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1 Korean J Gastroenterol Vol. 57 No. 5, DOI: /kjg ORIGINAL ARTICLE 위정맥류출혈에대한내시경적정맥류폐색술, 내시경적정맥류결찰술, 역행성경정맥위정맥류폐색술간의치료효과비교 민슬기, 김상균, 김영석, 배준용, 이종찬, 이세환, 김홍수, 정승원, 장재영, 문종호, 이문성, 김부성 순천향대학교의과대학내과학교실 Comparison among Endoscopic Variceal Obliteration, Endoscopic Band Ligation, and Balloon-occluded Retrograde Transvenous Obliteration for Treatment of Gastric Variceal Bleeding Seul Ki Min, Sang Gyune Kim, Young Seok Kim, Jun Yong Bae, Jong Chan Lee, Sae Hwan Lee, Hong Soo Kim, Soung Won Jeong, Jae Young Jang, Jong Ho Moon, Moon Sung Lee and Boo Sung Kim Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea Background/Aims: Endoscopic variceal obliteration (EVO), endoscopic variceal ligation (EVL), and balloon-occluded retrograde transvenous obliteration (BRTO) are used to manage gastric variceal bleeding. We compared the re-bleeding rates and survival times of these modalities. Methods: The study enrolled 103 patients with suspected gastric variceal bleeding between July 2001 and May For the management of gastric variceal bleeding, 52 patients underwent EVO; 36, EVL; and 15, BRTO. We evaluated their laboratory results and vital signs, and calculated the Child score, Child classification, and Model for End-stage Liver Disease score. Rebleeding was defined as new-onset hematemesis, hematochezia, melena, or endoscopically proven bleeding. Time-to-rebleeding and survival time were examined by Kaplan-Meyer analysis. A value of p<0.05 indicated statistical significance. Results: There were no significant differences in baseline characteristics among the three groups. The overall follow-up period averaged months. During follow-up, rebleeding occurred in 17 patients (11 EVO, 5 EVL, and 1 BRTO). The times-to-rebleeding were 63.59, 75.79, and months for EVO, EVL, and BRTO, respectively, and did not differ significantly (p=0.515). The median survival times were 77.42, 70.14, and months, respectively, and also were not different significantly (p=0.978). Conclusions: There were no significant differences in the time-to-rebleeding or survival time among EVO, EVL, and BRTO. Further prospective, large-scale studies are needed. (Korean J Gastroenterol 2011;57: ) Key Words: Esophageal and gastric varices; Gastrointestinal hemorrhage; Liver cirrhosis; Treatment 서론 위정맥류는간경변환자의약 20-70% 에서발생하고, 1-4 일단출혈이발생하면자연적인지혈이나시술후지혈모두어렵다. 