CASE REPORT 음압상처치료를이용한개방성복부의치료 연세대학교의과대학외과학교실, 중환자관리및외상외과 심홍진ㆍ장지영ㆍ이재길 Management of Open Abdominal Wound with Negative Pressure Wound Therapy Hongjin Shim, M.D., Ji Yong Jang, M.D., Jae Gil Lee, M.D., Ph.D. Division of Surgical Critical Care and Trauma, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea 책임저자 : 이재길서울시서대문구연세로 50, 129-752, 연세대학교의과대학외과학교실, 중환자관리및외상외과 Tel: 02-2228-2127 Fax: 02-313-8289 E-mail: jakii@yuhs.ac Negative Pressure Wound Therapy (NPWT) is very effective to not only simple wound but also such a complicated wound that can be observed in trauma patients. Herein, we introduce two experiences that the NPWT is used in surgical patient s wound management effectively. One is a postoperative patient with abdominal wall defect and the other is a trauma patient with hip joint amputation and adjacent abdominal defect. (J Surg Crit Care 2012;2:62-66) Key Words: Negative Pressure Wound Therapy, Open abdomen 서론 음압을이용한창상치료 (NPWT: Negative Pressure Wound Therapy) 는과거단순창상치료에이용되었으나최근영역이확대되어손상통제수술 (Damage control surgery) 과같은외상및중환자관리영역에서도많이이용이되고있다. 특이복벽의손상이동반되어폐복이어렵거나다른장기가노출되어있는경우, 음압을이용한창상처치는문헌상보고가드물지만많은장점을가지고있어이에대한경험을소개하고자한다. 증례증례 1 50세여성이난소암으로병기설정수술을시행하다가구불결장이손상되어전방절제술을시행하고대장문합을시행하였다. 수술후 2일째부터고열이있었으며 3일째장문합부누출이확인 되어응급수술 ( 하트만씨수술 ) 을진행하고중환자실로입실하였다. 중환자실입실당시패혈증으로활력지수는노르에피네프린 (0.49 mg/kg/min) 의사용으로혈압 110/60, 맥박 99회 / 분이었다. 응급수술당시폐복은 Retention suture 를이용했는데상태안정화후앉은자세가반복되면서 Retention suture에의한복벽의허혈성괴사가진행되었고수술적처치로괴사된부분을제거하였다. 재수술후환자는배꼽주변으로 25 15 cm 정도의복벽손실부위가생겼으며소장이노출되었다 (Fig. 1). 소장은실리콘을근막에고정하여보호막을만들었으며그위쪽으로음압을걸어서계속적인음압상태를유지하였다 (Fig. 2). 음압치료는음압창상치료 (VAC R, Vacuum-Assisted Closure, KCI, San Antonio, Tx, USA) 제품을사용하였으며일주일에 2회정도주기적인교체를통해복벽의상태와배안쪽의상태를확인하였다. 상처는육아조직이성장하여 38일후에 15 5 cm로줄어들었다 (Fig. 3). 환자는음압기를유지한채이차병원으로전원하여하트만복구및폴리프로필렌인공막 (Parietene R, Covidien, USA) 을이용하여 62 Journal of Surgical Critical Care Vol. 2 No. 2, October 2012
심홍진외 : Management of Open Abdomen Fig. 1. Abdomen picture in two-days after reoperation for necrosis of abdominal wall (Case 1). Fig. 2. (A) Both lateral margins of the abdominal defect were approximated with suture ligation and negative pressure system. (B) Abdomen in 12 days after reoperation. A silicon mesh is protecting the small bowel. There is no adhesion and adjacent granulation in intra-abdomen (Case 1). Fig. 3. Decreased wound size in postoperative 49th day. (A) The silicon sheet was holdedby the suture ligation to adjust to the wound which size was decreased. (B) Abdominal defect was filled with granulation tissue and decreased in size with VAC system (Case 1). 