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J Korean Surg Soc 2009;76:371-377 DOI: 10.4174/jkss.2009.76.6.371 원 저 황색육아종성담낭염 : 36 예의후향적분석 인제대학교의과대학부산백병원외과학교실 서상혁ㆍ박정익ㆍ김진수ㆍ김광희ㆍ최창수ㆍ최영길 Xanthogranulomatous Cholecystitis: A Retrospective Analysis of 36 Cases Sang-Hyuk Seo, M.D., Jeong-Ik Park, M.D., Jin-Soo Kim, M.D., Kwang-Hee Kim, M.D., Chang-Soo Choi, M.D., Young-Kil Choi, M.D. Department of Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea Purpose: Xanthogranulomatous cholecystitis (XGC) is an uncommon, benign destructive and chronic inflammatory disease which is characterized by a marked proliferative fibrosis within the gallbladder wall. XGC occasionally involves adjacent organs and mimicking an advanced gallbladder carcinoma (GBC). The purpose of this study was to review the clinical manifestations, radiologic and pathologic findings of XGC and to investigate an appropriate treatment plan for patients with XGC. Methods: We retrospectively analyzed the clinical data of 36 patients with a pathologic diagnosis of XGC operated between January 2003 and June 2008. Results: The most frequent clinical symptom was biliary colic (88.8%). Radiologic studies revealed cholelithiasis in 30 patients (83.3%), thickening of gallbladder wall in 24 patients (66.6%), suspicious cancer in 11 patients (30.5%) and Mirizzi syndrome in 3 patients (8.3%). Laparoscopic cholecystectomy was planned in 18 patients but converted to open surgery in 9 patients. Open cholecystectomy was planned and performed in 13 patients including 8 cases of T-tube choledocholithotomy and 1 case of excision of a cholecystoduodenal fistula. Extended cholecystectomy was performed on 3 patients. GBC was suspected before operation in 11 patients. Of these, frozen-section biopsy was performed in 6 and found to be malignant in 1 patient. One patient who had no operative suspicion of malignancy turned out to have GBC at final histology. Conclusion: XGC is difficult to diagnose either preoperatively or intraoperatively and definite diagnosis can be obtained by pathologic examination only. If there is an intraoperative suspicion of GBC, frozen-section biopsy will help to decide the appropriate mode of operation. (J Korean Surg Soc 2009;76:371-377) Key Words: Xanthogranulomatous cholecystitis, Gallbladder cancer, Cholecystectomy 중심단어 : 황색육아종성담낭염, 담낭암, 담낭절제술 서 론 책임저자 : 박정익, 부산시부산진구개금동 633-165 614-735, 인제대학교부산백병원외과 Tel: 051-890-6352, Fax: 051-898-9427 E-mail: jeongikk@hotmail.com 접수일 :2009 년 1 월 9 일, 게재승인일 :2009 년 2 월 11 일본논문은 2008 년한국간담췌외과학회추계학술대회에서포스터발표되었음. 