대한내과학회지 : 제 75 권제 6 호 2008 특집 (Special Review) - 담석증의진단과관리 담낭담석의치료및관리 원광대학교의과대학내과학교실 김태현 Current management of gallstone disease Tae Hyeon Kim, M.D., Ph.D. Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea In asymptomatic gallstone patients, the risk of developing symptoms or complications requiring surgery is small in the range of 1~4% per year. Thus a recommendation for cholecystectomy in a patient with gallstones should probably be based on assessment of three factors: (1) the symptoms that are frequent enough or severe enough to interfere with the patient's general routine; (2) the presence of a prior complication of gallstone disease or (3) the presence of an underlying condition predisposing the patient to increased risk of gallstone complications (e.g., calcified or porcelain gallbladder and/or a previous attack of acute cholecystitis). Laparoscopic cholecystectomy is the procedure of choice for most patients with gallbladder stones. Its advantages include a markedly shortened hospital stay, minimal disability, as well as decreased cost. In carefully selected patients with a functioning gallbladder and with radiolucent stones <5 mm in diameter, complete dissolution can be achieved in ~50% of patients with ursodeoxycholic acid (UDCA). Early cholecystectomy is considered the treatment of choice of acute cholecystitis. In the small minority of patients with severe acute cholecystitis or who are poor candidates for surgery, initial conservative management with antibiotics is recommended with percutanous cholecystostomy. (Korean J Med 75:624-632, 2008) Key Words: Silent gallstones; Laparoscopic cholecystectomy; Cholecystitis; Porcelain gallbladder 서론담석증은동서양을막론하고흔한임상질환의하나이며국내에서도지방섭취가많은식생활의변화와더불어증가추세에있다. 또한최근건강검진에관심이높아지면서복부초음파가검사가필수검사처럼되어증상이없는담석증으로병원을내원하는환자가증가하고있다. 담낭은담석의생성장소일뿐만아니라병인론적으로담석의생성원인이되기도하므로담낭절제술이가장확실한치료수단이다. 20년전복강경담낭절제술이처음시행된이후급속하게전파되고발전되어기존의개복담낭절제술을대치하게되었고, 현재는전신마취가가능한담낭결석환자에서절대적인금기가없다면담낭절제술의표준술식으로시행 되고있다. 최근에는로봇담낭절제술이시도되고있고많은발전가능성을보이고있다. 대부분의담낭담석은증상이없거나경미하여진단되지않거나무증상담석증으로지내게되지만소수에서는중증의담낭염, 담관염, 급성췌장염을유발할수있어문제시되고있다. 담낭담석에의한증상과합병증이발생한경우는명확한수술의적응증이되지만무증상의담낭담석은일반적으로관망을하지만담낭제거술이필요한경우도있다. 또최근에는복강경수술의급속한발전으로담낭절제술의적응증이확대되고있는경향을보이고있어일선진료에서는치료대상과방법에많은고민을가지게되었다. 수술이불가능한경우나수술을거부하는경우등에서시도해볼수있는비수술적치료방법으로는경구담즙산용해요 - 624 -