폐복을한후피부이식을받았다. 이후난소암에대한치료를받았다. 증례 2 39세남자가지게차에수상후직장파열, 좌측장골혈관파열, 복합골반골절, 천골골절로수상후타병원경유하여 3일후본원으로내원하였다. 수상당시타병원에서좌측내장골동맥혈관조영술과색전술을시행하였으며외장골동맥은혈관문합 ( 단단문합 ) 을하였고문합부에스텐트를위치시켰다. 골반골절에대해서는외부고정을시행한상태였다 (Fig. 4A). 입원당시혈역학지표는혈압이 125/63 mmhg, 맥박이 126회 / 분으로비교적 안정적이었으나좌측다리의심한부종과피부습진이관찰되었고, 혈액순환이원활해보이지않았다. 또한좌측발등동맥의맥박이희미하게촉지되었다. 좌측다리를보존하려노력하였으나결국입원 19일에좌측다리의허혈성손상과괴사가진행되어입원 20일째에무릎위절단수술을시행하였다. 회복중이던환자는입원 34일에스텐트를삽입하였던좌외장골동맥에서스텐트에의한출혈로보이는대량출혈이발생하여출혈성쇼크가발생하였고응급으로좌장골동맥결찰과함께임시적폐복, 장루형성을하였다. 좌장골동맥의결찰로좌측넙적다리부위의허혈성괴사가진행되었으며 (Fig. 4B) 결국입원 35일째좌측고관절탈구를시행하며주변의괴사된조직을제거하고장골까지노출 www.surgicalcriticalcare.org 63
J Surg Crit Care Vol. 2, No. 2, Oct. 2012 Fig. 4. (A) Initial status of left leg. Peripheral edema and multiple skin bulla were noted. (B) Ischemia of left thigh (Case 2). Fig. 5. (A) Amputation of left thigh and hip joint. (B) Disarticulation of left acetabulum (Case 2). Fig. 6. Follow up picture of hip joint (Case 2) (HD: Hospital day). 이되는개방성상처를남겼다 (Fig. 5). 개방성상처에는계속적인음압을적용하였고복부와고관절부위에각각적용을하여상처들을관리하며주기적인교체와괴사조직의제거를반복하였다. 환자상처의변화양상은 Fig. 6와같다. 육아조직의빠른성장으 로입원 164일째음압장치를제거하고단순상처치료로전환하였으며입원 210일에퇴원하여외래추적관찰을하였다 (Fig. 6). 3개월후성형외과에서피부이식을받았다. 64 www.surgicalcriticalcare.org
심홍진외 : Management of Open Abdomen Table 1. Summary of acute indications for topical negative pressure wound therapy *Open abdomen *Sternal wounds *Soft tissue defects *Trauma, necrotizing fasciitis, hydradenitis, suppurativa and extravasation injury *Skin graft fixation *Burns 고찰 상처를치료할때 NPWT는많은이점이있다. 1,2 삼출액과박테리아를제거시키고혈액순환을원활히하면서새로운조직의혈관신생을가속화한다. 또한주변조직의건조를방지하여조직의손상을막아준다. 2 음압을이용한상처치료는이미국소적급성또는만성상처에서표준치료로서이용이되고있으며최근에는외상, 화상및피부이식분야에걸쳐사용을넓혀가고있다 (Table 1). 3 특히외과영역에서시행하는복부의손상통제수술과접목을하면서일시적폐복 (Temporary closure of abdomen) 을하는방법으로이용이되거나영구적폐복 (permanent closure of abdomen), 손상된조직의재생성및상처감염관리의도구로서사용되고있다. 개방성복부수술에있어서도 NPWT의효용성에대해서는많은연구에서보고되고있다. 4 아직까지무작위조절임상시험에서입증되지는않았지만전향적연구를통해복압의감소, 폐복의성공률, 감염의기회에있어우월성이보고되었고최근에는복부패혈증환자에서도효과가있음을보고하는연구결과들도나오고있다. 5,6 1990년대발달하기시작한손상복구수술과복부구획증후근의개념은외상환자의치료에많은변화를가져오면서좋은성적을낼수있는도구로서자리잡았다. 7 여기에일시적인개복상태를잘유지하도록하는음압기술이부합되면서더욱완성도를높였다고할수있다. 4 하지만국내에서는아직손상복구개복술에대한인식이부족하며상처치료에있어서도음압치료는아직생소하다. 증례 1에서소개되었던환자는 retention suture를사용하여배를닫았다. Retention suture 는절개부위가염증이심하고감염의가능성이있는경우에배액이잘되고복부전층에장력을분산시킴으로써절개부위의파열을막을수있는방법이다. 