황색육아종성담낭염은국소적혹은미만성파괴적염증반응으로인한담낭벽의심한비후소견을보이는비교적드문담낭염이다. 이질환은 1970년 Christensen과 Ishak(1) 에의해서섬유성황색육아종성염증 (fibroxanthogranulomatous inflammation) 으로처음기술되었고이후밀랍양조직 371

372 J Korean Surg Soc. Vol. 76, No. 6 구증 (ceroid-like histocytic granuloma), 밀랍육아종 (ceroid granuloma), 그리고담도육아종성담낭염 (biliary granulomatous cholecystitis) 등의여러질환명으로보고되어오다가,(2,3) 1976년 McCoy 등 (4) 에의해서황색육아종성담낭염 (xanthogranulomatous cholecystitis) 으로통일되었다. 황색육아종성담낭염은육안적으로담낭벽의황색결절을동반하는불규칙한담낭벽의비후소견이특징이며조직학적으로는풍부한조직구와염증세포그리고섬유모세포의침윤을특징으로한다.(5) 황색육아종성담낭염의발병기전은정립된것은없는데몇몇저자들은담석, 담즙저류및황색육아종성염증반응이 Rokitansky-Aschoff sinus의벽내파열로인한주변조직으로의담즙유출로설명하고있다.(6) 이러한염증소견은간상부, 간문부, 십이지장그리고횡행결장등의주변조직으로의심한침윤소견을동반하게되어수술전영상의학적소견이나수술중육안적소견으로진행된담낭암과의감별이어려운경우가많아불필요한광범위절제수술이시행될우려가있다. 저자들은본원에서경험한황색육아종성담낭염증례를통해임상양상, 수술전영상의학적검사소견그리고수술소견을분석하여적절한수술범위결정을위해서수술중동결절편조직생검의역할에대해서알아보고자하였다. 동통 (88.8%) 을호소하였고, 이들중에는통증과발열을동반하는급성담낭염의양상으로호소한환자가 6예 (16.7%) 있었다. 폐쇄성황달은비교적흔하지않은임상양상으로 10명 (27.7%) 의환자에서보였는데그원인으로비후된염증성담낭벽에의해총담관이압박되어폐쇄성황달을야기하는 Mirizzi 증후군이었던경우는 3예이었고, 악성종양이동반한경우는 2예, 나머지 5예는총담관결석이원인이었다. 그외식욕과체중감소가주된임상증상으로호소한경우는 3예 (8.3%) 가있었다 (Table 1). 16명 (44.4%) 의환자에서동반질환을가지고있었는데당뇨와고혈압을동반하고있는경우가대다수였다 (Table 2). 2) 수술전영상의학적검사소견수술전진단을위한영상의학적검사로복부전산화단층촬영 (computed tomography) 은 31예에서, 복부초음파검사 (ultrasonography) 는 15예, 자기공명영상화담췌관조영술 (magnetic resonance cholangiopancreatography) 은 17예에서시행되었고, 그외내시경적역행성담췌관조영술 (endoscopic retrograde cholangiopancreaticography) 과경피적경간담도조영술 (percutaneous transhepatic cholangiography) 은각각 10예에서시행되었다. 수술전복부통증및발열등의증상과환자의전신상태의악화로인해경피적경간담낭배액 방법 2003년 1월부터 2008년 6월까지인제대학교부산백병원외과학교실에서시행한 2,132예의담낭절제술중에서병리학적으로황색육아종성담낭염으로진단받은 36예 (1.68%) 를대상으로하였고, 임상자료를후향적으로검토하여수술전임상양상, 복부초음파, 복부전산화단층촬영, 자기공명영상화담췌관조영술등의영상의학적소견그리고수술소견과수술방법들을분석하였으며, 특징적인수술전영상의학적소견을통한담낭암과의감별여부, 수술중동결절편조직생검의필요성과수술범위결정에의유용성등에대해서고찰하였다. 결과 1) 임상양상 대상환자군의평균연령은 58.9세이고 (28 80), 남자가 19명, 여자가 17명이었다. 