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EndoTODAY ³»½Ã°æ ±³½Ç


[º¹°­°æ Ç׿ª·ù¼ö¼ú. Laparoscopic anti-reflux surgery (LARS)]

[Position statement (2018-6-13. ÀÌÁØÇà)]

º¹°­°æ Ç׿ª·ù¼ö¼úÀº À§½Äµµ¿ª·ùÁúȯ Ä¡·áÀÇ Áß¿äÇÑ ¹æ¹ý Áß ÇϳªÀÔ´Ï´Ù. Hiatal hernia µî ÇغÎÇÐÀû ÀÌ»óÀÌ ÀÖ°í, PPI ¹ÝÀÀÀÌ ÁÁÀ¸³ª, Áö¼ÓÀûÀ¸·Î ¾àÀ» º¹¿ëÇØ¾ß ÇÏ´Â ºñ±³Àû ÀþÀº ȯÀÚ¿¡¼­ º¹°­°æ Ç׿ª·ù¼ö¼úÀ» ±ÇÇÒ ¼ö ÀÖ½À´Ï´Ù. ¾ÆÁ÷±îÁö refractory GERD³ª ½Äµµ¿Ü Áõ»ó¿¡ ´ëÇÑ º¹°­°æ Ç׿ª·ù¼ö¼úÀÇ ¿ªÇÒÀº Á¦ÇÑÀûÀÔ´Ï´Ù.


1. History

2010³â Á¦1ȸ KARS conference


2. KARS 2015 (Á¦1ȸ ´ëÇÑÀ§½Äµµ¿ª·ùÁúȯ ¼ö¼ú¿¬±¸È¸ Çмú´ëȸ, ¼­¿ï)

[History of Korean Antireflux Surgery Study Group (KARS)] ¾ÆÁÖ´ë ÇÑ»ó¿í

KARSÀÇ ÀüȸÀå´ÔÀ̽Š¾ÆÁÖÀÇ´ë ÇÑ»ó¿í ¼±»ý´Ô²²¼­ KARS ÀÇ ¿ª»ç¸¦ ¼Ò°³Çϼ̽À´Ï´Ù. ÃÖ±Ù ´ëÇÑÀ§¾ÏÇÐȸ »êÇÏÀÇ ¿¬±¸È¸·Î ½Â°ÝÇÏ¿© óÀ½À¸·Î Çмú´ëȸ¸¦ °³ÃÖÇÑ °Í¿¡ ´ëÇÑ ¼Òȸ¿´½À´Ï´Ù.

¹Ì±¹¿¡¼­´Â 1³â¿¡ 2¸¸ °ÇÀÇ Ç׿ª·ù¼ö¼úÀÌ ½ÃÇàµÇ´Âµ¥ ¹ÝÇÏ¿©, ¿ì¸®³ª¶ó¿¡¼­´Â 2014³â¿¡ ¾à 45°ÇÀÇ Ç׿ª·ù¼ö¼úÀÌ ½ÃÇàµÇ¾ú´Ù°í ÇÕ´Ï´Ù.

À§½Äµµ¿ª·ùÁúȯ °¡À̵å¶óÀÎ(2012) ÀÛ¼º ÀÛ¾÷¿¡ ¸î ºÐÀÇ ¿Ü°ú ¼±»ý´Ô²²¼­ Âü¼®Çϼ̴ٰí ÇÕ´Ï´Ù. 23¹ø ±Ç°í¹®ÀÌ Ç׿ª·ù ¼ö¼ú¿¡ ´ëÇÑ °ÍÀÔ´Ï´Ù.


[ÃÊû¿¬ÀÚ °­ÀÇ - Guilherme M Campos, Virginia Commonwealth University]

¹Ì±¹»ç¶÷µéÀÌ heartburnÀ̶ó°í Çصµ ±× Àǹ̰¡ ´Ù¸£¹Ç·Î ȯÀÚÀÇ ÁøÂ¥ Áõ»óÀÌ ¹«¾ùÀÎÁö Àß µûÁ®ºÁ¾ß ÇÕ´Ï´Ù.

Three essentials of laparoscopic antireflyx surgery
1) Reduction of hiatal hernia with hernia sac - Excision / Division
2) Closure of diaphragmatic hiatus
3) Fundiplication

New technologies - Campos ¹Ú»ç´Â ¾à¹°Ä¡·á¿Í Ç׿ª·ù¼ö¼úÀÇ Áß°£´Ü°è Ä¡·á·Î °£ÁÖÇÏ°í ÀÖ¾ú½À´Ï´Ù.


1) Stretta (low frequency RFA)
2) Transoral incisionless fundoplication (TIF)
3) LINX
4) EndoStim therapy (LES electrical stimulation)
5) MUSE system

Rise and fall of anti-reflux surgery in US

Spechler ³í¹®ÀÌ µÎ¹ø ³ª¿Â´Ù´Â Á¡ÀÌ Èï¹Ì·Î¿ü½À´Ï´Ù. °æÇèÀÌ ¾ø´Â SurgeonÀÌ ¸¹´Ù.


