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1 The Korean Journal of Gastrointestinal Endoscopy Case Report 양성유문부협착에대한일시적스텐트삽입술후점막내부분함몰된스텐트의아르곤플라즈마응고법을이용한제거 1 예 오주연ㆍ박종재ㆍ박자인ㆍ이원우ㆍ노승영ㆍ강현석ㆍ김재선ㆍ박영태 고려대학교의과대학내과학교실 A Case of a Removal of Pyloric Stent That Was Partially Embeded in the Mucosa after Temporary Stenting for the Benign Pyloric Stenosis and It Was Removed Using Argon Plasma Coagulation Joo Yeon Oh, M.D., Jong-Jae Park, M.D., Ja In Park, M.D., Won Woo Lee, M.D., Seung Young Roh, M.D., Hyun-Seok Kang, M.D., Jae Seon Kim, M.D. and Young-Tae Bak, M.D. Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea Generally, self expandable metallic stents (SEMSs) are widely used for the treatment of malignant gastrointestinal stenosis due to their effectiveness and low complication rate. On the contraty, balloon dilatation or Bougie dilatation is commonly used for treating benign gastrointestinal stenosis as non-invasive methods. However, their such complications such as recurrence, hemorrhage and perforation are problematic when these dilation techniques are used. Temporary placement of a SEMS in a benign gastric outlet obstruction is expected to be a promising therapeutic modality despite of several major complications such as migration. Rarely, stent removal can, on rare occasions, be difficult or cause bleeding or perforation when the stent is embeded in the mucosa due to mucosal hyperplasia at the tips of the stent. We report here on a case of a stent, partially embeded in the mucosa after temporary stenting for treating a benign pyloric stenosis, which was successfully removed using argon plasma coagulation. (Korean J Gastrointest Endosc 2010;40:31-35) Key Words: Benign pyloric stenosis, Gastric outlet obstruction, Temporary stenting, Argon plasma coagulation, Stent removal 교신저자. 박종재고려대학교의과대학구로병원소화기내과학교실 ( ), 서울시구로구구로 2 동 97 전화 : 팩스 : 이메일 : gi7pjj@yahoo.co.kr 접수 년 9 월 21 일승인 년 11 월 11 일 서론소화성궤양이나부식성위염의합병증으로유문부나십이지장구부의양성협착에의한폐쇄증상의비수술적치료법으로과거에는내시경풍선확장술을시도하였으나그효과는크게만족스럽지못하였다. 최근에는또다른비수술적치료법으로자가팽창형피막형금속스텐트삽입술 ( 스텐트삽입술 ) 의치료효과가드물게보고되고있다. 1 이는스텐트일탈외에는중증의합병증이적을뿐아니라반복적인시술없이협착부위의지속적인확장을기대할수있는장점이있어서풍선확장 술의단점인반복적인시술, 천공등의합병증을극복할수있다. 2,3 그러나스텐트내로점막증식이나스텐트말단부의조직과증식등으로스텐트가점막내에함몰되면스텐트제거시기계적으로어렵거나출혈및천공등의합병증이발생할수있어양성협착치료에스텐트를사용하는것은제한적이다. 3-5 이에저자들은재발성만성위유문부궤양에의한위배출구폐쇄증상의치료로일시적인스텐트삽입술후점막내부분함몰된스텐트를아르곤플라즈마응고법을이용하여제거한 1예를문헌고찰과함께보고한다. Vol. 40, No. 1 January, 2010 (31-35) 31

증례 51세남자환자가위배출구양성협착에대한치료로유문부에삽입한스텐트의제거를위해본원에내원하였다.

스텐트삽입술후위배출구협착증상은호전되었고내원 1개월전시행한추적위내시경검사에서스텐트일탈등의합병증없이스텐트개방성은유지되고있었다. 내원시계통문진에서조기팽만감, 구역이나구토, 소화불량, 그리고체중감소등은없었다. 활력징후는혈압 110/60 mmhg, 맥박 64회 / 분, 체온 36.

