제 4 차한국간담췌외과학회연수강좌 송태진 고려대학교의과대학외과학교실 서론 원발성간세포암 ( 간암 ) 은전세계적으로다섯번째로흔한암종이며, 구미보다특히아시아지역에서집중되고, 우리나라에서도세번째의높은발생빈도를유지하고있다 1-3. 간암이최근들어간염보균자등고위험군의경우지속적추적검사를통해조기발견이되기도하지만, 많은경우이미병기가어느정도진행되어발견이되므로이런경우발견후급속히사망에이르는일이아직도흔하다 4. 이렇게진단시진행이많이되어있거나기저에만성간염, 간경변등간질환을동반하는경우많아수술적치료의선택이제한적인경우가아직도많다 5,6. 따라서수술적난제를해결하기위한다양한신기술과치료기법이매년새로이대두되어쓰이고또효용에따라개선을거듭하거나다른새로운기술에밀려폐기되고있어, 외과적간암치료에있어간의절제나이식기교의개인차를최대한좁혀가야만할수밖에없는현대의외과의들은이러한기술들을모두수용하기에도벅찬형국에처하여있다. 하지만이들기법의빠른응용이타당한가등은실제기술발달의속도를개개인이모두따라가기힘든현실을감안하여개념파악정도로서이해를하여둘필요는있어보인다. 이러한간암치료의신기술을문헌과경험을통하여부분적으로나마나열하여정리하며논의하고자한다. 본론 우리나라에서간암은잘알려져있는바와같이간경변이동반된경우가많으며이런경우비록근치적절제가가능한경우에도출혈및수술후유병율증가로수술위험도는매우증가되기도한다. 간암에대한기존외과적치료의상황을한번살펴보면, 간기능에따라대형간암의경우에도절제가가능한경우가있으나, 불가능한경우가더많으며, 간기능이나쁜소형간암의경우각기관의수술정책과범주에따라간이식을고려하기도한다 7-10. 실제간이식을선호하는그룹에서는생체부분간이식등을통한이식이좋은결과를보여이에힘을얻고있는반면, 다른그룹에서는부분간절제혹은국소치료가가능한경우먼저이런조작을하고재발등으로필요하다면추후기회를엿보는교량적방법을추구하기도한다 11-13. 당연하지만간암에있어수술적치료의궁극적목적은수술후간기능을보존함으로서생존률을높이고삶의질을좋게하는데있다 14. 이렇듯처음부터절제가가능하여수술적치료가가능한경우에는이론의여지가별로없겠으나수술의범주를벗어나는경우는다른비수술적치료를할것인지아니면비수술적치료를병행할것인지적절한타협안을찾아야한다. 절제불가능한간암은대개진행정도가극심하거나전이가있어이식이나국소제거치료의적응또한되지않으며대개보존적완화치료의대상이되는데이런완화치료과정중절제가능케되는경우가어느 24
정도 (8-18%) 있으며, 이런경우구제수술의일환으로수술이진행된경우 24.9-57% 의상당히좋은 5년생존결과도보고되고있으므로 9, 이러한방법으로서새로운기법들의도입이요구되고있기도하다. 1. 간암의최소침습수술지난 20여년간괄목할성장을한복강경수술은양성간담췌질환뿐아니라악성종양에도적용되는것이예외가아니다. 이중간암도예외가아니어서암의위치에따라다양한수술법이적용이되나, 종양학적안전성에따른세심한관리를요구하며이제한점역시경험의축적으로극복되고있는상황이다. 또한진단, 생검, 그리고암의병기결정, 치료적절제및제거혹은암의파괴, 암과연관된환자의불편혹은증상제거, 그리고치료불가능한경우의고식적증상경감수술 (palliative surgery) 에도적용이될수있다. 또한기존수술과마찬가지로다른치료기법과병행할수있으며이역시기존보다회복기간을줄여입원기간을줄이고일상으로복귀를빨리할수있음이간암에서도다른최소침습수술과마찬가지장점이다. 복강경기술이발달되며첨단복강경수술기구들의발달또한눈부신데디지털보정영상장비이후 HD 디지털장비가보편화되며고선명, 고화질수술을연출하고있으며, 정교한기록장비들이발달되고, 또최근, 절제및지혈에있어서도 harmonic scalpel, liga-sure 같은장비, 또개복수술에서도쓰이는수술중초음파진단영상장비, 초음파절제기 (CUSA ), 수류제트절제기 (water jet dissector), Tissue link, Argonplasma coagulator 및 cool tips 같은각종 RFA장비등이루헤아릴수없는많은수술기계들이매일등장과도태의부침을거듭하고있으며, 보완된보조수술기구들이하루가멀게개선되어사용이용이하면서최소침습의목적달성을쉽게할수있게하고있다. 또한단공수술 (one port surgery), NOTES (natural orifice transluminal endoscopic surgery) 등기법이간암수술에이미일부도입이되고머지않아보편적으로도입될태세로연구되고기구들이고안이되고있으며, 일일이나열하기힘들정도의장비들이수술실을첨단으로꾸며놓고있다. 이최소침습에쓰이는첨단장비중화두는역시로봇을또한꼽을수있겠으며로봇수술의도입은, 복강경수술이외과영역에이미보편화된시점에서업그레이드에대한신경을쓰지않던지난몇년을다시최첨단으로올려놓는역할을하게되고있다. 로봇이란이름이일반대중에게주는첨단적이미지로말미암아도입시환자의순응도를변화시키며, 복강경수술의한계극복을하는할수있게희망과또한여러의견에따른걱정또한외과의에게동시에가져다주고있는것도현실이다. 