하지만복압을증가시키거나복벽을국소적으로압박하여허혈성괴사를유발할수있는단점이있다. 8 이환자의수술의는 retention만적용하고다른 suture는시행하지않았는데아마도 그이유는배안의염증이너무심하여수술부위의파열을의식하였던것으로생각된다. 하지만수술후 retention suture 하나하나에걸리는장력의증가로허혈성괴사가유발되었다. 일시적개복을유지하고이차수술을계획하며 NPWT를이용하였다면허혈성괴사는피할수있었을가능성이크다. 염증이심한상처의경우 NPWT는계속적인배액을유지하기때문에박테리아의군체형성기회를줄일수있을뿐만아니라산소의원활한공급을통해혐기성세균의증식을막는역할을하기도한다. 또한혈액순환을좋게하여조직의산소와영양공급을풍부히할수있다. 9,10 돼지를이용한동물실험에서상처에음압을걸어준경우, 상처주변의혈액흐름은대조군보다의미있게증가하였다. 상처에서혈액순환의장애는조직의부종이미세한말초림프계와말초혈관의압박하여발생한다. 음압을걸어주어간질액의배액을능동적으로유도하는것은말초혈관과림프순환의압박을줄여새로운혈액의공급을원활히한다고주장되고있다. 11 다만, 개방성복부에 NPWT를적용할때는음압이직접적으로장에걸리지않도록하는것이중요하다. 장피누공은 NPWT의합병증중에가장많이보고되고있는데이것은음압에의해장이천공이되고복벽은폐쇄가되면서발생하는것으로보인다. 천공된장은주변의유착과육아조직으로수술적처치가매우어렵다. 따라서음압을걸어줄때장을격리시키는여러종류의막을사용하는데필자는대개의경우비닐로이루어진 separation bowel bag을이용하였고증례 1의환자에서는장의유착방지와장력을견딜수있도록실리콘 (Silicon sheeting, Inch-Reinforced, EA-bioplexus) 을사용하였다. 실제로환자가퇴원하기전까지주변복벽층은장과유착이거의되지않고처음의상태를유지하는것이관찰되었다 (Fig. 2). 증례 2에서고관절을포함한절단으로상처는골반뼈까지노출될정도로심하였으나육아조직이자라면서골조직은자취를감추었다 (Fig. 6). 이와같은상처주변부의굴곡이심한경우음압을유지하는것이어려울수있지만장루에서사용되는접착재료를이용을하면굴곡이어느정도보완되어음압을유지할수있다. 음압을적용하기전단순소독처치를시행하였을때는소독때마다심한통증으로치료의어려움이많았다. 하지만 NPWT의적용이후통증은있었으나잦은소독을피할수있어서환자에게만족도는높았다. 실제로 NPWT는기존의방법에비해소독의회수가줄었으며 12 ambulation의향상을가져온다. 13 따라서소아환자나관리가어려운환자에게효과적으로시도해볼수있으며 14 말기암환자의통증조절목적으로사용되기도한다. 15 음압을이용한후육아조직의재생은매우효과적이었다. 육아 www.surgicalcriticalcare.org 65
J Surg Crit Care Vol. 2, No. 2, Oct. 2012 조직화에대한실험연구에서 NPWT의적용은 growth factor를사용한경우보다더욱효과적이다. 음압에의해육아조직이생성되는기전은음압이세포와외부환경을유지해주는 integrin bridge를자극하여구조적인변화를가능하게하고 cytoskeleton 을자극하여세포의증식과세포주변환경의합성을일으키는이차메신저 (prostaglandin, inositol phosphate, protein kinase C, and intracellular calcium) 의분비를촉진하는것이다. 16,17 이차메신저의분비는계속적인음압보다는주기적으로음압을적용하였을때더욱효과적이며이것은육아조직의증가를가속화한다. 11 증례 1과 2의환자모두상처의측면부터육아조직이형성이잘되었고경우에따라서는물리적인힘 ( 봉합, 물리적접합 ) 을이용해상처의크기를줄이고 growth factor spray를사용하여육아조직이잘채워지도록유도하였다. 간혹접합의과정이없이음압을적용한상태가오래되면상처가섬유화가되면서말려들어가는현상이있어봉합하기가어려울수있다. 단순히육아조직만을키워상처를채울것이아니라주변피부조직이벌어진부분을물리적인방법으로접합시켜상처의크기를줄여나가는것도또하나의요령이될수있다. 음압을걸어주면서 retention을같이시행한환자가음압만단독으로사용한환자보다개복기간, 소독회수, 병원입원기간, 폐복의성공률에서우월성을보였다는연구결과가이를뒷받침한다. 18 결론 NPWT를이용한상처치료는국소적인상처뿐만아니라외상환자나복부를수술받은외과환자와같이중증외과환자에있어서효과적인치료도구로서유용하다. 다만출혈이나천공의가능성이있는부위에는사용을신중하게고려해야하며, 반복적인괴사조직제거, 상처접합등의방법들과병행해서사용하는것이더욱효과적일것으로생각된다. 참고문헌 1. Mendez-Eastman S. Negative pressure wound therapy. Plast Surg Nurs 1998;18:27-9, 33-7. 2. Mendez-Eastman S. Guidelines for using negative pressure wound therapy. Adv Skin Wound Care 2001;14:314-22. 