직장 및 항문암의 임상적 고찰 : 부위에 따른 수술식과 추적조사 중심으로

Abstract

[영문]

[한글]

직장 및 항문암의 수술은 이의 해부학적 구조, 특히 임파계의 배설체계에 근거를 두고

그 방법이 달라진다. 직장 및 항문암의 임파계 배설체계는 하부직장암 및 항문암의 경우

상방, 하방 및 측방으로 통하며 중간부 이상의 직장암에서의 하방 및 측방의 전이는 광범

위한 전이가 있어 상방전이가 막히는 경우에 된다. 따라서 직장및 항문암의 수술식에 대

해서는 여러가지 조건이 따라야 되지만 암의 위치만 볼때는 하부직장암 및 항문암에 있어

서는 복회음부절제술이 되어야 하고 상부직장암에 있어서는 복부전방절제술이 우선되고

있으나 중간부직장암에 있어서는 최근 괄약근보존술식인 복부전방절제술 및 pull - throu

gh operation이 많이 선호되는 경향이다.

이에 저자는 1971년 1월부터 1982년 12월까지 만 12년간 연세대학교 의과대학 외과학

교실에서 암 절제수술을 받은 9예의 항문암과 암절제수술후 병리조직학적으로 선암이 확

진된 210예의 직장암에 대하여 시기에 따른 수술식의 변화와 암의 위치에 따른 수술식 및

그 생존율을 조사하여 다음과 같은 결과를 얻었다.

1) 항문암 9예를 따로 볼때 수술식은 모든 예에서 복회음부절제술이 시행되었고 3예에

서 서혜부 임파절절제술이 같이 시행되었다.

수술후 생존은 추적조사가 가능했던 8예에서 4년이상 생존 1예, 2년이상 생존 2예, 1년

이상 생존 5예였다.

2) 직장암을 위치별로 구분해 볼때 하부직장암 99예, 중간부직장암 89예, 상부직장암 2

2예였다.

3) 암의 진행정도를 Manual for staging of cancer에 따른 TNM분류에 따라 볼때 Stage

Ia가 1.9%, Ib가 21.4%, Ⅱ가 30.5%, Ⅲ가 37.6%, Ⅵ가 8.8%였다.

4) 수술식은 복회음부절제술 72%, 복부전방절제술 21.4%, pull-through operation 4.7%

, Hartmann's procedure 1.9%였다. 이를 시기별로 보면 전반기에 복회음부절제술 76.3%,

복부전방절제술 14.5%, pull-through operation 6.6%, Hartmann's procedure 2.6%였고,

후반기에는 복추음부절제술 69.4%, 복부전방절제술 25.4%, pull-through operation 3.7%,

Hartmann's procedure 1.5%였다.

이를 암의 위치별로 볼때 하부직장암의 경우 복회음부절제술 99%, 복부전방절제술 1%였

고, 중간부직장암의 경우 복회음부절제술 56.2%, 복부전방절제술 31.5%, pull-through op

eration 11.2%,Hartmann's procedure 1.1%였으며, 상부직장암의 경우 복회음부절제술 13.

6%, 복부전방절제술 72.8%, Hartmann's procedure 13.6%였다.

5) 중간부직장암에 있어 괄약근보존술식인 복부전방절제술 및 pull-through opration을

시대별로 보면 전반기에 32.3%, 후반기에 49.1%로 증가되는 추세였다.

6) 수술후 5년생존율은 46.4%였다.

이를 시대별로 보면 전반기에 44.2%후반기에 49.6%였다.

이를 암의 위치별로 보면 하부직장암이 44.2%, 중간부직장암이 48.1%, 상부직장암이 52

,9%였다.

7) 진행정도에 따른 5년생존율은 Stage Ia가 100%, Ib가 64.9%, Ⅱ가 55.6%, Ⅲ가 26.3

%, Ⅳ가 5.7%였다.

8) 수술식에 따른 5년생존율은 복회음부절제술 44,7% 복부전방절제술 53.2% pull-throu

gh operation 31.3%, Hartmann's procedure 24.8%였다.

9) 중간부직장암에 있어 진행정도에 따른 5년생존율은 Stage Ib가 62.7%, Ⅱ가 59.4%,

Ⅲ가 25.4%, Ⅳ가 17.6%였다.

중간부직장암에 있어 수술식에 따른 5년 생존율은 복회음부절제술이 49.5%, 복부전방절

제술이 54.9%, pull-through operation이 31.3%, Hartmann's procedure가 0%였다.

