CASE REPORTS pissn 1976-3573 eissn 2288-0941 THE KOREAN JOURNAL OF PANCREAS AND BILIARY TRACT 괴사를동반한급성중증췌장염에서경피적내시경적괴사제거술의성공적인치험 1예 권문혁, 김현수, 김태훈, 권재춘, 정호진, 박명일, 김현지, 강균은 대구파티마병원내과 Percutaneous Endoscopic Necrosectomy In Acute Severe Pancreatitis With Infected Necrosis: A Case Report. Moon hyuk Kwon, Hyun soo Kim, Tae hoon Kim, Jaechoon Kwon, Ho Jin Jung, Myung il Park, Hyun ji Kim, Gyoun Eun Kang Department of Internal Medicine, Daegu Fatima Hospital Percutaneous endoscopic necrosectomy in acute severe pancreatitis with infected necrosis: a case report. Patients with acute infected necrotizing pancreatitis undergoing surgical management may have high risks of complications and mortality. Thus, as an alternative to surgical management, an endoscopic approach has been introduced. We report a case of successful treatment of acute severe pancreatitis with infected necrosis by percutaneous endoscopic necrosectomy (PEN). A 42-year-old man was hospitalized for acute pancreatitis resulting from biliary sludges. He had some fluid collections around the pancreas with severe epigastric pain. Emergency ERCP with EST was performed, and plastic stents were inserted into the bile duct and pancreatic duct for drainage. Despite using the antibiotics, fever developed with increased fluid collections and necrotic tissues which were found on the follow-up abdominal CT scan. Percutaneous catheter drainage (PCD) was performed, but fever did not go down even though several changes of catheter. We then performed the PEN through the opening of PCD. After four sessions of the procedure, much improvement was seen on the follow-up CT scan. With more research and progress, PEN will become a suitable alternative treatment for infected necrotizing pancreatitis Key words: pancreatitis, infected necrotizing, percutaneous endoscopic necrosectomy. 서론 1) 급성췌장염은조직학적형태에따라부종성 (edematous) 췌장염과괴사성 (necrotizing) 췌장염으로구분되며임상적인경과는다양하다. 1 급성췌장염의 80% 이상을차지하 Corresponding author. 김현수대구파티마병원내과대구광역시동구아양로 99번지 Tel: 02-940-7222 Fax: 02-940-7458 E-mail: khsmhj@gmail.com 는부종성췌장염은대부분보존적치료만으로도호전이되나약 20% 에서는괴사성췌장염으로진행되며이중 20-30% 에서감염이동반되고그사망률은 39% 에이른다고보고되었다. 2 한편급성췌장염의합병증으로는급성액체고임 (acute fluid collection), 췌장괴사 (pancreatic necrosis), 가성낭종 (pseudocyst) 등을일으킬수있으며, 감염이되면췌장농양 (pancreatic abscess), 감염성궤사 (infected necrosis) 등을유발할수있다. 1 감염성췌장괴사가의심이되면임상증상과복부전산화단층촬영을이용하여진단하며, 복부초음파유도하세침흡입술 (fine needle aspiration, FNA) 을시행하여세 39
권문혁외 7 명 40 균을증명할수있으며그민감도가 89-100% 로높다. 3 감염성췌장괴사의치료는감염된액체를배액하고괴사된췌장이나췌장주의의조직을제거하는것이기본이되나환자의상태가혈역학적으로안정적일경우먼저항생제치료및보존적치료를하면서추적관찰할수있다. 1 괴사조직의제거는수술적인괴사제거술이고전적인방법이나개복수술에따르는높은사망률과합병증을줄이고, 환자들에게수술로인한스트레스를최소화하기위하여최근다양한경로를통한최소침습시술이시행되고있으며기존의개복수술보다더좋은결과들을보고하고있다. 4-5 현재까지보고된괴사성췌장염에대한최소침습술식으로는경피적혹은내시경적배액및괴사제거술과복강경을이용한괴사제거술이있다. 저자등은감염성췌장괴사환자에서경피적배액술및경피적내시경적괴사제거술을단계적으로시행하여성공적으로시행하여치료한 1예를문헌고찰과함께보고하는바이다. 증례 42세남자환자가내원당일식후발생한심한심와부통증으로내원하였다. 평소음주는거의하지않는환자로내원 9년전에도췌장염의병력이있었다. 이학적검사상혈압은 100/60 mmhg, 맥박은 100회 / 분, 호흡수는 22회 / 분, 체온은 36.2 c 였다. 