2016-PE-내과-13번

38세 남성이 크론병을 진단받고 치료를 받았다. 환자는 지난 수 일간 지속된 복통, 고열을 호소하여 대장내시경과 복부 CT 검사를 받았으며, 그 결과 회장에 4cm 길이의 협착 및 폐색이 동반된 병변이 관찰되었다, 그 이외에도 크론병으로 보이는 병변은 관찰되었으나 폐색이 없었다. 이에 대한 적절한 수술 방법은?

 38세 남성이 크론병을 진단받고 치료를 받았다. 환자는 지난 수 일간 지속된 복통, 고열을 호소하여 대장내시경과 복부 CT 검사를 받았으며, 그 결과 회장에 4cm 길이의 협착 및 폐색이 동반된 병변이 관찰되었다, 그 이외에도 크론병으로 보이는 병변은 관찰되었으나 폐색이 없었다. 이에 대한 적절한 수술 방법은?  1. 회장루 2. 회장결정루 3. 회장절제술+일차문합술 4. 온대장 절제술 5. 회장낭항문문합술 - 해설:  회장에 4cm 길이의 협착 및 폐색이 동반된 병변이 관찰되었다. 이는  협착 부위만을 절제하고 문합해주면 된다.   However, a randomized controlled trial comparing  side-to-side anastomosis versus end-to-end anastomosis determined that there was no diﬀerence  in overall complication rates, anastomotic leak rates, or rates of symptomatic recurrence, with only a slight increase in endoscopic recurrence seen in the end-to-end anastomosis group (43% vs. 38%). Additionally,  a new antimesenteric functional end-to-end hand-sewn anastomosis (known as Kono-S anastomosis)  was created to minimize anastomotic restenosis in Crohn disease. This technique was demonstrated to have a signifcantly lower rate of stenosis and recurrence compared to conventional end to end anastomosis. Although further randomized control trials are needed, these fndings demonstrate a promising novel surgical approach that may decrease the need for additional biologic therapy.    The treatment of choice for intestinal obstruction in patients with Crohn disease is segmental resection of the involved segment with primary reanastomosis.   This may involve  segmental resection and primary anastomosis  of a short segment of ileum or an ileocecectomy if both the ileum and cecum are involved  (Fig. 50.23).   &nbsp;  &nbsp;      In selected patients with obstruction caused by strictures (single or multiple), one option is to perform a strictureplasty that eﬀectively widens the lumen but avoids intestinal resection. Strictureplasty is performed by making a longitudinal incision through the narrowed area of the intestine, followed by closure in a transverse fashion in a manner similar to that for a Heineke-Mikulicz pyloroplasty  (Fig. 50.24A) . For longer diseased segments (&gt;10 cm), the strictureplasty can be performed similar to a Finney pyloroplasty  (Fig. 50.24B)  or a side-to-side isoperistaltic strictureplasty.24 Strictureplasty is best used in those patients with multiple short areas of narrowing present over long segments of intestine, in those who have already had several previous resections of the small intestine, and in those with chronic fbrous obstruction. Tis procedure preserves intestine and is associated with complication and recurrence rates comparable to those of resection and reanastomosis. Given the concerns for development of carcinoma at chronically strictured segments, full-thickness biopsy with frozen section of the stricture site has been advocated at the time of surgery to rule out malignant disease before strictureplasty is performed, (Box 50.5)   (Sabiston 21th, p1268)     

해당 문제는 선지에 일차 문합술이라고 되어 있습니다. 크론병 특성상 segmental 하고, 현재 염증으로 인해 협착된 부위를 잘라내는 것이 치료입니다. 해설을 보시면 아시겠지만, 교과서에서도 primary anastomosis를 한다고 나와있습니다.The treatment of choice for intestinal obstruction in patients with Crohn disease is segmental resection of the involved segment with primary reanastomosis. This may involve segmental resection and primary anastomosis of a short segment of ileum or an ileocecectomy if both the ileum and cecum are involved

크론병 obstruction에서 일차 봉합이 가능한가

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