임상증상은대다수가우상복부 Table 1. Clinical manifestation in 36 patients with xanthogranulomatous cholecystitis Clinical manifestation Number of patients (%)* Biliary colic 32 (88.8) With fever (acute cholecystitis) 6 (16.7) Obstructive jaundice 10 (27.7) Loss of appetite and weight 3 (8.3) *some of the patients had more than one clinical manifestation. Table 2. Associated diseases in patients with xanthogranulomatous cholecystitis Diseases Number of patients (%) Diabetes mellitus 5 (13.8) Hypertension 4 (11.1) Gastric cancer 3 (8.3) Common bile duct cancer 1 (2.7) Intrahepatic duct stone 1 (2.7) Hepatocelluar carcinoma 1 (2.7) Hypothyroidism 1 (2.7) None 20 (55.5)

Sang-Hyuk Seo, et al:xanthogranulomatous Cholecystitis: A Retrospective Analysis of 36 Cases 373 술 (percutaneous transhepatic gallbladder drainage) 을시행한경우는 4예가있었다. 복부전산화단층촬영소견에서담낭결석은 30예 (83.3%) 에서, 담낭벽의비후소견은 24예 (66.6%) 에서관찰되어대다수의황색육아종성담낭염환자들이동반하는소견이었고, 간상부위의불명확한경계소견이 6예, 담낭주위체액저류및침윤소견이 5예, 담낭벽내의조영이감소되는결절소견 (intramural hypoattenuated nodule) 이 5예, 담낭벽비후로인한주변조직의침윤으로 Mirizzi 증후군을동반한경우는 3 예, 담낭벽내의농양동반이 2예에서관찰되었다 (Table 3). 담낭벽의국소적비후등의소견으로인해서수술전영상의학적으로담낭암으로진단된경우는 11예가있었는데이중 2예에서만조직학적으로담낭암이확진되었다. 담낭암으로확진된 2예에서의수술전복부전산화단층촬영소견은담석과담낭벽의비후소견이공통적이었고, 담낭주위침윤소견과담낭벽내의농양동반소견을보여황색육아종성담낭염과구분할수있는특징적소견은관찰되지않았다. 담낭벽내의조영감소성결절소견은모두황색육아종성담낭염에서만관찰되는영상검사소견이었다 (Fig. 1). 절개로결석제거후 T관을삽입하였고, 담낭과십이지장간의누공이형성된 1예에서십이지장일차봉합술및 T관삽입후급양공장루 (feeding jejunostomy) 형성술을시행하였다. 수술전영상소견과수술중육안소견에서악성으로판단하여동결절편조직생검을시행하지않은 1예와동결절편조직생검에서악성암을확진할수는없지만비정상세포의모양을띠고있었던경우 1예와악성세포가확인된 1예에서확대담낭절제술이시행되었다. 위암이동반된 1예 3) 수술후경과및합병증수술소견상정도의차이는있었지만대부분의예에서담낭벽비후소견을보이며주변조직과염증성유착양상을띠고있었고, 담낭결석은 30예 (83.3%) 에서동반하고있었다. 수술방법으로복강경담낭절제술은 9예시행하였고, 복강경절제술을시도하였으나개복절제술로전환한예가 9예있었다. 총담관결석이동반하였지만수술전내시경적역행성담췌관조영술로제거가곤란하였던 8예에서담관 Table 3. Computed tomographic findings in 36 patients with xanthogranulomatous cholecystitis Finding Number of patients (%) Cholelithiasis 30 (83.3) Thickening of gallbladder wall 24 (66.6) Suspicion of carcinoma 11 (30.5) Choledocholithiasis 8 (22.2) Distension of gallbladder 6 (16.6) Gallbladder bed hyperemia 6 (16.6) Pericholecystic infiltration/fluid collection 5 (13.8) Intramural hypoattenuated nodule 5 (13.8) Collapse of gallbladder 3 (8.3) Mirizzi syndrome 3 (8.3) Intramural abscess 2 (5.5) Fig. 1. Several computed tomographic findings in patients with xanthogranulomatous cholecystitis. (A) CT scan shows focal gallbladder wall thickening and mass like lesion. This patient was diagnosed with gallbladder carcinoma preoperatively. (B) CT scan shows diffuse gallbladder wall thickening with multiple intramural hypoattenuated nodules. (C) CT scan shows irregular gallbladder wall thickening with hyperemic change of gallbladder bed, and pericholecytic infiltration.