말초혈액검사, 혈청생화학, 혈청전해질및혈액응고검사는모두정상범위였으며, 단순흉부촬영에서특이소견없었고, 단순복부촬영에서는특이소견없이이전에삽입된스텐트가위유문부주위에유치되어있었다.

(A) Chronic duodenal ulcer with pyloric stenosis is found, and the scope can not be passed beyond the pyloric ring.

2 증례 51세남자환자가위배출구양성협착에대한치료로유문부에삽입한스텐트의제거를위해본원에내원하였다. 2년전부터십이지장궤양에의한재발성위배출구폐색으로타원에서총 3회의간헐적인내시경적풍선확장술을받아왔으나증상이재발되어내원 2개월전본원에서는직경 18 mm, 길이 8 cm의자가팽창성피막형금속스텐트를사용하여위유문부에스텐트삽입술을시행받았다 (Fig. 1). 스텐트삽입술후위배출구협착증상은호전되었고내원 1개월전시행한추적위내시경검사에서스텐트일탈등의합병증없이스텐트개방성은유지되고있었다. 내원시계통문진에서조기팽만감, 구역이나구토, 소화불량, 그리고체중감소등은없었다. 활력징후는혈압 110/60 mmhg, 맥박 64회 / 분, 체온 36.2 o C, 호흡수 20회 / 분이었으며, 두경부검사에서결막창백이나공막황달은없었고, 경부림프절은촉지되지않았다. 흉부진찰에서심음은규칙적이었고심잡음은들리지않았으며, 호흡음도특이소견없었다. 복부진찰에서장음은정상적이었고압통이나반발통의소견도없었으며만져지는종괴도없었다. 말초혈액검사, 혈청생화학, 혈청전해질및혈액응고검사는모두정상범위였으며, 단순흉부촬영에서특이소견없었고, 단순복부촬영에서는특이소견없이이전에삽입된스텐트가위유문부주위에유치되어있었다. 스텐트제거를위한위내시경검사에서는피막형스텐트의근위부약 10 mm가정상위점막과는달리적색을띄는점막으로완전히덮여있어스텐트의근위부말단을관찰할수없었다 (Fig. 2). 이는스텐트근위부의비피막부위로점막의과증식이원인이라생각되었다. 위내시경을제거하고, 2 채널치료 Figure 1. Endoscopic findings. (A) Chronic duodenal ulcer with pyloric stenosis is found, and the scope can not be passed beyond the pyloric ring. (B) The self expandable metallic stent is inserted for bridging the stenosed pylrorus, and endoscopic clipping is done on the proximal part of the stent to prevent migration. Figure 2. Endoscopic findings. (A) After the stent insertion, hyperemic mucosal hyperplasia is found, and the proximal part, about 10 mm in length of the stent is embeded in the gastric wall (arrows). (B) Other distal part of the stent is patent, and the scope can be passed without difficulties. 32 The Korean Journal of Gastrointestinal Endoscopy

Figure 3. Endoscopic findings of stent removal using argon plasma coagulation (APC).

5 L/min argon flow, is being done for ablation of the mucosa covering proximal part of the stent.

(C) Using two working channel therapeutic endoscopy, the most proximal part of the exposed stent

scope itself, and the whole stent is extraxcted from the pylorus.

removed outside the gastrointestinal tract. Figure 4. Endoscopic findings.

(B) 6 months after the procedure, the pyloric ring is patent without stenosis, and the scope can

3 Figure 3. Endoscopic findings of stent removal using argon plasma coagulation (APC). (A) APC, with settings of forced APC mode, 80 watts power, 1.5 L/min argon flow, is being done for ablation of the mucosa covering proximal part of the stent. (B) After two sessions of APC, the embeded stent is exposed. (C) Using two working channel therapeutic endoscopy, the most proximal part of the exposed stent is being grasped by Rat-tooth and biopsy forceps, and is being pulled back to the stomach with the scope itself, and the whole stent is extraxcted from the pylorus. (D) In the stomach, the mid portion of the stent is being re-grasped by polypectomy snare, being removed outside the gastrointestinal tract. Figure 4. Endoscopic findings. (A) Immediately after removal of the stent, no significant bleeding nor perforation is developed. (B) 6 months after the procedure, the pyloric ring is patent without stenosis, and the scope can be passed through the duodenal bulb. 용내시경을삽입한후스텐트의가장근위부를파악겸자와생검겸자로잡고내시경과함께구측으로당기면서함몰된스텐트를위내강으로끄집어내기를시도하였으나실패하여아르 곤플라즈마응고법으로과증식된점막을제거하기로결정하였다. 아르곤플라즈마응고법에의한과증식점막의절제는독일세링사시스템을이용하여 (forced APC mode, 80 watts po- Vol. 40, No. 1 January, 2010 (31-35) 33