검사실소견으로말초혈액검사에서백혈구 14,250 /ul, 혈청생화학검사에서 total bilirubin 4.58 mg/dl, direct bilirubin 2.7 mg/dl, AST (aspartate aminotransferase) 123 U/L, ALT (alanine aminotransferase) 90 U/L, γ-gtp (γ-glutamyl transpeptidase) 666 IU/L, amylase 1,791 U/L, lipase 1,620 U/L 으로증가된소견을보였으며, ALP (alkaline phosphatase) 92 IU/L, albumin 4.3 g/dl, CRP (C-reactive protein) 0.13 mg/dl 으로정상소견을보였다 (APACHE II score 3점 ). 복부전산화단층촬영에서췌장체부에급성체액저류를동반한급성췌장염소견 (CT severity index score 5점 ) 및담낭비후소견을보였다 (Fig. 1A). 환자의급성췌장염원인으로병력상알코올에의한가능성이떨어져담석등의다른원인을찾기위해시행된내시경초음파검사 (endoscopic ultrasound, EUS) 에서담낭내에다발성결석및슬러지가발견되어 (Fig. 2) 내시경적역행성담췌관조영술 (endoscopic retrograde cholangiopancreatography, ERCP) 및내시경하유두괄약근절개술 (endoscopic sphincterotomy, EST) 을시행하였으며담즙및췌즙배액을위해내시경적역행성담즙배액술 (endoscopic retrograde biliary drainage, ERBD) 및내시경적역행성췌관배액술 (endoscopic retrograde pancreatic drainage, ERPD) 을시행하였다. 보존적치료를시행하던중내원 10일째환자는항생제의지속적인사용에도불구하고 38.5 C 이상의고열이지속되고백혈구 18,640 /ul, CRP (C-reactiveprotein) 21.6 mg/dl 으로증가되는소견이관찰되었으며, 추적복부전산화단층촬영에서췌장주변및우측신장주변부에괴사를동반한약 12cm에이르는체액저류 (fluid collection) Fig. 1. Abdominal Computer Tomography (CT) view. (A) On admission day showed Pancreas swelling, fluid collection at pancreas head uncinate process and anterior renal fascia. (B) On 10th admission day (before PCD) showed increased fluid collections and necrosis at peripancreatic and right anterior pararenal space. (C) On 30th admission day (before necrosectomy) showed walled-off pancreatic necrosis(wopn) and air forming at right paracolic gut and right anterior pararenal space. (D) On after 4 session of necrosectomy showed marked decreased fluid collections and pancreatic necrosis at right paracolic gut and right anterior pararenal space.
괴사를동반한급성중증췌장염에서경피적내시경적괴사제거술의성공적인치험 1 예 41 Fig. 2. Endoscopic ultrasound (EUS) view. Multiple GB stones and sludges with cholecystitis were detected. 의증가가관찰되어 (Fig. 1B) 우측복부를통한경피적배액술 (percutaneous catheter drainage, PCD) 을시행하였다 (10.2Fr). 배액관을통하여배액된액체는매우혼탁하였고 (turbid) 끈적하여 (thick) 배액이잘되지않았고간헐적인발열이지속되어수차례배액관을좀더굵은것으로교정하였으며 (14 Fr, 16 Fr) 추가적인도관의위치조정을시행하였다. 그럼에도불구하고내원 30일째환 자는계속적인 38 c 이상의고열과추적복부전산화단층촬영에서췌장주위체액저류증가및괴사물질증가, 그리고잘형성된벽으로잘싸여있는췌장괴사 (walled-off pancreatic necrosis, WOPN) 소견이관찰되어 (Fig. 1C) 경피적배액관도관삽관자리를통한경피적내시경적괴사제거술을췌장주변및우측신장주변부, 우측하복부까지시행하였다 (Fig. 3A,3B). 시술은 midazolam 및 pethidine 을사용하여의식하진정상태에서시행하였으며방사선유도하에유도관을삽입한후기존의배액관삽입구를확장기 (Dilator, 20Fr, COOK medical, USA) 를통해확장을하였고외과용투관침 (trocar, 11mm) 을이용하여삽입구를고정한후직경 5.5mm 의경비강내시경 (transnasal endoscopy, GIF-XP260N, Olympus) 을통해시행하였다. 내시경시야상상행결장주변의복강내부에매우점도가높고혼탁한흰색에서황색의농 (white to yellow pus) 과같은액체와많은괴사조직이존재하였고 Basket (Memory eight wire basket, 5Fr, COOK medical, USA), Net-snare (Roth Net -foreign body, 2cm, 1.8mmØØ, US endoscopy, USA) 등을사용하여괴사조직을내시경으로직접관찰하면서제거하였으며 (Fig. 4A,4B) 내시경을통한생리식염수세척 (lavage) 을병행하였고시술이후다시배액관을유지하였 Fig. 3. Fluoroscopic view. Endoscope was reached peri-pancreas (A) to the right lower abdomen (B).