374 J Korean Surg Soc. Vol. 76, No. 6 에서위전절제술이, 우간내담석이동반된 1예에서우간절제술이, 담도암이동반된 1예에서췌십이지장절제술이동반시행되었다 (Table 4). 환자들의수술후합병증으로창상감염이 5예로가장많았으며, 창상부위출혈이 1예, 수술후섬망상태에서 T관자의제거로인한담즙누출이 1예, 우간절제술을동반시행하였던 1예에서의흉수, 그리고혈전정맥염이 1예가있었다 (Table 5). 이들환자들은모두보존적치료로치유가되었다. 찰되었다. 5) 담낭암의동반수술전영상의학적검사에서담낭암으로진단된환자는 11명, 수술중동결절편조직생검에서담낭암으로진단된환자는 1명, 그리고수술후최종적인조직검사에서담낭암으로확진된환자는 2명이었다 (Table 6). 최종수술후조직학적검사에서확진된담낭암 2예는모두수술전복부전산 4) 병리소견수술후적출한담낭의병리학적검사결과에서확인된담낭벽의두께는 8 20 mm ( 중앙값 12 mm) 이었다. 담낭벽은비후되거나섬유화소견을동반하고있었으며현미경적소견으로국소적이거나미만성의심한염증반응을보이며지질을함유하고있는대식세포등의조직구세포들이침윤되어있었다 (Fig. 2). 담낭암으로진단된 2예의경우는담낭벽이미만성으로비후된소견을보이며광범위한황색육아종성염증양상을띠고있었지만, 담낭선암은이러한황색육아종성염증에서떨어진담낭경부에서국소적으로관 Table 4. Summary of operative procedures Operation Number of patients (%) Laparoscopic cholecystectomy 9 (25.0) Open cholecystectomy 24 (66.6) Conversion 9 (25.0) T-tube choledocholithotomy 8 (22.2) Excision of cholecystoduodenal fistula 1 (2.7) Right hepatectomy* 1 (2.7) Pancreaticoduodenectomy 1 (2.7) Extended cholecystectomy 3 (8.3) Total gastrectomy 1 (2.7) *combine with right intrahepatic duct stone; combine with distal common bile duct cancer; combine with gastric cancer. Table 5. Postoperative complications in patients with xanthogranulomatous cholecystitis underwent cholecystectomy Complication Number of patients (%) Wound infection 5 (13.8) Wound bleeding 1 (2.7) Bile leakage* 1 (2.7) Pleural effusion 1 (2.7) Thrombophlebitis 1 (2.7) *due to T tube removal by patient himself. Fig. 2. Microscopic finding of xanthogranulomatous cholecystitis Xanthogranulomatous inflammation of the gallbladder wall, characterized by histocytes containing neutral fat and lipofucin pigment (H&E, 200). Table 6. Profiles of patients with radiologically suspected gallbladder carcinoma Cases Frozen-section biopsy Operation Permanent biopsy 1 Not-done LC XGC 2 Atypical cell EC (+BDR) XGC 3 Inflammation OC with TTC XGC 4 Adenocarcinoma EC with TG GBC (T2N0) 5 Not-done OC with RH** XGC 6 Abscess OC with PD XGC 7 Not-done LC XGC 8 Not-done OC GBC (T2Nx)* 9 Not-done EC XGC 10 Not-done OC XGC 11 Inflammation OC with TTC XGC *additional operation was not performed due to patient s refusal; LC = laparoscopic cholecystectomy; EC = extended cholecystectomy; OC = open cholecystectomy; TTC = T-tube choledocholithotomy; TG = total gastrectomy; **RH = right hepatectomy; PD = pancreaticoduodenectomy; XGC = xanthogranulomatous cholecystitis; GBC = gallbladder carcinoma.