4 wer, 1.5 L/min argon flow) 1차로약 10분동안시행하고종료하였고시술후출혈등의합병증은발생하지않았다 (Fig. 3A). 다음날다시 2 채널치료용내시경을이용하여함몰된스텐트의 wire 일부가노출될때까지 2차로플라즈마응고법을약 10분동안시행하였고 (Fig. 3B), 노출된스텐트의가장근위부를파악겸자와생검겸자로잡고내시경과함께구측으로당겨함몰된스텐트를과증식점막에서분리후위강내로스텐트를이동시켰다 (Fig. 3C). 이어용종절제용올가미로스텐트중간부위를잡고내시경과함께체외로제거하였다 (Fig. 3D). 시술과관련하여출혈과천공그리고식도손상등의합병증은발생하지않았다 (Fig. 4A). 시술다음날환자는특별한증상없어식이시작후퇴원하였고현재까지약 2년간추적관찰중이며재협착에의한위장관증상은없었다 (Fig. 4B). 고찰 일반적으로근치적절제가불가능한소화관악성협착의비수술적치료법으로스텐트삽입술은효과적이고합병증이비교적적어널리시행되고있다. 6 그러나소화성궤양, 부식성손상, 수술후문합부협착등에의한양성유문부협착의비수술적치료법으로내시경풍선확장술의효과는크게만족스럽지못한실정이다. 풍선확장술시행후위배출구폐색증상이지속적으로소실되는경우는 16 70%, 천공합병증에의한응급수술을하는경우는 %, 그리고반복적인시술이필요한경우는 22 32% 로보고되고있다. 5,7 이를극복하기위한시도로서양성협착에스텐트삽입술을시행하여증상의유의한호전을보인연구결과가보고되고있다. 1-3,8 그러나양성유문부협착에서스텐트삽입술시는스텐트일탈등의합병증이비교적흔하다는문제가있을뿐만아니라, 스텐트내로점막증식이나스텐트말단부의점막과증식등이발생했을때스텐트의제거가곤란할수가있기때문에시술에제한이있다. 양성유문부협착에서스텐트삽입술의합병증으로는특히일정기간이지난후스텐트를제거해야하기때문에피막형스텐트를사용해야되고, 이럴경우스텐트일탈이가장흔하다. 저자들의보고에의하면양성유문부협착에일시적으로스텐트삽입술을한 8명의환자중 4명에서스텐트일탈이발생하였고, 3 또다른최근의연구에서는 11명중 3예 (27%) 에서스텐트일탈이발생하였다. 1 그러나일탈된환자에서도약반수에서는증상의개선이있었는데이는적어도 1주이상이라도스텐트가유치된후스텐트가일탈되면일탈되기전까지스텐트에의한지속적확장효과에의해서충분한치료효과가있었기때문으로생각된다. 스텐트일탈의예방을위해서스텐트삽입술후클립을이용하여스텐트근위부를고정하여예방하였다는보고도있지만, 9 아직까지클립의효과에대해서는더많은연구결과가필요하다. 이번증례에서는일탈을예방하기 위해클립을이용하여고정하였고적어도조기일탈의예방에는일조를하였으리라생각한다. 