3 따라서사망률은식도정맥류에비해높아약 45-55% 까지이르며, 이는측부순환정맥의혈류가풍부하여 출혈량이많고, 식도정맥류에비해내시경시술로지혈이더어려우며, 재출혈률이높기때문이다. 3,5-7 위정맥류출혈시초치료로는내시경정맥류결찰술 (endoscopic variceal ligation, EVL), Histoacryl R (n-butyl-2-cyanoacrylate) 을이용한내시경적정맥류폐색술 (endoscopic variceal obliteration, EVO), 그리고경경정맥간내문맥전신단락술 (transju- Received August 24, Revised December 7, Accepted December 7, CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 교신저자 : 김영석, , 부천시원미구중동 1174, 순천향대학교의과대학내과학교실 Correspondence to: Young Seok Kim, Department of Internal Medicine, Soon Chun Hyang University College of Medicine, 1174, Jung-dong, Wonmi-gu, Bucheon , Korea. Tel: , Fax: , liverkys@schmc.ac.kr Financial support: None. Conflict of interest: None. Korean J Gastroenterol, Vol. 57 No. 5, May

2 Min SK, et al. Comparison of Treatments for Gastric Variceal Bleeding 303 gular intrahepatic portosystemic shunt, TIPS) 등여러치료법이추천되어왔다. 위정맥류출혈의예방에대해서는비선택적베타차단제또는 TIPS를제시하고있으나자료가부족하다. 8,9 1986년 Soehendra 등 10 이처음으로시술을보고한 Histoacryl R 을이용한내시경적위정맥류폐색술은비교적안전하고효과적인위정맥류출혈의지혈법으로현재일부지역을제외한전세계에서널리사용되고있다. 11,12 하지만안정성에대한논란이남아있으며재출혈률과합병증및장기효과에관한연구는많지않다. 한편 1996년 Kanagawa 등 13 에의해예방적시술로시도된역행성경정맥위정맥류폐색술 (balloon- occluded retrograde transvenous obliteration, BRTO) 은출혈성위정맥류의치료에도사용되어높은지혈률, 정맥류소실률을보여주고있다 EVL은많은발전과안전성이입증되어정맥류출혈의치료에널리사용되어온방법으로경화요법에비해낮은재출혈률, 합병증및치사율을보여주나정맥류의재발이더빈발한것으로보고되고있다. 17 현재위정맥류출혈의치료에있어주로두가지치료법에대한연구는단일군분석연구나두군간의비교연구가주를이루어세방법을동시에비교한연구는없는실정으로, 세방법을동시에비교할경우통계학적제한점을가지게된다. 이에저자는위정맥류출혈후치료에대해상기세치료법간의재출혈률, 생존기간을비교하고자이번연구를시행하였다. 대상및방법 1. 대상 2001년 7월부터 2009년 5월까지순천향대학교부천병원에위정맥류출혈을주소로내원한환자들가운데보존적치료후 48시간이내에재출혈의예방목적으로 EVO를시행받은환자 52명, EVL을시행받은환자 36명그리고 BRTO를시행받은환자 15명을대상으로하였다. 2. 방법 1) 내시경적정맥류폐색술 (EVO) 사용기기는직시경인 GIF series (Olympus Co., Tokyo, Japan) 와 23 G 주사침그리고 1,650 mm의주입도관을사용하였다. 위정맥류내 Histoacryl R 의주입방법은 Histoacryl R 0.5 ml와 lipiodol (Guerbet, Aulnay-Sous-Bois, France) 0.5 ml를혼합한용액을위정맥류내로신속하게주입한후 X-선투시하에위정맥류내 lipiodol의위치를확인하고곧바로순수 lipiodol을주입하면서정맥류주사침을정맥류로부터제거하고난다음, 증류수로정맥류주입도관을세척하였 다. 필요에따라위정맥류내에 2-4차례반복적으로주입하였다. 