- Tae Hyeon Kim. Current management of gallstone disease - Table 1. Natural histroy of asymptomatic gallstones Author Patients (n) Years Biliary pain (%) Biliary complication (%) Gracie et al. 2 Attili et al. 3 McSherry et al. 4 Cucchiaro et al. 5 Zubler et al. 6 123 118 135 125 32 15 10 4 5 5 18 26 10 12 25 2 3 0 2 3 법, 체외충격파쇄석술, 직접접촉용해요법, 경피경간담낭배액관을통한담석의제거등여러가지방법이있다. 이글에서는담석증에관한중요한최근문헌을바탕으로무증상담낭담석의적절한치료와관리대책, 급성담낭염의치료, 그리고다양한담낭담석치료법의장단점과효용성에대하여소개하고자한다. 무증상담낭담석의치료 1. 무증상담낭담석의자연경과와관망치료서구에서는 10~20% 인구가담석을가지고있고연령이증가하면서같이증가하여 60대에는 30%, 80대에는 60% 까지증가한다 1). 무증상의담낭담석의치료방법을결정하기위해서는자연경과에대한연구가반드시필요하지만장기간환자를관찰해야되고환자의증상이나통증이주관적이고담낭절제술의선택에편견이들어갈수있어자연경과연구에어려움이있다. 1982년무증상담낭담석에대한 24년간의장기추적연구에서 2) 18% 의낮은증상이나합병증의발생률을보고하면서이후에몇개의비슷한연구들이발표되었다 ( 표 1) 2-6). 이들의결과를종합하면무증상담석증의증상발현율은매년 1~4% 이고, 첫증상으로심각한합병증이발생할수있는빈도는 0.1% 로매우드물다 1). 무증상담낭담석의발현율은 5년에 10%, 10년에 15%, 그리고 15년에 18% 정도이고 2), 15 년동안무증상인환자들은그이후추적관찰에서증상의발현은드물다 7). 복강경담낭절제술이시행되기전이었지만그이후무증상담석에대한예방적담낭절제술보다는관망치료를선호하게되었다. 대부분의다른보고들도무증상담석증의증상발현빈도는 10~25% 였다 2-6). 담낭절제술이필요한담석증의합병증은전형적인담도통의기왕력있는담낭담석에서잘발생하고, 담낭담석을처음으로진단된연령이 60세이상인환자보다는젊은연령에서증상이발생할가능성높다 1). 이밖에도지금까지알려 진위험인자는다발성담석, 담석의크기가다양하면서작은경우, 여성, 담낭담석의가족력, 담낭이조영되지않아담낭기능이없는경우, 담석의크기가 2~3 cm 이상인경우등이거론되고있지만연구자들마다결과가서로일치하지않아아직정확하게위험인자를예측할수없다 8). 담낭절제술은신체의일부를절제하는침습적인수술이고장기의절제나전신마취에따른예기치않은합병증발생할수있다. 관망치료의단점은누구도담낭담석을가진환자가췌장염, 담낭암, 담낭천공을동반한담낭염등의심각한합병증이초래되지않는다고보장할수없고, 이심각한합병증발생으로응급수술을받게되거나개복수술과더불어수술로인한여러가지합병증이초래될수있다는점이다. 그러나이러한경우는매우드물고무증상환자가바로심각한합병증으로진행되기보다는쓸개급통증 (biliary colic) 같은전구증상이경고적으로나타나는경우가대부분이다 9). 결론적으로무증상담석증은대부분일생동안증상발현율이낮고심각한합병증의발생빈도가낮기때문에몇가지예외경우를제외하고는예방적담낭절제술을할필요가없다. NIH consensus conference 보고에서도복강경담낭절제술의유용성이담낭절제에대한적응증을확대할필요가없다고하였다 10). 2. 무증상담석증에서예방적담낭절제술담낭절제술의표준으로정립된복강경수술은대절개없이복부에내시경이삽입될 3개또는 4개의구멍을만들고, 이를통해담낭을제거한후 1~2 일내에퇴원할수있다. 개복술과비교하여통증및흉터가적고, 회복이빨라퇴원후 1주내봉합사의제거가가능하고일상으로의복귀도수술 1~2 주후에가능하다. 최근들어급속하게발전한여러복강경기구와경험이축적되면서고령환자나응급수술을제외한정규수술의경우수술과관련된합병증발생률은 2~4%, 사망률은 0.1% 미만으로보고되는안전한치료법이 - 625 -