3. GERD academy (2017-2018)

[2017-10-21. GERD academy 1°­]

Á¦°¡ GERD ȯÀÚÀÇ ³»½Ã°æ °ü·Ã °­ÀǸ¦ ÇÏ¿´½À´Ï´Ù.

PPT PDF 9.7M


[2018-2-24. GERD academy 2°­]

[Surgical indication and principles of GERD (°í·ÁÀÇ´ë ±èÁ¾ÇÑ, °¡Å縯ÀÇ´ë ¼Û±³¿µ)

°¡Àå ³ÐÀº indicationÀº SAGES¿¡¼­ Á¦½ÃÇÏ¿´½À´Ï´Ù.

  1. Failed medical therapy
  2. Opt for surgey despite successful medical management
  3. Have complications of GERD
  4. Have extra-esophageal manifestation

±èÁ¾È¯ ¼±»ý´ÔÀº "¿ì¸®³ª¶ó¿¡¼­´Â subtype 1 ȯÀÚ°¡ ¼ö¼ú ÀǷڵǴ °æ¿ì°¡ ÀûÀ¸¹Ç·Î subtype 2³ª ÀϺΠsubtype 3µµ ¼ö¼úÀ» °í·ÁÇØ¾ß ÇÑ´Ù"°í Çϼ̴µ¥ Àú´Â ´Ù¼Ò ¿ì·Á½º·´´Ù°í »ý°¢µÇ¾ú½À´Ï´Ù.

Essential elements of fundoplication

Anatomical failure

Transient dysphagia´Â tight fundoplication ¶§¹®À̶ó±âº¸´Ù´Â ¼ö¼ú ÈÄ edema ¶§¹®ÀÏ ¼ö ÀÖ½À´Ï´Ù. Anatomical failure¿¡¼­´Â revisionÀÌ ÇÊ¿äÇÕ´Ï´Ù.


4. KARS 2018 (Á¦3ȸ Çмú´ëȸ, ´ëÀü)

1) ÀÌÇÑÈ« ¼±»ý´Ô²²¼­´Â KARS¿¡¼­ ¸¸µé°í ÀÖ´Â Korean guidelineÀÇ ÁøÇà»óȲÀ» ¼³¸íÇϼ̽À´Ï´Ù.

Key questionsEvidenceRecommendation
1. À§½Äµµ¿ª·ùÁúȯ¿¡¼­ Ç׿ª·ù¼ö¼úÀº ¾ç¼ºÀÚÆßÇÁ¾ïÁ¦Á¦¿¡ ºñÇÏ¿© À¯È¿ÇÑ°¡?HighStrong for
2. ¾ç¼ºÀÚÆßÇÁ¾ïÁ¦Á¦ ºÒÀÀ¼º À§½Äµµ¿ª·ùÁúȯ¿¡¼­ Ç׿ª·ù¼ö¼úÀº ¾ç¼ºÀÚÆßÇÁ¾ïÁ¦Á¦¿¡ ºñÇÏ¿© À¯È¿ÇÑ°¡?ModerateWeak for
3. À§½Äµµ¿ª·ùÁúȯ¿¡¼­ ºÎºÐÀû±âÀúºÎÁÖ¸§Àº Àü±âÀúºÎÁÖ¸§¿¡ ºñÇÏ¿© À¯È¿ÇÑ°¡?HighStrong for
4. ¿­°øÅ»ÀåÀÌ µ¿¹ÝµÈ À§½Äµµ¿ª·ùÁúȯ¿¡¼­ Å»À庹¿ø ¹× Ç׿ª·ù¼ö¼úÀº À¯È¿ÇÑ°¡?HighStrong for
5. À§½Äµµ¿ª·ùÁúȯÀÇ ½Äµµ¿Ü Áõ»ó¿¡¼­ Ç׿ª·ù¼ö¼úÀº ¾ç¼ºÀÚÆßÇÁ¾ïÁ¦Á¦¿¡ ºñÇÏ¿© À¯È¿ÇÑ°¡?ModerateStrong for

2) Postoperative stasis (Ãæ³²´ëÇб³ ÀÌ»óÀÏ)