2) EVL Saeed TM Multi-Band Ligator (Cook Medical, Winston- Salem, NC, USA) 를상부위장관내시경 GIF series (Olympus Co., Tokyo, Japan) 의말단에부착한후출혈가능성이높은정맥류부위에대해결찰술을시행하였으며이후주변의정맥류에대해추가적인결찰술을시행하였다. 1회에 1-4개의고무밴드가사용되었으며위정맥류의감소또는소실이이루어질때까지정기적으로상부소화관내시경을시행하였다. 3) 역행성경정맥위정맥류폐색술복부전산화단층촬영, 신동맥조영술을통해위신정맥단락의존재가확인된환자를대상으로시행하였다. 대퇴정맥을천자하여폐쇄풍선도관을위신정맥단락기시부에위치시키고좌측신정맥조영술을시행하였으며조영제가위정맥류내에 4분이상저류하는것을관찰하였다. 투시유도하에풍선을팽창시켜위신정맥단락을폐쇄하고 50% glucose 20 ml를주입한후조영제와경화제를 1:1 비율로혼합한용액 10 ml 를위정맥류에가득찰때까지주입하였다. 3. 정의위정맥류는 Sarin 등 3 의분류에따라 GOV1, GOV2, IGV1, IGV2로나누었으며, 위정맥류의형태는 Hashizume 등 18 의분류에따라 F1, F2, F3로나누었다. 위정맥류의재출혈은지혈술을시행한이후에임상적으로토혈, 커피색의토사물, 혈변또는흑색변이보이면서동시에, 첫째, 내시경적으로위정맥류에서피가분출되거나스며나오는것이확인되었을때, 둘째, 위정맥류위로혈전이붙어있는것이확인되거나궤양이관찰될때, 셋째, 임상적으로의미가있는식도정맥류또는다른부위에서의출혈의증거없이적색흔을동반하고있는 F2 이상의위정맥류가관찰될때로정의하였다. 19,20 4. 통계통계분석은윈도우용 SPSS 12.0 (SPSS Inc., Chicago, IL, USA) 을사용하였다. 각치료방법에따른환자군간의임상적특징의비교에는연속변수에대해서는 one-way ANOVA 또는 Kruskal-Wallis test를, 범주형변수에대해서는 Chi-square test 또는 Fisher s exact test를사용하였다. 위정맥류의출혈및사망누적발생률은 Kaplan-Meyer survival analysis를이용하여계산하였고, log-rank test를이용하여비교하였다. 모든통계분석에서 p-value가 0.05 미만인경우를유의한것으로간주하였다. Vol. 57 No. 5, May 2011

3 304 민슬기등. 위정맥류출혈에대한치료법간의효과비교 Table 1. Baseline Characteristics of Patients EVO EVL BRTO p-value Age (mean+sd) 54.75± ± ± Gender Male Female Etiology of liver cirrhosis Hepatitis B Hepatitis C Alcohol Others Coincidence of HCC Yes No Serum albumin (g/dl) 5.95± ± ± Serum total bilirubin (mg/dl) 2.51± ± ± PT (INR) 1.44± ± ± Child Score 9.70± ± ± Child-Pugh Classification Child A Child B Child C MELD score Sarin Classification GOV GOV IGV Form F F F EVO, Endoscopic variceal obliteration; EVL, endoscopic variceal ligation; BRTO, balloon-occluded retrograde transvenous obliteration; MELD, model for end stage liver disease; HCC, hepatocellular carcinoma. 결과 1. 연령및성별분포대상이되는총 103명환자중 EVO군의평균연령은 54.75±9.43세이었으며남녀각각 41명과 11명이었고, EVL 군의평균연령은 53.19±9.62세이었으며남녀각각 31명과 5명, 그리고 BRTO군은평균연령이 50.73±9.19세이었으며남녀각각 12명과 3명으로세집단간에서통계적으로유의한차이는없었다 (Table 1). 2. 간경변증의원인및내시경소견 EVO군의기저간질환으로는만성 B형간염 20명, 만성 C 형간염 2명, 알코올성간경변 24명, 원인미상 6명이었으며, EVL군은각각 12명, 3명, 18명, 3명이었고 BRTO군은각각 8명, 3명, 3명, 1명이었다. 통계적으로유의한차이는없었다. (p=0.243) Child-Pugh 분류상 EVO군에서 Child A는 13명, Child B는 31명, Child C는 8명이었고, EVL군에서는각각 9명, 21명, 6명, 그리고 BRTO군에서는각각 4명, 8명, 3명이었다. 