Sang-Hyuk Seo, et al:xanthogranulomatous Cholecystitis: A Retrospective Analysis of 36 Cases 375 화단층촬영에서담낭암의가능성이높다고진단되었던환자들이었다. 하지만수술전에담낭암으로영상의학적진단이내려졌던 11예모두에서동결절편조직생검을시행하지는않았고, 수술중육안소견에서담낭암과감별되지않았던 5예와수술전영상의학적소견에서담낭암으로진단되지는않았지만수술중담낭암이의심되었던 1예에서시행하였다. 동결절편조직생검을시행한환자들중 1예에서만담낭암으로진단되었고, 수술전영상의학적검사상에서는담낭암이의심되었으나수술중육안소견에서악성가능성이낮다고판단하여동결절편조직생검을시행하지않았던 6예중 1예에서최종적인조직학적검사에서담낭암으로진단되었다. 동결절편조직생검에서담낭암으로확인하였던 1예는확대담낭절제술이시행되었지만, 동결절편조직생검을시행하지않고단순담낭절제술을시행하였다가최종조직검사에서담낭암으로확진된 1예는환자의거부로추가적인절제술을시행하지는못하였다. 고찰 황색육아종성담낭염은 1976년 McCoy 등 (4) 에의해명명되어진드문형태의만성담낭염으로발생빈도는절제된담낭의 1.46% 에서관찰되고, 남녀의성비는비슷한것으로보고되고있다.(7) 본연구에서의빈도는전체담낭절제술 2,132예중 36예로 1.68% 에해당하였다. 발병기전은명확하게규명된것은없지만담석을동반하는경우가많고이에따른폐색현상과뒤이은담즙저류로인해서염증반응이시작되고, 담낭점막의궤양과 Rokitansky- Aschoff sinus의파괴로이어져담즙등이담낭벽내기질로침습되게된다.(8,9) 염증부위에조직구세포가모이게되면비수용성콜레스테롤과다른담즙지질들이식균작용에의해담낭벽내미세농양을형성하여황색육아종으로발전하게되며결국에는이런염증반응이치유되면서섬유화반응과반흔조직으로남게되는것으로알려져있다. 이는만성적인감염과결석이동반되는것이일반적임상양상인육아종성신우신염의발병기전과도유사하다.(10,11) 황색육아종성담낭염과담석이동반하는비율이 95 100% 에이르는것으로밝혀져이는황색육아종성담낭염으로의초기발전단계로서결석이발생함을간주할수있지만,(11) 또다른보고에서는단지 70 85% 의동반율을보이고있어담석의존재는동반된조건이지염증반응의원인은아닌것이라고도주장하였다.(7,12,13) 본연구에서는 83.3% 에서담석이동반하고있었다. 황색육아종성담낭염에특징적인임상증상이나징후는없는데, 담도산통, 발열등과같은증상이대표적이어서급성이나만성담낭염의임상양상과유사하다.(14) 본연구에서도 88.8% 의환자에서담도산통을호소하였고, 10명의환자에서폐쇄성황달을보였지만 3명은 Mirizzi 증후군에의해서, 5명은총담관결석에의해서, 그리고나머지 2명은악성종양이원인이어서황색육아종성담낭염의특이적인증상으로관찰되지는않았다. 수술전복부전산화단층촬영소견은담석, 담낭벽의비후등담낭의염증성병변의특징과큰차이가없는소견들을보였다. 수술전전산화단층촬영소견으로 30.5% 에서악성종양이의심되었으나 2예 (5.5%) 에서만최종수술후조직검사결과와일치하는소견을보여수술전영상진단만으로는염증성병변과종양성병변을감별하기는매우어려움을시사하였다. Kim 등 (15) 은 19명의황색육아종성담낭염환자모두에게서수술후조직검사에서담낭벽내결절 (intramural nodule) 소견이관찰되었고, 수술전전산화단층촬영소견에서는이들중 10명 (52.6%) 에서담낭벽내결절이관찰되어수술전영상의학적소견에서담낭벽내결절을보이는경우황색육아종성담낭염의진단에도움을줄수있다고보고하였다. Chun 등 (16) 도수술전전산화단층촬영에서황색육아종성담낭염환자 11명모두에서담낭벽내결절을동반하는소견을보인반면담낭암에서는 17명중 7명에서만관찰되었고, 담낭벽이미만성으로두꺼워져있는소견이담낭암 (17명중 7명 ) 에서보다황색육아종성담낭염 (11명중 10명 ) 에서보다많이관찰된다고보고하였다. Shuto 등 (17) 과 Kim 등 (18) 도전산화단층촬영에서담낭벽의저밀도결절과자기공명영상화촬영의 T2 weight 영상에서의 Rokitansky-Aschoff sinus에상응하는두터워진담낭벽내의고신호성결절은담낭암과의감별에도움을준다고하였다. 본연구에서는담낭벽내저밀도성결절소견이동반된경우는 5예로 13.8% 에서보였고이들모두황색육아종성담낭염에서만동반되고있었다. 하지만이러한특징적소견들은황색육아종성담낭염환자들에게서언제나일정하게관찰되는소견이아니기때문에수술전감별진단으로서전적으로의존하기는어렵다. 강력한만성적인염증소견은지속적인담낭벽의비후소견뿐아니라인근조직에의유착을야기하고드물지않게 Mirizzi 증후군을보이기도하며인근장과담낭사이의누공형성과같은합병증을동반하기도한다. Roh 등 (19) 은