- 대한내과학회지 : 제 75 권제 6 호통권제 580 호 2008 - Table 2. Selective cholecystectomy for asymptomatic gallstones Clear indications Suspicion/risk of malignancy Gallstones associated with gallbladder polyps >1 cm in diameter Calcified (porcelain) gallbladder Some ethnic groups or subjects living in areas with high prevalence of gallbladder cancer associated with gallstones (American Indians, Mexican Americans; Colombia, Chile, Bolivia, Maori population of New Zealand) Presence of large (>3 cm) gallstones Asymptomatic gallstones associated with CBD stones Transplant patients (before or during transplantation) Chronic hemolytic conditions (sickle cell anemia) Relative indications Increased risk of conversion from aymptomatic to symptomatic disease Life expectancy > 20 years Calculi >2 cm in diameter Calculi <3 mm and patent cystic duct Nonfunctioning gallbladder Diabetes mellitus Vague dyspeptic symptoms in the presence of gallstones Questionable indications Patient living in an area remote from medical facilities Incidental (concomitant) cholecystectomy during another abdominal operation 다 11). 몇개의무작위전향적연구에서도개복담낭절제술과합병증을비교하였을때상처감염이월등히적게발생하여전반적으로는합병증이비슷하거나오히려적으며, 복강경수술이가지고있는장점인빠른회복과조기사회복귀, 미용적효과에의한환자만족도가높음을보고하였다 12). 복강경담낭절제술의가장심각한합병증인담도손상은초창기에 0.5~0.6% 였지만수술기법의발달로 0.1~0.3% 로감소하였다. 이러한장점들때문에무증상담석증에서담낭절제술이현실적으로많이시행되고있다. 복강경수술의기법과경험이증대되어합병증이감소하고있지만수술과연관된심각한합병증들이여전히발생할수있고, 환자의나이와순환기질환유무에따라수술후사망률이달라질수있다. 따라서무증상담낭담석환자에서일률적으로예방적담낭절제술을시행하는것은비용- 효과적인측면에서합리적이지못하다. 그러나임상적으로담낭암의위험발생률이높거나담석으로인한합병증발생이높을것으로예견되는몇가지경우에는예방적담낭절제술이인정받고있지만아직논란이되고있는질환도있어이들질환에대하여논의하고자한다 ( 표 2). 1) 담낭암 (Gallbladder carcinoma) 인종에따른담낭암의발생위험에도큰차이가나는데백인종은담낭암의위험성이드물지만북미나남미의토착인디언, 뉴질랜드의마오리족에서는담낭담석의조기발생으로담낭암의발생위험이높다 13). 크기가큰 ( 약 3 cm 이상 ) 담석은오랜기간담낭점막의염증을유발하여만성염증-암의연계를추측해볼수있고, 실제적으로담낭암을가진환자의 80% 에서 3 cm 이상의담석이발견되었다는보고도있다 14). 석회화담낭 (porcelain gallbladder) 에서는 13~25% 의담낭암동반이관찰되고 1 cm 이상의담낭용종이동반된담석에서는담낭암의발생률이증가한다. 또한담도확장이없는췌담관합류이상도중요한담낭암의위험인자로알려져있다 15). 따라서이들질환들에서는담낭암의예방을위하여예방적담낭절제술이인정되고있다. 2) 애매한소화불량증후군 (Vague dyspeptic syndromes) 실제임상에서담낭담석은있지만쓸개급통증없이상복부동통이나불편감, 트름과같은소화불량증상만호소 - 626 -
