해부학적이상환자에서시행한복강경유도경피적내시경위조루술

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1 대한내과학회지 : 제 87 권제 3 호 해부학적이상환자에서시행한복강경유도경피적내시경위조루술 건국대학교의학전문대학원충주병원 1 내과, 2 소아청소년과, 3 외과 박상훈 1 ㆍ이정록 1 ㆍ임종구 1 ㆍ박종훈 1 ㆍ윤형석 1 ㆍ이정화 2 ㆍ유준식 3 Laparoscopy-Assisted Percutaneous Endoscopic Gastrostomy in a Patient with Distorted Anatomy Sang Hoon Park 1, Jeong Rok Lee 1, Jong Gu Lim 1, Jong Hoon Park 1, Hyung Suk Yoon 1, Jung Hwa Lee 2, and Jun Sik Yu 3 Departments of 1 Internal Medicine, 2 Pediatrics, and 3 Surgery, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju, Korea Percutaneous endoscopic gastrostomy (PEG), which was first introduced in 1980, was quickly adopted for use in pediatric and adult patients. However, problems such as severe kyphoscoliosis, interposed organs, or other forms of distorted anatomy, may prevent effective and safe PEG tube placement. In such cases, laparoscopy-assisted PEG (LAPEG) is a useful optional procedure for patients with distorted anatomy and an initial unsuccessful PEG attempt. Furthermore, less invasive measures are preferable over surgical gastrostomy. We present a 27-year-old-male patient with severe kyphoscoliosis and a history of PEG-related complications with a colocutaneous fistula appearing 10 months earlier in whom a feeding tube was successfully placed by LAPEG. There were no LAPEG-related complications in the perioperative period, either technical or metabolic. After discharge, the patient was effectively fed using the bolus method. (Korean J Med 2014;87: ) Keywords: Laparoscopy; Gastrostomy; Endoscopy; Kyphoscoliosis 서론경관영양법은구강을통한섭취가어렵거나불가능할경우선택할수있는가장좋은방법중하나이다. 1980년에경피적내시경위조루술 (percutaneous endoscopic gastrostomy, PEG) 이소개된이후전연령대에서가장널리이용하는경관영 양의통로가되었다 [1]. PEG를통해위조루관 (gastrostomy tube) 을유치하는과정에는위를적절한방향으로위치시키고주위장기를보호하며위벽과복벽을올바르게접근시키는것이중요한요소이다 [2]. 이러한원칙을방해하는조건으로심한척추측후만증등의해부학적이상, 복강내유착및종괴, 간종대, 식도열공탈장, 비만, 복수, 위를덮는장기 Received: Revised: Accepted: Correspondence to Jeong Rok Lee, M.D., Ph.D. Department of Internal Medicine, Konkuk University Chungju Hospital, Konkuk University School of Medicine, 82 Gugwon-daero, Chungju , Korea Tel: , Fax: , flyingbass93@gmail.com Copyright c 2014 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 - Sang Hoon Park, et al. Laparoscopy-assisted PEG - 등이있을경우내시경을통해복벽으로빛이투과되지않기때문에안전한 PEG를시행할수없다 [2,3]. 과거에는개복술을통하여침습적으로위조루관을삽입하는것이거의유일한대안이였으나현재는방사선유도또는복강경수술을이용하여위조루관을삽입할수있다. 특히복강경유도경피적내시경위조루술 (laparoscopy-assisted percutaneous endoscopic gastrostomy, LAPEG) 을통하여위조루관을삽입할경우보다덜침습적으로안전하게삽입할수있다 [2,4]. 저자들은뇌성마비와심한척추측후만증으로해부학적이상이있고과거 PEG 연관합병증발생의과거력이있어서다시 PEG를시행하거나방사선유도위조루관을삽입할경우합병증발생의위험도가높을것으로예상되는환자를대상으로안전하게 LAPEG 를통하여위조루관을삽입한예를보고한다. 