권문혁외 7 명 42 Fig. 4. Endoscopic view. (A, B) Endoscopy showed removal of necrotic debris by net-snare. (c) Endoscopy showed clean cavity after completion of percutaneous endoscopic necrosectomy. 다. 제거된괴사조직의조직소견에는효소성지방괴사조직으로괴사에합당한소견이었다. 2주동안총 4회에걸쳐위에기술한방법으로경피적내시경적괴사제거술을시행하였으며마지막추적내시경상에서병변의괴사조직은현격한감소를보였다 (Fig. 4C). 4차시술후검사한추적복부전산화단층촬영에서췌장주위의체액저류및괴사조직은이전과비교하여현저하게감소하여호전된소견을보였다 (Fig. 1D). 환자의활력징후는안정적이되었고검사실소견과발열및복통등의임상양상도호전을보였다. 괴사제거술첫시행한날로부터약 5주후경피적배액관을제거할수있었으며담낭담석에대한수술은좀더전신상태가좋아진후시행하기로하고퇴원하였다. 환자는퇴원 1개월후담석을동반한담낭을복강경으로제거가능하였으며총담관및췌관에삽입되었던플라스틱스텐트를전부제거하였다. 그후 6개월뒤시행한추적복부전산화단층촬영에서재발및특별한소견은발견되지않고현재까지외래에서추적관찰을지속하고있으며환자는특별한증상없이잘지내고있다. 고찰 급성감염성췌장괴사의고전적인치료방법은수술적괴사제거술이다. 괴사된췌장이나췌장주위조직을제거하는것을기본으로하며, 여러수술방법에따라수술후경과및사망률에차이가있다고보고되고있다. 이는환자의다양한임상양상과외과의의수술적경험이수술방법에큰영향을주기때문으로생각된다. 6-7 Hartwig 8 등의 연구에서급성괴사성췌장염환자에서조기수술과지연수술의사망률을비교하였을때 39% 대 12% 로조기수술환자의사망률이의미있게높게보고되었고이연구결과는가능한보존적치료후수술을지연하는것이전신마취등에의한직접적인환자의스트레스를줄이고췌장괴사의경계가분명해져불필요한정상췌장조직의제거를막으며출혈, 천공등의합병증을최소화함으로써환자의사망률을감소시킬수있음을강조하고있다. 현재까지감염성췌장괴사의치료방법에대한많은증례들이보고되어왔고, 이들의내용을종합해보면감염성췌장괴사환자에서전신상태가안정적이면보존적치료가일차적치료가될수있음을알수있다. 9-10 하지만보존적치료중괴사된췌장과췌장주위의액체고임의악화또는감염등합병증으로인한후복막의염증이진행되어환자의전신상태가불안정해지면염증의확산을줄이고괴사된조직제거를위한추가적인수술적방법이필요하다. 최근급성감염성췌장괴사의치료로최소침습시술이대두되고있으며이는앞서언급한개복수술에대한높은사망률과합병증을줄이는데근거를두고있다. 최소침습시술은경피적경로, 경구적경로및복강경을이용한경로를통해시행하며, 각각의경로를통한배액관삽입을통한배액술및괴사제거술을시행할수있다. 배액술로써경피적경로를통한시술은영상의학과시술의가도관을방사선유도하에후복강내의병변부위에복벽을통하여경피적으로직접삽입하여배액하는방법이며, 경구적배액법은소화기내시경시술의가내시경초음파유도하또는기존내시경을이용하여위벽 ( 낭위루, cys-
괴사를동반한급성중증췌장염에서경피적내시경적괴사제거술의성공적인치험 1 예 43 togastrostomy) 혹은십이지장벽 ( 낭십이지장루, cystoduodenostomy) 을천공시켜병변에배액관을유치하여배액하는방법이다. 이러한경피적경로및경구적내시경을통한시술은소량의진통제, 진정제만을사용하여시행할수있고환자의협조하에이루어질수있으며비교적통증이적고출혈및천공의위험을줄일수있는장점이있다. 괴사제거술은감염성췌장괴사환자에서괴사조직을직접제거하는방법으로염증및괴사조직이막으로견고하게잘싸여진상태 (WOPN) 가이르렀을때주로시행을고려하게되며병변의위치와접근성에따라경로를선택하게된다. 복강경을이용한괴사제거술은외과의가시행하며최소한의상처를통하여광범위한괴사제거에용이한데기존의개복수술에비하여사망률, 재원기간, 수술후집중치료기간등에서우수한성적을보인후향적연구 11 가있으나전신마취의필요등수술자체의스트레스는존재하고한번에괴사제거를전부시행하지못하는경우여러번재시술이어렵다는단점이있다. 경피적경로를통한괴사제거술은방사선유도하에서간접적으로시술이이루어지기때문에많은시술횟수로인한재원기간의연장이예상되고직접보면서괴사조직을제거할수없기때문에혈관손상으로인한출혈, 주변장기천공등의합병증이많으며광범위한병변의괴사물질을모두다제거가어렵다는제한점이있다. 1 Gambiez LP 12 등의연구에서경피적괴사제거술과개복수술적치료를비교하였으며개복수술환자군에서는합병증으로 9명중절개탈장 2건만이발생하였으나, 경피적괴사제거술을시행한환자군에서 20명중대장누공 1건, 비장출혈1건, 후속개복2 건, 피부로의췌장누공 2건, 절개탈장 2건등총 8건이발생하여합병증과추가시술의발생이오히려증가함을보고하였다. 한편내시경을통한괴사제거술은직접괴사조직을관찰하면서시술을할수있어비교적합병증이적고, 병변에정확한접근이가능하기때문에시술횟수를줄일수있으며광범위한병변에서도시행할수있다는장점이있다. Seifert H (the GEPARD Study) 13 등의연구에서내시경초음파유도하에시행한경구적내시경적괴사제거술의치료성공률이 73%-92% 로보고된바있으며, 급성괴사성감염성췌장염환자들을대상으로한경구적내시경적치료와수술적치료를비교한 Bakker OJ 14 등의연구에서도내시경적치료가수술적치료에비해합병증발생률및사망률이의미있게적었다고보고하였다. 내시 경시술경로는병변의위치에따라경피적내시경적괴사제거술및경구적내시경적괴사제거술로나누게된다. 경피적경로는주로양쪽대장주변에병변이위치할때시행할수있으며기존의경피적배액경로를유지확장하여이용할수있다. 경구적경로는주로췌장주위에병변이있을때시행하며역시기존의낭위루또는낭십이지장루를확장시켜시술할수있다. Van Santvoort H 15 등의연구에서는본증례와같이단계적으로경피적혹은내시경적배액법시행후경피적내시경적괴사제거술을시행한환자와개복괴사제거술을시행한환자군을비교하였으며사망또는술후다발성장기부전등의주요합병증은 39.5% (17명/43명) 대 68.9% (31명/45명) 로단계적접근을통한경피적내시경적괴사제거술을시행한환자군에서개복괴사제거술을시행한환자군에비하여유의하게낮았으며, 6개월후의추적관찰에서도경피적내시경적괴사제거술이개복수술에비하여췌관루의형성 (27.9% 대 37.8%), 헤르니아 (7% 대 24.4%), 새로운당뇨병의발현 (16.3% 대37.8%) 등합병증발현빈도가낮게관찰되었다. 본증례는급성감염성괴사성췌장염환자에서경험적항생제치료등보존적치료및경피적배액법을시행하였음에도불구하고전신상태가악화되어단계적인경피적내시경적괴사제거술을시행한예이다. 감염성췌장괴사환자에서경피적내시경을통하여환부를직접보면서괴사조직을효율적으로제거하여시술의횟수를감소시키는효과를가져왔으며정맥주사진정제만으로시술을진행하여전신마취등환자에게주는스트레스를최소화하였다. 결과적으로환자는추가적인개복수술이나복강경수술없이감염성췌장괴사치료에성공하였고출혈, 누공, 천공및재발등의합병증도나타나지않았다. 감염성췌장괴사환자에대한다양한치료접근방법의하나로경피적내시경적괴사제거술이개복수술을대신하여최소침습술식의하나로감염성췌장괴사환자의치료에도움이될수있을것이다. 경피적내시경적괴사제거술에대한선행적연구또는다기관연구를통한경피적내시경적괴사제거술의정립과적응증의확대에대한연구가필요하다. 요약 감염성췌장괴사의고전적인치료는개복수술이었다.