이상의 결론으로 직장 및 항문암의 수술식은 하부직장암 및 항문암의 경우 복회음부절

제술이 절대적이고 상부직장암의 경우 복부전방절제술이 우선되고 있으나 중간부직장암의

경우 괄약근보존술식인 복부전방절제술 및 pull-through operation이 최근들어 많이 선

호되고 있었으며 이왕에 수술식간의 수술사망율 및 수술후 생존율의 차이가 없다면, 영구

인공항문형성을 피할 수 있는 괄약근보존술식을 가능한한 많이 시행함으로써 환자가 사회

생활을 하는데 도움을 줄 수 있다고 생각된다.

A Clinical Analysis of Carcinoma of the Anus and Rectum(Trends in the type of

operation and survival rate)

Kuk Hwan kwon, M.D.

Department of Medical Science, The Graduate School Yonsei University

(Directed by prof. Choon kyu Kim, M.D.)

Operations for carcinoma of the anus and rectum are considered on the anatomical

locations, most importantly the lymphatic drainage. The lymphatic drainage of the

rectum below 6-7㎝ from the anal verge may either be cephalad or caudad. Above this

level, the drainage is cephalad, unless blocked by extensive lymphatic metastasis.

Abdominoperineal resection has been the generally accepted procedure for

carcinoma of the anus and lower two thirds of the rectum, and anterior resection

with primary anastomosis are the most often used for carcinoma of the upper rectum.

But recently, the use of sphincter saving procedures, anterior resection and

pull-through operation, for lesions in the middle third, has increased

significantly, theoretically offering as good a chance for long tern survival as

does abdminoperineal resection.

In this regard, the author has reviwed 9 cases of anal cancer and 210 cases of

surgically resected adenocarcinoma of the rectum from Jan. 1971 to Dec. 1982 at

Severance Hospital, Yonsei Medical center. The objectives of this paper are to

study the recent trends toward sphincter saving procedures and the survival rate of

carcinoma of the anus and rectum especially in the middle third of the rectum.

The results are as follows :

1. It all 9 cases of anal cancer, abdominoperineal resection was performed. For 3

cases, inguinal node dissection was performed synchronously. Follow up was possible

in 8 cases, one had live over 4 years, two had live over 2 years, and five had live

over 1 year.

2. Lesions in rectum are divided according to the distance from the anal verge,

with 99 patients having had a lesion located less than 6cm from the anal verge, in

89 patients, the lesion was between 6 and 11.9cm; in the remaining 22 patients, the

lesion was more than 12cm from the anal verge.

3. The distribution according to TNM classification by the Manual for staging of

cancer was as follow: stage Ⅰa 1.9%, stage Ⅰb 21.4%, stage Ⅱ 30.5%, stage Ⅲ

37.6% and stage Ⅳ 8.6%.

4. The type of operation was as follows: abdominoparineal resection 72%, anterior

resection 21.4%, pull-through operation 4.7% and Hartmann's procedure 1.9%. The use

of sphincter saving procedures, anterior resection and pull-through operation, has

increased recently: in '71-'76 21.1%, in '77-'82 29.1%. 5. The types of operation

according to the distance from the anal verge were as follows: in the lower third;

abdominoperineal resection was performed in 99%, in the middle third;

abdominoperineal resection in 56.2%, anterior resection in 31.5%, pull-through

operation in 11.2%, and Hartmann's procedure in 1.1%, in the upper third; the

anterior resection was performed in 72.8%.

In the middle third, the sphincter saving procedures, anterior resection and

pull-through operation, has increased significantly: in '71-'76 32.3% and in

'77-'82 49.1%.

6. The actuarial 5 year survival rate was 46.4%.

The 5 year survival rate according to TNM classification was follows: stage Ⅰa

100%, stage Ⅰb 64.9%, stage Ⅱ 55.6%, stage Ⅲ 26.3%, and stage Ⅳ 5.7%.

The 5 year survival rate according to the distance from the anal verge was as

follows: in the lower third 44.2%, in the middle third 48.1% and in the upper third

52.9%.

The 5 year survival rate according to the type of operation was as follows:

abdominoperineal resection 44.7%, anterior resection 53.2% pull-through operation

31.3% and Hartmann' procedure 24.8%.

7. In the middle third, the 5 year survival rate according to the TNM

classification was as follows: stage Ⅰb 62.7%, stage Ⅱ 59.47%, stage Ⅲ 25.4%,

and stage Ⅳ 17.6%.

The 5 Year survival rate according to the type of operation was as follows:

abdominoperineal resection 49.5%, anterior resection 54,9%, pull-through operation

31.3%. and Hartmann's procedure 0%.

In this regard, the abdominoperineal resection are generally accepted procedure

for carcinoma of the anus and lower rectum, and anterior resection are the most

often used for carcinoma of the upper rectum. But in the middle third, the

sphincter saving procedures, anterior resection and pull-through operation, has

increased significantly. And then if the postoperative mortality and the survival

rate are not different between abdominoperineal resection and sphincter saving

procedures, the sphincter saving procedures are preferable for the quality of the

patient.