증례환자 : 27세남자주소 : 위조루관삽입현병력 : 출생시뇌성마비와심한척추측후만증이있어움직일수가없었고연하장애로인하여 4년전첫 PEG를시행했다. 내원 10개월전위조루관삽입부위에결장피부루 (colocutaneous fistula) 가발생하여위조루관을제거한후내시경치료및보존적인관리로봉합했던과거력이있다. 이후코위관을통하여경관영양식을해서새로운위조루관삽입을위해내원하였다. 가족력 : 특이소견없음. 사회력 : 음주, 흡연하지않음. 진찰소견 : 내원당시혈압은 110/70 mmhg, 맥박 76회 / 분, 체온 36.7 였다. 신체검사에서심한척추측후만증으로거동이불가능한상태이며복부좌상부에과거위조루관이거치되었던상처반흔이관찰되었고복부압통은없었다. 검사실소견 : 말초혈액검사에서백혈구 6,500/mm 3, 혈색소 14.5 g/dl, 혈소판 365,000/mm 3 이었다. 혈청생화학검사에서총단백 6.4 g/dl, 알부민 3.6 g/dl, 총콜레스테롤 165 mg/dl, 혈액요소질소 13 mg/dl, 크레아티닌 0.55 mg/dl이었다. 영상의학소견 : 흉부방사선촬영에서심한척추측후만증이있었고삽입된코위관의말단부는복부가아닌늑골아래흉부쪽에서관찰되었다 (Fig. 1). Figure 1. Chest X-ray findings. Severe kyphoscoliosis with an interposed organ and the internal tip of the nasogastric tube can be seen in the chest cage. 상부위장관내시경소견 : 일반적인 PEG 시술이가능한지확인하기위해서시행한상부위장관내시경검사에서빛이복벽으로투과되지않고흉부에서관찰되었으며손가락을이용하여복벽을압박할때위로압박되는부분이관찰되지않았다. 심한해부학적변이가있어서 PEG를시행할경우합병증의발생위험도가높고과거 PEG 이후결장피부루발생의과거력이있어수술적방법으로위조루관을삽입하기로했다. 개복술을통하여위조루관을삽입하는것이원칙이나환자의심폐용적이정상보다작을것으로예상되었고, 전신마취및수술이후무기폐등의합병증을줄이기위해개복술보다짧은수술시간과덜침습적인방법이필요했다. 복강경을이용하여해부학적위치를확인하면서 PEG를시행하는 LAPEG 에대해환자보호자에게설명하고동의를구했다. LAPEG 시술 : 전신마취를하였고수술전예방적항생제를투약했다. 복부소독이후배꼽아래에 Hasson s technique 을이용하여 5 mm 포트를삽입했고트로카를통하여이산화탄소를주입하여공기배증을만들었다 (Fig. 2A). 복강내압력은 8 mmhg 로유지했다. 위가흉부에가깝게위치하고있어좌상복부에 5 mm 포트를추가적으로삽입하고겸자를

3 - 대한내과학회지 : 제 87 권제 3 호통권제 649 호 A B C D Figure 2. Laparoscopic findings. (A) The white arrow indicates the stomach while the black arrow shows the puncture site on the abdominal wall. (B) The stomach was grasped and then drawn from the chest side to the abdominal side. (C) An introducer needle was passed directly into the stomach under laparoscopic and endoscopic visualization. (D) The PEG tube was pulled through the abdominal wall (i.e., the pull technique). 이용하여위를복부쪽으로당겼다 (Fig. 2B). 겸자로위를고정한상태에서구강을통하여위내시경을삽입하였고좌상복부지점에유도바늘을찔렀다 (Fig. 2C). 복강경과위내시경으로안전한시야확보가된상태에서위하체부전벽에바늘을밀어넣었고 (Fig. 3A), 유도철사를삽입하여올가미로잡아당기는 Pull method 를이용하여위조루관을위치시켰다 (Figs. 3B and 2D). 수술시간은 25분, 마취시간은 47분이었다. 임상경과 : LAPEG 시행 1일후삽입한위조루관을통하여식이를시작하였고삽입부주위의누출과감염등의급성 합병증이없어수술후 3일째퇴원하였고현재합병증없이외래추적관찰중이다. 고찰 1980년에 PEG가처음소개된이래대부분의경우 PEG를통한위조루관삽입은안전하고합병증이적어널리사용되고있다 [1]. 특히전신마취를피할수있고시술시간이짧으며합병증이적고외래에서도시행할수있으며비용이적게소요된다 [5,6]. 그러나안전한위조루관삽입을위해서

4 - 박상훈외 6 인. 복강경유도경피적내시경위조루술 - A B Figure 3. Endoscopic findings. (A) An introducer needle was inserted through the anterior wall side of the lower body. (B) A guide wire was passed into the stomach through the needle and then snared. 는내시경이식도를잘통과해야하고복벽을통해위의빛투과성이있어야한다 [2-4]. 혈액응고장애, 심한복수, 복막염과위장관폐색이있는경우는금기이며심각한척추측후만증과해부학적이상이있는경우에도상대적인금기가될수있다 [4,7]. 