권문혁외 7 명 44 하지만개복수술후합병증, 사망률의유의한증가가보고되면서항생제와보존적치료가일차적치료로서우선적으로선택되고있다. 보존치료에반응이없는경우에는다양한경로를통한배액법및괴사제거술등의최소침습시술이대두되고있으며, 이러한최소침습시술의선택은환자의임상양상, 보존적치료에대한치료반응, 괴사조직과위장관의해부학적위치관계에대한정확한평가및그에따른시술방법의선택이이루어져야한다. 저자들은급성감염성췌장괴사에서항생제등의보존적치료와경피적배액술을시행하였으나치료반응이없는환자에서경피적내시경적괴사제거술을통한성공적인괴사치료1예를경험하였기에보고하는바이다. 색인단어 : 내시경역행성담췌관조영술, 합병증, 급성담낭염, 담낭천공 참고문헌 1. 김태현. The treatment of local complication of acute pancreatitis and necrotizing pancreatitis. 대한췌담도학회지 2012 년 17 권 1 호 57-66. 2. Banks PA, Freeman ML. Practice Parameters Committee of the AmeriCollege of Gastroenterology. Practice guidelines in acute pancreati Am J Gastroenterol 2006;101:2379-2400. 3. Banks PA, Gerzof SG, Langevin RE, Silverman SG, Sica GT, Hughes MD. CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome. International Journal of Pancreatology 1995;18:265-270. 4. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc 2005;62:92-100. 5. Bucher P, Pugin F, Morel P. Minimally invasive necrosectomy for infected necrotizing pancreatitis. Pancreas 2008;36:113-119. 6. Buchler MW, Gloor B, Muller CA, Friess H, Seiler CA, Uhl W. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000;232:619-626. 7. Fernandez-del Castillo C, Rattner DW, Makary MA, Mostafavi A, McGrath D, Warshaw AL. Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 1998;228:676-684. 8. Hartwig W, Maksan SM, Foitzik T, Schmidt J, HerfarthC, Klar E. Reduction in mortality with delayed surgical therapy of severe pancreatitis. J Gastrointest Surg 2002;6:481-487. 9. Runzi M, Niebel W, Goebell H, Gerken G, Layer P. Severe acute pancreatitis: nonsurgical treatment of infected necroses. Pancreas 2005;30:195-199. 10. Sivasankar A, Kannan DG, Ravichandran P, Jeswanth S, Balachandar TG, Surendran R. Outcome of severe acute pancreatitis: is there a role for conservative management of infected pancreatic necrosis? Hepatobiliary Pancreat Dis Int 2006;5:599-604. 11. Lee JK, Kwak KK, Park JK, et al. The efficacy of nonsurgical treatment of infected pancreatic necrosis.pancreas 2007;34:399-404. 12. Gambiez LP, Denimal FA, Porte HL, Saudemont A, Chambon JP, Quandalle PA. Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections. Arch Surg 1998;133:66-72. 13. Seifert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009;58:1260-1266. 14. Bakker OJ, van Santvoort HC, van Brunschot S, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012;307:1053-1061. 15. van Santvoort HC, Besselink MG, Bakker OJ et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. New England Journal of Medicine 2010;362:1491-1502.