3. Bovill E, Banwell PE, Teot L, Eriksson E, Song C, Mahoney J, et al; International Advisory Panel on Topical Negative Pressure. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J 2008;5:511-29. 4. Swan MC, Banwell PE. The open abdomen: aetiology, classification and current management strategies. J Wound Care 2005;14:7-11. 5. Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma 2000;48:201-6. 6. Kaplan M. Managing the open abdomen. Ostomy Wound Manage 2004;50(1A Suppl):C2, 1-8. 7. Miller PR, Thompson JT, Faler BJ, Meredith JW, Chang MC. Late fascial closure in lieu of ventral hernia: the next step in open abdomen management. J Trauma 2002;53:843-9. 8. Cheatham ML, De Waele J, Kirkpatrick A, Sugrue M, Malbrain ML, Ivatury RR, et al. Criteria for a diagnosis of abdominal compartment syndrome. Can J Surg 2009;52:315-6. 9. Kucan JO, Robson MC, Heggers JP, Ko F. Comparison of silver sulfadiazine, povidone-iodine and physiologic saline in the treatment of chronic pressure ulcers. J Am Geriatr Soc 1981;29:232-5. 10. Seiler WO, Stähelin HB, Sonnabend W. Effect of aerobic and anaerobic germs on the healing of decubitus ulcers. Schweiz Med Wochenschr 1979;109:1594-9. 11. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997;38:553-62. 12. Mouës CM, van den Bemd GJ, Meerding WJ, Hovius SE. An economic evaluation of the use of TNP on full-thickness wounds. J Wound Care 2005;14:224-7. 13. Sposato G, Molea G, Di Caprio G, Scioli M, La Rusca I, Ziccardi P. Ambulant vacuum-assisted closure of skin-graft dressing in the lower limbs using a portable mini-vac device. Br J Plast Surg 2001;54:235-7. 14. Caniano DA, Ruth B, Teich S. Wound management with vacuum-assisted closure: experience in 51 pediatric patients. J Pediatr Surg 2005;40:128-32. 15. Ford-Dunn S. Use of vacuum assisted closure therapy in the palliation of a malignant wound. Palliat Med 2006;20:477-8. 16. Ingber D. Integrins as mechanochemical transducers. Curr Opin Cell Biol 1991;3:841-8. 17. Ingber D. Extracellular matrix and cell shape: potential control points for inhibition of angiogenesis. J Cell Biochem 1991;47:236-41. 18. Pliakos I, Papavramidis TS, Mihalopoulos N, Koulouris H, Kesisoglou I, Sapalidis K, et al. Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial. Surgery 2010;148:947-53. 66 www.surgicalcriticalcare.org