따라서해부학적이상이나복강내부장기의위치가정상과다른경우, 예를들면간종대, 비장종대, 심한복부비만또는복강내종양, 위와관련된수술을받은경우, 식도암이나위를통한빛투과가되지않는경우에는복강경, 방사선, 또는초음파유도 PEG를시행한다 [4]. LAPEG는개복술을통한위조루관삽입에비해덜침습적인방법이며해부학적이상소견이있는경우사용할수있는좋은방법이다. 복강내장기를직접관찰하며시술하므로장기손상의위험성이없고위와복벽에삽입되는위조루관의적절한위치를결정할수있게하여누공형성의합병증을피할수있다 [6,7]. 1993년 Raaf 등 [8] 은대장이위대만부앞에위치하여 PEG 삽입이어려운환자를대상으로 LAPEG 를처음시행하여특별한합병증발생이없었다고보고한이래현재까지약 20예이상의보고가있다 [4,6,9,10]. 각각의증례를비교하면 1995년에는각각심한비만과척추측만증때문에 PEG를통해위조루관삽입이실패한 2명의환자를대상으로 LAPEG를시행하였는데모두합병증이발생하지않고안전하게시행되었다 [9]. 15명의소아를대상으 로 LAPEG를시행한후 5년동안추적한연구에서는모두위와복벽을통한빛투과가되지않아서 PEG를대체하는수단으로시술되었는데어떠한합병증도없었다 [10]. 최근뇌성마비와심한척추측만증의해부학적이상이있어 PEG 가불가능했던 12명의소아와성인대상의 LAPEG도모두성공적이었으며평균시술시간은 16.5분, 평균입원기간은 1.5일이었다 [4]. 이러한 LAPEG 관련연구들은모두해부학적변이가심하여일차적으로 PEG 삽입이실패한환자를대상으로시행하여성공적으로시술되었지만 [2,4,6,8-10] 국내에서시행한연구나증례보고는없었다. 본증례의경우 4년전처음 PEG를통해위조루관을삽입하여경관영양법을시행하고있었으나 10개월전위조루관을교체하는과정에서복막염이없는결장피부루가확인되어서금속클립을이용하여내시경봉합을시행한병력이있었고, 다시일반적인 PEG를통한삽관이이뤄질경우유도바늘이복벽을통과하는부위와위를통과하는부위의거리가멀어위와복벽사이에다른장기가끼어들어시술중에주위장기의손상가능성이높고과거와같이결장피부루나출혈등의합병증이발생할위험성이높았다. 이와같이통상적인 PEG를시행할해부학적조건이충족되지않아서수술적위조루술이적응증이나환자의상태를고려하여보다덜침습적인 LAPEG를결정하였다. 시술시간이개복술을

5 - The Korean Journal of Medicine: Vol. 87, No. 3, 통한위조루관삽입보다짧아심폐합병증발생의위험도를줄이고복강내장기를관찰하면서진행할수있어서안전하게시술할수있었다. 그러나 LAPEG는 PEG보다는침습적이며비용및시간이많이들기때문에해부학적이상소견이있거나 PEG 삽입이실패한경우를대상으로선별적으로시행해야한다. 요 경피적내시경위조루술은해부학적이상을동반할경우합병증의발생위험이높으며기술적으로실패할수있다. 저자들은심한척추측후만증으로비정상적인복강내장기의위치를가졌고경피내시경위조루술이후결장피부루발생의과거력이있는환자에서복강경유도경피적내시경위조루술을통하여성공적으로위조루관을삽입한예를보고한다. 약 중심단어 : 복강경 ; 위조루술 ; 내시경 ; 척추측후만증 REFERENCES 1. Gauderer MW. Percutaneous endoscopic gastrostomy and the evolution of contemporary long-term enteral access. Clin Nutr 2002;21: Lopes G, Salcone M, Neff M. Laparoscopic-assisted percutaneous endoscopic gastrostomy tube placement. JSLS 2010;14: Prosser B. Common issues in PEG tubes: what every fellow should know. Gastrointest Endosc 2006;64: Hermanowicz A, Matuszczak E, Komarowska, et al. Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy. World J Gastroenterol 2013;19: Marin OE, Glassman MS, Schoen BT, Caplan DB. Safety and efficacy of percutaneous endoscopic gastrostomy in children. Am J Gastroenterol 1994;89: Takahashi T, Okazaki T, Kato Y, et al. Laparoscopy-assisted percutaneous endoscopic gastrostomy. Asian J Surg 2008; 31: El-Matary W. Percutaneous endoscopic gastrostomy in children. Can J Gastroenterol 2008;22: Raaf JH, Manney M, Okafor E, Gray L, Chari V. Laparoscopic placement of a percutaneous endoscopic gastrostomy (PEG) feeding tube. J Laparoendosc Surg 1993;3: Stringel G, Geller ER, Lowenheim MS. Laparoscopicassisted percutaneous endoscopic gastrostomy. J Pediatr Surg 1995;30: Yu SC, Petty JK, Bensard DD, Partrick DA, Bruny JL, Hendrickson RJ. Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents. JSLS 2005;9: