맞는적절한수단을이용하는것이바람직하다. REFERENCES 01) Rogers SJ, Cello JP, Schecter WP. Endoscopic retrograde cholangiopancreatography in patients with pancreatic trauma. J Trauma 2010;68:538-44. 02) Eimiller A. Complication in endoscopy. Endoscopy 1992; 24:176-84. 03) Mayer JM, Tomczak R, Rau B, Gebhard F, Beger HG. Pancreatic injury in severe trauma: early diagnosis and therapy improve the outcome. Dig Surg 2002;19:291-7; discussion 7-9. 04) Al-Ahmadi K, Ahmed N. Outcomes after pancreatic trauma: experience at a single institution. Can J Surg 2008;51:118-24. 05) Recinos G, DuBose JJ, Teixeira PG, Inaba K, Demetriades D. Local complications following pancreatic trauma. Injury 2009;40:516-20. 06) Seamon MJ, Kim PK, Stawicki SP, Dabrowski GP, Goldberg AJ, Reilly PM, Schwab CW. Pancreatic injury in damage control laparotomies: Is pancreatic resection safe during the initial laparotomy? Injury 2009;40:61-5. 07) Jones RC. Management of pancreatic trauma. Am J Surg 1985;150:698-704. 08) Farrell RJ, Krige JE, Bornman PC, Knottenbelt JD, Terblanche J. Operative strategies in pancreatic trauma. Br J Surg 1996;83:934-7. 09) Patton JH, Jr., Lyden SP, Croce MA, Pritchard FE, Minard G, Kudsk KA, Fabian TC. Pancreatic trauma: a simplified management guideline. J Trauma 1997;43: 234-9; discussion 9-41. 10) Asensio JA, Demetriades D, Hanpeter DE, Gambaro E, Chahwan S. Management of pancreatic injuries. Curr Probl Surg 1999;36:325-419. 11) Hwang SY, Choi YC. Prognostic determinants in patients with traumatic pancreatic injuries. J Korean Med Sci 2008;23:126-30. 12) Tan KK, Chan DX, Vijayan A, Chiu MT. Management of pancreatic injuries after blunt abdominal trauma. Experience at a single institution. JOP 2009;10:657-63. 13) Wisner DH, Wold RL, Frey CF. Diagnosis and treatment of pancreatic injuries. An analysis of management 116
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