기타합병증으로스텐트삽입후확장에의한통증이나스텐트선단의기계적점막자극에의한출혈이나궤양, 천공등이이론적으로발생할수있으나이러한합병증은대개는보존적치료로호전될수있다. 아주드물게는스텐트내점막증식이나스텐트말단부의조직과증식에의해스텐트의폐쇄가발생할수있고, 또한스텐트제거시어려움이있을수있다. 스텐트내점막증식은주로악성협착에서장기간스텐트유치시대개담즙이나위산에의해서피막이융해가되어발생하나, 양성협착에서는유치기간이 8 주이내로제한되어있기때문에임상적으로문제가되는경우는드물다. 스텐트말단부의조직과증식이발생할경우스텐트폐쇄는드물지만본증례처럼스텐트의제거가어려울수있다. 일반적으로스텐트삽입술후점막증식에의한스텐트폐쇄가발생하면이의치료법으로 Nd:YAG laser나아르곤플라즈마응고법을이용할수있는데아르곤플라즈마응고법은 Nd: YAG laser에비해치료술기가쉽고, 2 3 mm의비교적제한된깊이로침투되어조직손상의깊이가적어전층괴사 (transmural necrosis) 나천공등의위험도가낮으며, 또한장비가간단하고경제적인이점이있다. 10,11 아르곤플라즈마응고법은최근위장관출혈의지혈목적외에도방사선에의한직장염의치료, 바렛식도및식도게실의치료, 위장관암종이나용종의내시경절제후절제면의보조적조직파괴, 위석등점차그임상적적용영역이확대되고있다 특히최근에는다양한위장관이나담췌관질환의보존치료법의하나로스텐트삽입술이널리이용되면서이의합병증의치료에도이용된보고가증가하고있다. 담관스텐트나직장스텐트삽입후스텐트의선단이각각십이지장벽이나항문괄약근에닿아각각궤양이나출혈, 혹은항문주위동통이나후중감등을유발하거나이러한합병증이예상되는경우예방적으로스텐트의선단을절단하는스텐트트리밍 (trimming) 이그예이다 본증례에서는스텐트삽입술후점막내부분함몰된유문부스텐트를아르곤플라즈마응고법을이용하여제거한예로서, 비교적간단히 2차례, 각 10분간의아르곤플라즈마응고법으로스텐트근위부의과증식된조직을괴사시킴으로써출혈이나천공등의합병증없이스텐트를제거할수있었다. 아르곤플라즈마응고법에의한합병증으로가스팽창, 창자벽공기증, 기종격증, 피하기종, 치료부위통증, 만성궤양, 협착, 출혈, 천공등이 0 24% 까지보고되고있지만, 19 31명의환자에서스텐트트리밍시술을시행하고평균 15.8개월을관찰한한연구에서는시술중혹은추적관찰중합병증은대부분발생하지않았다. 3 요약하면본증례는십이지장궤양으로인한만성재발성의양성위배출구폐쇄환자에게일시적인스텐트삽입술로치료효과를거둔후조직과증식에의해점막내부분함몰된스텐 34 The Korean Journal of Gastrointestinal Endoscopy