- 김태현. 담낭담석의치료및관리 - 하는경우를자주볼수있다. 이러한증상들은대부분기능성위장증상이나과민성대장증후군같은질환과더관련이많을것으로추정되지만담낭절제술후에 70% 환자에서증상의개선이있었다는보고도있어담낭담석에의해서이러한증상이유발될수있음을시사한다 16). 또한담석증때문에애매한소화기증상이발생할수있어복강경담낭절제술이고려될수도있다. 그러나이러한불편감은개인편차가많고어느정도의불편감이담석증과연관이되는지객관적인평가가어렵다. 또한이러한증상들이담낭절제술후에소실될지사전에알수없으므로일률적으로담낭절제술을권고할수없다. 3) 당뇨 (Diabetes Mellitus) 과거에는당뇨환자에서담낭담석이동반되면감염에더취약하고비당뇨환자에비해서괴저담낭염, 담낭의천공과같은합병증이호발할것이라는믿음을바탕으로예방적담낭절제술이시행되었다 17). 초기보고들에서는급성담낭염의합병증, 수술후합병증과사망률이당뇨환자에서높았다고하였다 18). 이는자율신경의손상으로담낭염으로인한증상이나타나지않아진단과치료가지연되었기때문으로생각하였다 19). 또한당뇨병환자에서비당뇨환자보다합병증이더높게발생한것은주로감염과연관되고동반된심장및신장질환이합병증을더욱악화시킨다 18). 최근당뇨환자에서무증상담낭담석의자연경과에관한연구에서과거에비해서더합병증발생률이감소하였고, 담도수술후합병증발생률과사망률은비당뇨환자에비해서큰차이가없었다 20). 무증상담낭담석을가진 NIDDM 환자들에서증상발생과합병증의누적률은각각 14.9% 와 4.2% 로낮았다 20). 담도계수술의합병증과사망률에대한당뇨환자와비당뇨환자사이의비교연구에는심장및신장질환의합병증을고려하여비교할필요가있다. 아직까지는당뇨환자에서예방적담낭절제술의필요성에대해서는논란이많지만복강경시술의안전성증가, 당뇨병합병증관리의향상, 담석증합병증후에도치료기술의발전이위험성감소에기여할것으로생각된다. 결국당뇨환자에서예방적담낭절제술이큰이득이없으므로비당뇨환자처럼관망을하다가증상이발생하면조기에담낭절제술이시행되어야한다 21). 4) 만성용혈증후군 (Chronic hemolytic syndrome) 만성용혈질환에서는일반인에비해담석증이나담석으 로인한합병증발생의위험성이높아진다. 특히 sickle cell disease 같은질환은젊은연령에서담석이발생되고담석이발생되면다른일반인보다증상이나합병증이생길가능성이높기때문에무증상이라도예방적담낭절제술의필요하다 22). 5) 장기이식 (Transplantation) 장기이식을받은환자는만성적으로면역억제치료를받고있기때문에담낭담석으로인한합병증이생겨도증상이뚜렷하지않아진단이어렵고, 이는사망률과수술합병증의증가로이어질수있어무증상담석증의예방적담낭절제술이인정되고있다. 대부분이식수술후 2년내무증상담석이유증상으로전환되므로담낭절제술은이식수술전이나가능하면이식수술중에시행할것을권고하고있다 23). 그러나신장이식환자들에서는무증상담낭담석을관망하다가증상이발생하여복강경담낭절제술을시행하여도일반인과비슷한낮은합병증발생률을보였다 24). 향후더욱복강경시술이나로봇수술이발전하게되면이식환자에서무증상담석증에대한대책이변화될수있다. 6) 기타질환유두근괄약근절개술을통한담관담석제거후무증상담낭담석은총담관담석재발의원인이될수있어예방적담낭절제가필요하다 25). 특히담낭염이없는담낭담석을가진젊은환자의경우에총담관담석제거후복강경담낭절제술을연기하는것은개복술로의전환과수술합병증의증가와연관될수있으므로예방적담낭절제술이필요하다 26). 무증상담석증이라도낙후된의료지역이나산간오지에살고있는담석증환자에대해서는합병증이발생되어도의료의접근성이어려울수있어예방적담낭절제술이필요할수있다. 결론적으로무증상담낭결석은대부분경과관찰을하지만, 담낭암의발생위험이증가한다고알려진 3 cm 이상의큰결석, 췌담관합류이상을동반한경우, 1 cm 이상의담낭용종과동반된경우, 석회화담낭, 이식환자, 만성용혈성증후군, 총담관담석을동반한경우등에서는예방적담낭절제술을시행하는것이보편적으로인정되고있다 ( 표 2). 담석의내과적치료현재담석의치료에시도해볼수있는비수술적방법으 - 627 -