2. Operative Irreversible Electroporation for HCC Electroporation 은전기장으로세포막을와해시켜구멍을냄으로서세포내로정상적으로투입할수없는큰분자를넣거나하는분자생물학적기법인데, 이것을응용하여 irreversible electroporation 기구를만들어간암치료에응용하려는노력을하고있다. Irreversible electroporation 이라함은전기장을특수하게변형함으로서영구적세포막의변화를야기시키는방법으로, 절제불가능한간암의치료에있어서기존사용하던 RFA의알려진여러단점, 예를들어제한된크기, 혈관에가까운간암의경우냉각효과로인한효과의저하, 그리고가열된부위가 charcoal 화되어버리는현상으로말미암아영상의학적추적이불편하거나, 합병증을만들어효과를감쇄하는것을방지할수있는방법이연구되고있는데, 이는전신마취및근이완이절대적으로필요하므로, 중재방사선과영역보다는외과의영역에근접한치료방법으로서절제치료불가간암에새로운장비로활용이가능하다 15-21. 25
제 4 차한국간담췌외과학회연수강좌 3. Intraoperative Fluorescent Dye Imaging for HCC Indocyannine green은간의잔류능을검사하는데흔히쓰이는약제이며, 810 nm의적외선을흡광하고자극을받아 830 nm의적외선을다시방사한다. 적외선필터를장착한특수한카메라로이이미지를보게되면 ICG가농축된부위를강하게볼수있다 22,23. 이를간동맥혹은문맥에투여항여영상을얻을수있어, 수술중가이드혹은내비게이션목적의일환으로응용하는연구가되고있다. 또한 fluorescein 도안과에서안저검사할때흔히쓰이는황색염료로, 475 nm의청색광에반응하여 480 nm의녹색광을보여주는염료이다. 간암수술에서수술변연의종양침범과형태를수술중보다명확이하는데도움을줄수있음이속속밝혀지고있어간암수술의편의성증대에응용하여도움을줄수있겠다 24. 4. 그외발달되는첨단간암수술장비들하루가다르게발달되는장비들의수는이루헤아릴수없다. 그만큼간담췌영역에서특히간경변을포함하는간암의수술은결코만만하지않고쉽지가않다는반증일수있으며, 수술의결과또한장비에만의존할수없는다른많은요인이내재된어려운일이다. 따라서이런장비들은외과의의보조적도구일뿐그장비를다루는외과의의지속적연구와끊임없는기량연마가무엇보다절실하다. 결론 간암을수술하는신기술은기저간질환과해부학적인기술제한점을극복하려는부단한노력과다양한장비의진보로점차그한계의영역이줄어들고있지만이러한새기술들이보편화되기위하여서는많은임상시험을통한안전성입증, 또치료적효용성이입증되어야한다. 이에따른기술에적합한환자를선택하고철저한수술전검토그리고세심한수술진행과각기구사용의숙련이대두되고, 시뮬레이션과실제사용에대한기법습득이필요하다. 따라서외과의간의서로의많은경험과장기적추적이진행되면서간암치료에대한신기술의안전성과유효성에대해서도신뢰성있는결과들을수술에적용할수있을것이라생각된다. 이렇듯간암에대한치료는신기술적용에있어외과의그리고관련임상의간협력을통하여환자의안전과장기생존에도움을줄수있는방향으로많은다양한의견교환과기술적탐구가지속적으로병행해나갈수있어야할것으로생각된다. 참고문헌 1. Song TJ, Ip EW, Fong Y. Hepatocellular carcinoma: current surgical management. Gastroenterology. Nov 2004;127(5 Suppl 1):S248-260. 2. Little SA, Fong Y. Hepatocellular carcinoma: current surgical management. Semin.Oncol. 2001;28(5): 474-486. 3. American Cancer S. Cancer Facts and Figures 2010. 2011; http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-026238.pdf. 4. Song IH, Kim KS. Current status of liver diseases in Korea: hepatocellular carcinoma. Korean J Hepatol. Dec 2009;15 Suppl 6:S50-59. 5. Wang HJ, Lee H. [Surgical treatment of hepatocellular carcinoma]. Korean J.Gastroenterol. 2005; 45(4):247-257. 6. Cherqui D, Laurent A, Tayar C, et al. Laparoscopic liver resection for peripheral hepatocellular carcinoma in 26
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