376 J Korean Surg Soc. Vol. 76, No. 6 담낭벽의비후를동반한 Mirizzi 증후군의경우황색육아종성담낭염을감별진단으로서한번쯤은고려해볼필요가있다고도하였다. 본연구에서는 Mirizzi 증후군이동반된예는 3예가있었고, 십이지장과담낭사이의누공형성이동반된예는 1예가있었다. 황색육아종성담낭염의강력한염증성향은인근장과담낭사이의누공형성뿐만아니라담낭주변부의심한유착이나천공등의수술전합병증을동반하는빈도가높아서복강경담낭절제술에서개복절제술로의전환율도높았다. Guzman-Valdivia 등 (7) 은 80% 의전환율을보고하였고본연구에서는 18명의복강경담낭절제술시도중 9명의환자에서개복절제술로전환하여 50% 의전환율을보였다. 주위조직과감별이곤란할정도의심한유착성병변을보이는경우무리하게복강경시술을고집할필요도없을뿐만아니라개복절제술중에도담도손상을예방하기위해서수술중담관조영술을시행하거나내시경적경비담도배액관을촉지하여해부학적구분의기준으로삼음으로서수술중발생할수있는의인성담도손상의가능성을줄여줄수있겠다.(19,20) 황색육아종성담낭염은낮은사망률을보이는양성질환임에도불구하고다른일반적원인에의한담낭염으로담낭절제술을시행한환자들에비해서담즙유출, 담즙복막염, 담낭출혈, 간농양, 상처감염등의수술후합병증이많다. 이는심한염증반응으로인해주변장기와조직과의유착으로인해담낭을떼어내기가힘들고수술범위가큰것그리고환자의불량한신체상태등과연관이있는것으로되어있다.(21) 본연구에서는 9명의환자에서합병증이발생하였는데이중 5명에서창상감염이발생하였는데 2명은복강경담낭절제술에서개복절제술로전환하였던예이고, 3명은개복담낭절제술과 T관삽입술을시행하였던예이었다. 수술후섬망상태에서자의적으로 T관을빼서발생한담즙누출이 1예있었던것외에는심각한합병증은동반되지않았었다. 황색육아종성담낭염과담낭암모두담즙이기질로침습하는암성침윤과유사한조직의파괴를보이기때문에육안적으로담낭벽의불규칙한비후소견과주변장기로의심한유착이나종괴를형성하는소견을보이는경우는더욱담낭암과의감별이곤란하다. 이렇게담낭외조직을침범하고있는황색육아종성담낭염과담낭암이육안적으로감별되지않는상황에서광범위절제술을시행해야하는지여부에대해서명확한규정을정하는것은매우어렵다. 이렇기때문에수술중동결절편조직생검이수술의범위를 결정함에있어서매우중요하다. 뿐만아니라황색육아종성담낭염과담낭암은동일검체에서동시에관찰되기도하고암의침습을보이는담낭벽에서국소적으로황색육아종성변화가동반되는경우도있어서주변조직을침범하지않는황색육아종성담낭염에서도수술중동결절편조직생검의필요성이강조되고있다.(22,23) 본연구에서저자들이경험하였던수술전영상의학적검사에서는담낭암이의심되었음에도수술중육안소견에서악성가능성이낮다고판단하여동결절편조직생검을시행하지않았다가최종조직검사에서담낭암으로진단되었던경우와수술전영상의학적검사소견과수술중육안소견만으로진행성담낭암으로확신하여동결절편조직생검없이광범위절제술을시행하였다가최종조직검사결과담낭암이없었던경우를통해서황색육아종성담낭염환자의감별진단과적절한수술범위의결정을위해동결절편조직생검이반드시필요함을절감할수있었다. Chun 등 (20) 도수술전영상소견이나암으로보이는수술소견등으로섣부르게악성, 양성여부를판단하지말고언제라도적극적인동결절편조직생검을시행하여그결과에따라수술방침을결정할것을권장하였다. 또한황색육아종성담낭염에담낭암이동반되는경우암조직이비후된담낭벽전체에있는것이아니고특정부위에암병소를내포할수있기때문에가능한육아종성염증조직을완전하게제거해서동결절편조직생검을시행하는것이적절하며, 뿐만아니라이렇게인근구조물이나장기를침범하여황달이나담도염같은증상을보이거나장관폐색과천공과같은잠재적인치명적합병증을내포하는황색육아종성담낭염의상황이라면증상과치명적합병증을예방하기위해서침범한조직구조물을가능한완전하게절제술을해주는것이바람직하겠다.(24) 결론으로황색육아종성담낭염은드문형태의만성담낭염으로심한염증반응으로인해서주변장기로의침범이나인근조직과의유착을흔히동반한다. 수술전임상증상, 영상의학적검사소견, 그리고수술중육안소견만으로는담낭암과의감별진단이어려운경우가많다. 수술전영상의학적검사에서담낭벽내의저밀도성결절의소견은황색육아종성담낭염의진단에도움을줄수도있지만담낭암의동반가능성과담낭암과의정확한감별을위해서는수술중동결절편조직생검을적극적으로시행하여그결과에맞추어서적절한수술범위를결정하는것이바람직하다고생각한다.

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