¼ÒÈ­ºÒ·®, Á¶±âÆ÷¸¸°¨, º¹ºÎ Æظ¸, À§¸¶ºñÁõÀ¸·Î ³ªÅ¸³¯ ¼ö Àִµ¥, Ç׿ª·ù¼ö¼úÀ» ¹ÞÀº ȯÀÚ ´ëºÎºÐÀÌ ¼ÒÈ­ºÒ·®À» °Þ´Â´Ù. ¼ö¼ú ÈÄ º¹ºÎ Æظ¸, Á¶±âÆ÷¸¸°¨ÀÌ 30% À̻󿡼­ ¹ß»ýÇÏ¸ç ¼Ò¼ö¿¡¼­ À§¸¶ºñÁõ°ú °°Àº ½ÉÇÑ À§±â´ÉÀÌ»óÀÌ ³ªÅ¸³­´Ù. ÀÌ·± Áõ»óÀº fundoplicationÀ¸·Î ÀÎÇÑ À§»óºÎÀÇ °¨°¢°ú ¿îµ¿ ±â´É¿¡ º¯È­°¡ »ý±ä °ÍÀ¸·Î À§¹èÃâÁö¿¬°ú °°Àº À§¸¶ºñÁõÀÌ ÀÖ´Â °æ¿ì ¹ÌÁֽŰæ¼Õ»óÀÌ °ü·ÃÀÌ ±í´Ù. ¼ÒÈ­ºÒ·®¿¡¼­ accomodation reflexÀÇ ÀÌ»óÀÌ ¹®Á¦Àε¥, fundoplicationÀº accomodation¿¡ ÀÌ»óÀ» ÀÏÀ¸Å²´Ù. 360µµ fundoplication¿¡¼­ Áõ»óÀÌ ´õ ½ÉÇÏ¸ç ¿Ïº®ÇÏ°Ô ¼ö¼úÇÒ¼ö·Ï À§ÀúºÎÀÇ ÃÖ´ë ÀÌ¿ÏÀÌ À¯ÀÇÇÏ°Ô °¨¼ÒÇÑ´Ù.

À§¸¶ºñÁõÀº ¼ÒÈ­ºÒ·®°ú ±¸ºÐÀÌ ¾î·Á¿ï ¼ö Àִµ¥, ¼ÒÈ­ºÒ·®ÀÌ ½ÉÇϰųª µÚ´Ê°Ô À§¸¶ºñÁõÀÌ ¿À´Â °ÍÀ¸·Î »ý°¢µÈ´Ù. ÀÓ»óÀûÀ¸·Î Á¶ÀýÇϱ⠾î·Á¿î ±¸¿ª, ±¸Åä°¡ Ư¡À̸ç, À§¹èÃâÁö¿¬°Ë»ç¸¦ ÅëÇØ Áø´ÜÇÒ ¼ö ÀÖ´Ù. ÀÌ°ÍÀº ¹ÌÁֽŰæÀý´Ü ¶Ç´Â ¹ÌÁֽŰæ¼Õ»óÀ¸·Î ÀÎÇÑ °ÍÀ¸·Î Á¶±âÆ÷¸¸°¨(88%), º¹ºÎÆظ¸°¨(64%)ÀÌ ¼ö¼ú ÈÄ 3°³¿ù¿¡ ³ªÅ¸³ª´Â °¡Àå ÈçÇÑ Áõ»óÀ¸·Î, ¼ö¼ú ÈÄ 1³â¿¡ 90% À̻󿡼­ È£ÀüµÈ´Ù. ÃʱâÄ¡·á·Î´Â ¼öºÐ°ú ÀüÇØÁú ÀÌ»ó ±³Á¤, ¿µ¾ç Áö¿ø, üÁß °¨¼Ò ¿¹¹æÀ¸·Î ½ÃÀÛÇÑ´Ù. °æ±¸ ¼·Ãë°¡ ºÒÃæºÐÇÏ¸é °øÀå·ç Ä«Å×Å͸¦ ÀÌ¿ëÇÑ °æÀ念¾çÀ» ÀÌ¿ëÇÑ´Ù. Prokinetics¸¦ »ç¿ëÇÒ ¼ö ÀÖÀ¸³ª Áõ»óÀ» È£Àü½ÃÅ°´Âµ¥ È¿°ú´Â ¹Ì¹ÌÇÏ´Ù. Domperidone, itopride, metoclopramide, levosulpiride, erythromycin µîÀ» »ç¿ëÇÒ ¼ö ÀÖ´Ù. º¸Åø¸®´® Åå½Åµµ »ç¿ëÇÒ ¼ö ÀÖÀ¸³ª post-fundoplicationÀ¸·Î ÀÎÇÑ À§¸¶ºñ¿¡¼­ÀÇ È¿°ú´Â È®½ÇÇÏÁö ¾Ê´Ù. À§-ÆäÀ̽º¸ÞÀÌÄ¿¸¦ »ç¿ëÇÒ ¼ö ÀÖÀ¸¸ç, ¿µ¾ç½ÇÁ¶ Á¤µµ·Î Áõ»ó È£ÀüÀÌ ¾ø´Â °æ¿ì¿¡´Â À§ºÎºÐÀýÁ¦¸¦ Çϱ⵵ ÇÑ´Ù.

3) Dysphagia (¿ø±¤´ëÇб³ °­µ¿¹é)

Postoperative dysphagia is common after antireflux surgery and generally runs a self-limiting course. Nevertheless, part of these patients report long-term dysphagia. Inadequate surgical technique is a well documented cause of this result.

Early dysphagia is defined as during first six weeks after surgery and is a very common postoperative symptom which rarely requires some specific treatment. Persistent dysphagia beyond six weeks has been reported in 3-30% of patients.


[References]

1) EndoTODAY Ç׿ª·ù¼ö¼ú

2) ¾Æ»êº´¿ø ÀÌÀμ·±³¼ö °­ÀÇ µ¿¿µ»ó

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© ÀÏ¿ø³»½Ã°æ±³½Ç ¹Ù¸¥³»½Ã°æ¿¬±¸¼Ò ÀÌÁØÇà. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.