- The Korean Journal of Medicine: Vol. 75, No. 6, 2008 - 로담석을용해시키는방법에는경구담석용해제와담낭안에직접약물을주입하여담석을용해시키는방법이있고, 담석을분쇄하는방법에는체외충격파쇄석술과경피경간담낭배액술의누공을통하여담도경을삽입한후담낭담석을제거하는방법이있다. 그러나이방법들중아직효과적이고안전한치료방법은없고, 최근 20년간복강경담낭절제술이보편화되면서내과적치료의비중이감소하고있는추세이다. 1. 경구담즙산용해요법 1972년 chenodeoxycholic acid (CDCA) 가방사선투과성담석의용해에이용되기시작하였으며, 이후일본에서개발된 ursodeoxycholic acid (UDCA) 가담석치료에이용되기시작하였다. 현재가장많이사용되고있는경구제제는 UDCA 단독요법이고, UDCA와 CDCA 병합요법도사용되고있다. 국내는주로순수한콜레스테롤담석보다는색소성담석의비중이높아환자의선택이용이하지않다. 활성을증가시켜나타난다. transaminase의증가는일시적이며계속사용한경우에도정상적으로돌아오며간생검에서간조직의변화가경미하므로큰문제가되지않는다. 하지만이러한부작용으로인해 CDCA 단독치료는이용되지않고 CDCA와 UDCA의병합요법이이용된다. UDCA는친수성담즙산으로간혹은장내세균에의해형성되는 3차담즙산이며웅담의구성성분중하나로 8~10 mg/kg/day 용량이담석용해시적절하다. CDCA와달리 lithocholic acid의생성이증가되지않아간독성이적으며혈중콜레스테롤의상승효과가없고, 설사는 1% 이하에서발생한다 30). 3) 적응증경구담즙산용해요법은치료기간이길고성공률이낮으며재발률이높기때문에대상자선정에주의를요한다. 즉환자의증상, 담석의종류, 담석의크기와개수, 담낭의기능과담낭관의개방여부등을고려하여선정하여야한다 ( 표 3). 1) 담즙산의담석용해기전경구담즙산용해요법의이론적근거는콜레스테롤담석의형성과정에가장중요한요소인담즙내콜레스테롤의과포화를억제시키는데있다. CDCA의작용기전은간에서콜레스테롤합성에필요한 HMG CoA 환원효소의활성을저하시켜담즙으로의콜레스테롤분비를감소시키고, UDCA 는장내콜레스테롤의흡수를감소시킴으로써담즙내콜레스테롤의분비를감소시킨다 27). CDCA는정상적으로인체에존재하는 1차담즙산으로써정상담즙산저장고의 2~30% 를차지한다. CDCA를경구투여할경우용량의존적으로인체내담즙산은총저장고의약 80% 까지 CDCA로대치되며간에서의콜레스테롤합성이감소된다 28). CDCA 경우에콜레스테롤이불포화된담즙산이담낭내로들어가면담석내의콜레스테롤이미포내로용해되어나오게되고그결과담석의용해가일어나게된다. UDCA는주로액상결정체상태 (liquid crystalline phase) 의형성에의해콜레스테롤용해가일어나고담낭내항핵화인자를감소시키는효과도있다 27). 2) 경구담즙산제제 CDCA의제한점은부작용으로일일 750 mg을투여할경우약 20% 에서설사가발생하고, 15% 에서는혈중 transaminase와 low density lipoprotein이상승하게된다 29). 설사의원인은대장내 deoxycholic acid가장점막내의 adenyl cyclase 4) 치료및재발용해요법의좋은대상은크기가 5 mm 이하의방사선투과성담석으로경구담낭조영술에서담낭내에떠있는담석이다. 이와같은담석은용해율이 70~90% 에달하지만직경 5~10 mm의담석은 50% 로감소하며, 담석의직경이 10 mm 이상이면담석용해율은 35% 에불과하다. 약제는담석이완전하게용해될때까지투여를지속하고약물투여 6 개월후에도담석이용해되지않으면치료를중단한다. 경구담즙산용해요법은담석의형성과정을일시적으로차단하기때문에치료중단후담석이재발할가능성은매우높다. 일반적으로담석의용해후처음 5년간의담석재발률은 1년에 10% 로 5년후전체재발률은약 50% 에이르며 31), 11년간추적연구에서재발률이 50~70% 에이른다고보고하였다 32). 대부분담석의재발은 2년내에발생하고, 치료전단발성담석보다는다발성담석에서재발이많다 32). 따라서담석의용해요법후수년간은담석의재발에대한추적검사가필요하다. 담석의증상이있었던환자에서 UDCA는쓸개급통증의재발예방효과는무작위이중맹검연구에서미약하였으며급성담낭염의발생위험을낮추지는못했다 33). 그러나비만환자의급속한감량이나완전비경구영양법과같은담석이호발하는고위험군에서담석형성예방목적으로투여해볼수있다. - 628 -
- Tae Hyeon Kim. Current management of gallstone disease - Table 3. Criteria for oral bile acid dissolution therapy Diameter of gallstone <5 mm (optimal) 6~10 mm (acceptable) Calcium content of gallstone Radiolucency on plain X-ray CT density <100 HU (Usually not recommend) Normal gallbladder function Oral cholecystogram Ultrasonogram after fatty meal Cholescintigram 른것으로되어있다 37). MTBE 용액을분당 4~6 회주입한뒤다시제거해야하며, 전체약 12시간의치료가필요하므로주입과흡입을자동으로할수있는기계가필요하다. 직접접촉용해요법은콜레스테롤담석의경우담석용해시간이매우짧고담석의용해율도높으나시술이어렵고기계가필요하며담즙유출, 십이지장염, 용혈등의합병증이발생할수있어사용에제한점이있다. 경피경간담낭배액술의누공을만든후누공을확장하여직접담도경을직접담낭에삽입하고담석을전기수압쇄석술등으로분해하여담석을제거하는방법이있으나제한점이많다 38). 담석의용해에관한국내연구는별로없으나대부분의연구에서담석의완전용해율은약 20% 로외국의보고에비해현저히떨어지는데 34) 이는국내의경우콜레스테롤담석보다는색소성담석의비중이높으며방사선비투과성담석의상당부분이색소성담석이기때문인것으로설명된다. 따라서국내의경우경구담즙산용해요법의선정에있어서는보다신중한접근이필요할것으로생각된다. 2. 체외충격파쇄석술체외충격파쇄석술은담도계담석에서 1986년 Sauerbruch 등 35) 이처음으로담낭및총수담관담석환자에서사용을보고하였다. 담석을잘게분쇄시켜담낭관을통해빠져나가게하는치료법으로담석의크기가크고칼슘성분이많은경우시도해볼수있다. 그러나체외충격파쇄석술만으로는담석의완전한분쇄가어려우며대부분의경우담석조각이담낭내에남아있기때문에경구담즙산치료의병용요법이필요하다. 적응대상이되는환자는콜레스테롤담석이적절하며, 분쇄된담석을십이지장으로배출시켜야하므로담낭관이개존되어있고담낭의수축력이좋아야한다. 합병증으로는 30~60% 의환자에서경미한통증이발생하며피부의점상출혈, 혈뇨, 췌장염등이발생할수있다. 합병증은일시적이고경미한것이대부분이나시술수시간후급성심근경색증이나수주후에담관염에의한패혈증으로사망한예가보고되고있어주의를요한다 36). 3. 기타비수술적치료법직접접촉용해요법은경피담낭배액관이나역행성담도조영술을이용하여담낭관을통해담낭내로 MTBE (Methy Tert Butyl Ether), monooctanoin 등을주입하여담석을용해시키다. 특히 MTBE 가콜레스테롤을용해시키는능력이빠 급성담낭염의치료 1. 급성담낭염의내과적치료담낭절제술을고려하면서금식, 충분한수액과전해질을보충한다. 담석으로인한복통은마약성진통제나비스테로이드성진통제로조절하고, 가능하면담즙의세균배양결과를토대로항균제를선택한다. 금식에관해선의학적인증거는없지만초기의치료는식사를중단하는것이원칙이다. 쓸개급통증에대한 NSAID 의투여는급성담낭염으로의진행을막고진통효과가있다 39). 미국감염학회 (Infectious Disease of Society of America) 의지침에서는체온이 38.5 이상이거나혈액의백혈구가 12,500/mm 3 이상이고방사선검사에서담낭염을시사하는소견이있으면항생제를투여할것을권고하고있다. 또한항생제는 Enterobacteriaceae 계 (cephalosporin 또는 quinolone과 metronidazole의병합요법 ) 를대처할수있어야한다 40). 고령이나당뇨또는면역저하환자에서는감염이의심되지않더라도예방적항생제를투여한다. 2. Tokyo 지침일본의사들이급성담낭염의중증도에따른치료지침을다음과같이제시하였다 ( 표 4) 41). 경증 (mild) 담낭염에서는조기복강경담낭절제술을시행한다. 중등도 (moderate) 담낭염에서는조기또는지연복강경담낭절제술을시행할수있고, 수술시야가나쁘면바로개방성담낭절제술로전환을해야한다. 중증담낭염에서는항균제투여와더불어경피적담낭배액술을시행하고환자의폐혈증상태가호전되면수술을고려한다. 3. 담낭절제술급성담낭염은담낭담석의가장흔한합병증으로담석 - 629 -
- 대한내과학회지 : 제 75 권제 6 호통권제 580 호 2008 - Table 4. Severity assessment criteria for acute cholecystitis Grade 1 - Mild Cholecystitis No organ dysfunction Does not meet criteria for a more severe grade Grade 2 - Moderate Cholecystitis The presence of any of the following: WBC greater than 18,000 Palpable, tender RUQ mass Duration greater than 72hrs Marked local inflammation including pericholecystic abscess, hepatic abscess, gangrenous or emphysematous cholecystitis, or biliary peritonitis Grade 3 - Severe Cholecystitis; The presence of any of the following: organ system dysfunction hypotension requiring pressors mental status changes respiratory insufficiency with PaO2/FiO2 less than 300 oliguria, Cr greater than 2.0 INR greater than 1.5 platelet count less than 100k 의감돈에의한담낭의염증이원인이므로이를제거하기위하여결국외과적담낭절제술이필요하다. 특히심각한국소적합병증, 즉담즙성복막염, 담낭주위농양, 기종성담낭염, 괴저성담낭염등에서는전신상태를잘관찰하면서응급수술을시행한다. 담낭절제술은담낭염이발생하였을때시행하는조기수술과담낭염 2~3 개월후시행하는지연수술로구분할수있다 39). 조기복강경담낭절제술은지연수술에비해서개복수술로전환, 입원기간, 수술시간을줄일수있어서선호되고있다 42). 또한급성담낭염이호전된후지연수술를기다리는환자들중 15~20% 는수술전에치료를필요로할정도의증상의재발이나지속이발생할수있다 43). 담낭절제술합병증으로담즙유출과담도손상은지연수술에비해서조기수술때빈도가더많다는보고들도있지만다른소규모연구에서는그렇지않다는보고도있어아직논란이되고있다 44). 급성담낭염에서복강경수술에서개복전환율이약 5~ 30% 로보고되고있고, 급성담낭염환자에서무증상담낭담석환자보다개복전환률이더높다 45). 개복으로전환될수있는예측인자들은 60세이상연령, 18,000/mm 3 이상의백혈구, 72~96시간이상의증상기간이었다 39). 최근까지이질환의무작위연구들에서수술후사망률에대한보고가 없었는데, 최근한보고에서 Acute Physiology and Chronic Health Evaluation [APACHE] 점수가 12 점이상의고위험군사망률은 15% 이상으로나타났다 46). 수술의고위험환자, 심한중증의담낭염, 폐혈증을동반할경우에는응급수술을바로시행하기보다는경피적담낭배액술이좋은방책이될수있다 39). 결 담낭담석의유병률은사회가고령화되고비만화되면서진단기술의발전도움으로증가하는추세이다. 무증상의담낭담석의증상발생률은매년 1~4% 정도로낮다. 따라서대부분담낭담석환자를차지하는무증상환자들은대부분관망을하고, 담낭절제술의결정은세가지요소들즉, (1) 일상생활에지장을초래할정도의환자의증상 ; (2) 과거력에서담낭담석의합병증유무 ; (3) 담낭담석의합병증을유발할수있는기전질환유무 ( 석회화담낭, 급성담낭염의과거력 ) 를고려하여결정한다. 담석의담낭관폐쇄나 2차적인염증에의한급성담낭염이있으면항균제치료와복강경담낭절제술을시행하고, 중증의담낭염은일시적인경피적담낭배액술을시행한후담낭절제술을고려한다. 복강경담낭절제술은개복담낭절제술에비해입원기간단축, 우수한미용효과, 빠른회복등많은장점을갖고있어환자나의사모두에게만족스러운치료법이다. UDCA 는담즙내콜레스테롤농도를저하시키고담석을용해할수있어주로 5 mm 미만의콜레스테롤담석에효과적이고약물을중단하면재발이많은단점을가지고있다. 그러나담석발생의고위험군에서예방목적으로사용해볼수있다. 최근복강경담낭절제술이매우빠른속도로발전하면서비수술적인담석의치료에대한연구는활발하지않지만최근담석발생과지방대사기전에대한기초연구가새롭게규명되면서근본적인담석의발생을예방할수있는결과를기대해본다. 중심단어 : 복강경담낭제거술 ; 무증상담낭담석 ; 급성담낭염 ; 석회화담낭 론 REFERENCES 1) Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci 52:1313-1325, 2007 2) Gracie WA, Ransohoff DF. The natural history of silent - 630 -
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