5 트를아르곤플라즈마응고법을이용하여합병증없이성공적으로스텐트를제거한예로서이러한방법은스텐트삽입시술의제한점을극복할수있게하는새로운시도라고생각한다. 요약 소화관양성협착에대한비수술적치료로풍선확장술과부우지확장술이시행되어왔지만시술후출혈이나천공및재협착의문제점이있다. 양성협착에대한스텐트삽입술의치료효과의연구는일부에서보고되었으나적응증은아직명확하지않으며스텐트유치후스텐트일탈이나내증식으로인해제거가어렵고제거시출혈및천공등이발생할수있어그사용에제한이있어왔다. 저자들은십이지장궤양으로인한재발성의양성유문부협착환자에서위배출구폐쇄증상의치료로일시적인자가팽창형금속스텐트삽입후조직과증식으로점막내부분함몰된스텐트를아르곤플라즈마응고법을이용하여합병증없이성공적으로제거하고위배출구폐쇄증상의재발없이 2년간추적관찰중인 1예를보고한다. 색인단어 : 양성유문부협착, 위배출구폐쇄, 일시적스텐트삽입술, 아르곤플라즈마응고법, 스텐트제거 참고문헌 1. Han HW, Lee IS, Park JM, et al. Self-expandable metallic stent therapy for a gastrointestinal benign stricture. Korean J Gastrointest Endosc 2008;37: Park JJ, Yang CH. The current status and the future of upper GI stenting. Korean J Gastrointest Endosc 2009;38: Kim HJ, Park JJ, Kang CD, et al. Effect of the temporary placement of stent in benign pyloric stenosis. Gastrointest Endosc 2004;59(abstr):153A. 4. Seo YS, Park JJ, Kim BG, et al. Segmental amputation of esophagus with bronchial-wall rupture during removal of a stent for benign esophageal stricture. Gastrointest Endosc 2006;64: Yusuf TE, Brugge WR. Endoscopic therapy of benign pyloric stenosis and gastric outlet obstruction. Curr Opin Gastroenterol 2006;22: Kim JH, Song HY, Shin JH, et al. Metalic stent placement in the palliative treatment of malignant gastroduodenal obstructions: prospective evaluation of results and factors influencing outcome in 213 patients. Gastrointest Endosc 2007;66: Lau J, Chung S, Sung J, et al. Through-the-scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc 1996;43: Lee WW, Park JJ, Oh CR, et al. A case of endoscopic temporary stent insertion to treat a pyloric stenosis caused by endoscopic submucosal dissection for early gastric cancer. Korean J Gastrointest Endosc 2008;37: Jung WJ, Kang DH, Choi CH, et al. The usefulness of applying an additional clip when using a double-layered pyloric stent to treat gastric outlet obstruction. Korean J Gastrointest Endosc 2009;38: Vargo JJ. Clinical applications of the argon plasma coagulator. Gastrointest Endosc 2004;59: Demarquay JF, Dumas R, Peten EP, Rampal P. Argon plasma endoscopic section of biliary metallic prostheses. Endoscopy 2001;33: Shaver CP, Brady P, Pinkas H. You don't have to retrieve to relieve: how and when to trim a self-expanding metal biliary stent. Endoscopy 2004;36: Silva RA, Correia AJ, Dias LM, Viana HL, Viana RL. Argon plasma coagulation therapy for hemorrhagic radiation proctosigmoiditis. Gastrointest Endosc 1999;50: Ha BW, Kim JH, Seo YT. A case of huge gastric phytobezoar removed by endoscope using argon plasma. Korean J Gastrointest Endosc 2007;34: Kwon JH, Lee IS, Park JM, et al. Endoscopic argon plasma laser trimming of biliary self expanding metallic stent. Korean J Gastrointest Endoscopy 2006;33: Chen YK, Jakribettuu V, Springer EW, Shah RJ, Penberthy J, Nash SR. Safety and efficacy of argon plasma coagulation trimming of malpositioned and migrated biliary metal stents: a controlled study in the porcine model. Am J Gastroenterol 2006;101: Witte TN, Danovitch SH, Borum ML, Irani SK. Endoscopic trimming of a rectal self-expanding metalic stent by use of argon plasma coagulation. Gastrointest Endosc 2007;66: Yarze JC, Poulos AM, Fritz HP, Herlihy KJ. Treatment of metallic biliary stent-induced duodenal ulceration using endoscopic laser therapy. Dig Dis Sci 1997;42: Vanbiervliet G, Piche T, Caroli-Bosc FX, et al. Endoscopic argon plasma trimming of biliary and gastrointestinal metallic stents. Endoscopy 2005;34: Vol. 40, No. 1 January, 2010 (31-35) 35

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< C1F5B7CA20BDC5C3B5C8A32DC1A4BCAE D E687770> 대한내과학회지 : 제 85 권제 3 호 2013 http://dx.doi.org/10.3904/kjm.2013.85.3.297 유문부피막형금속스텐트의원위부이탈에의해발생한급성췌장염 1예 인하대학교의학전문대학원내과학교실 신천호 정석 이돈행 김성현 김경은 박성욱 방병욱 A Case of Acute Pancreatitis Caused by Distal Migration