통계적으로유의한차이는없었다 (p=0.983). Sarin 분류상 EVO군에서 GOV1는 24명, GOV2는 27명, IGV1 1명이었고, EVL군에서는 GOV1가 18명, GOV2가 18명이었으며, BRTO군에서는 GOV1 5명, GOV2 9명, IGV1 1명이었다. 통 Table 2. Analysis of Time to Rebleeding Number of patients with rebleeding (%) Mean time to rebleeding (months) p-value EVO 11/52 (21.2) ( ) EVL 5/36 (13.9) ( ) BRTO 1/15 (6.7) ( ) 계적으로유의한차이는없었다 (p=0.437). EVO군에서는 F1, F2, F3 각각 33명, 7명, 12명이었으며 EVL군에서는각각 22명, 8명, 6명이었고 BRTO군에서는각각 3명, 9명, 3명으로 BRTO군에서통계적으로유의하게정맥류의크기가큰결과를보여주었다 (p=0.004) (Table 1). 3. 위정맥류의재출혈및생존기간 평균추적기간 72.99개월간재출혈이발생한환자의수는 EVO군에서 52명중 11명 (21.2%), EVL군에서 36명중 5명 (13.9%) 그리고 BRTO군에서 15명중 1명 (6.7%) 이었다. EVO 군은재출혈까지평균 63.59개월 (95% CI: ), EVL 군은평균 75.79개월 (95% CI: ), 그리고 BRTO군은평균 51.41개월 (95% CI: ) 이었으며통계적으 The Korean Journal of Gastroenterology

4 Min SK, et al. Comparison of Treatments for Gastric Variceal Bleeding 305 Fig. 1. Kaplan-Meier plots of time to rebleeding. Fig. 2. Kaplan-Meier plots of time to survival. Table 3. Analysis of Patients Survival Number of expired patients (%) Mean survival time (months) p-value EVO 11/52 (21.2) ( ) EVL 8/36 (22.2) ( ) BRTO 3/5 (20) ( ) 로유의한차이는없었다 (p=0.515) (Table 2, Fig. 1). 평균추적기간 76.49개월 (95% CI: ) 동안 EVO 군에서는 52명중 11명 (21.2%), EVL군에서는 36명중 8명 (22.2%), BRTO군에서는 5명중 3명 (20%) 이사망하였다. EVO군의생존기간은평균 77.42개월 (95% CI: 개월 ), EVL군은평균 70.14개월 (95% CI: 개월 ), 그리고 BRTO군은평균 42.79개월 (95% CI: 개월 ) 이었으며통계적으로유의한차이는없었다 (p=0.978) (Table 3, Fig. 2). 고 찰 대상간경변환자의약 40% 에서식도위정맥류를가지고있고정맥류발생은매년 6% 정도증가하며, 위정맥류발생빈도는보고자마다다양하나간경변환자의 20-70% 에서발생하는것으로알려져왔다. 1-3,18 위정맥류의출혈은식도정맥류의출혈보다는빈도가적으나 14-36% 의정맥류출혈은위정맥류의출혈에의해발생한다. 21 위정맥류는위의전부위에서발생가능하나 60-75% 가위분문부, 나머지 25-40% 가위기저부로대부분위분문부와위기저부에서발견된다. 위정맥 류는식도정맥류와는다른혈류공급을받게되는데원칙적으로위정맥류는어떤위정맥에의해서도발생할수있으나대부분의위정맥류는좌측위정맥과후위정맥의혈액공급을받게된다. 좌측위정맥에의한위정맥류는주로위분문부에발생하며후위정맥및단위정맥에의한위정맥류는주로위기저부에발생하게된다. 22 대부분의위기저부에발생한위정맥류의경우는하위횡경정맥으로유출되어좌측신정맥과만나위신정맥단락 (80-85%) 을형성하거나횡경막직하부에서하대정맥과만나위대정맥단락 (10-15%) 을형성한다. 23,24 위정맥류는또한식도정맥류와달리혈류량이많고측부혈관이발달하였으며위내측뿐만아니라외측에도정맥류가발달해있어치료가힘들며정립된치료지침이없는현실이다. 위정맥류의출혈에대해서는크게내과적치료와외과적치료가있으며내과적치료로는 vasopressin이나 terlipressin 등과같은혈관에작용하는약물이나초기출혈을방지하는비선택적베타수용체차단제등의약물치료, 내시경적치료, Sengstaken-Blackmore tube를이용한기계적인지혈법등이있으며외과적수술방법과난치성정맥류출혈의치료에 TIPS를시도해볼수있다. 위정맥류내시경치료술의적응증에대한일반적인견해는활동위정맥류출혈환자는응급내시경지혈술이요구되며, 지혈술후재출혈의빈도가높으므로반복대기요법으로정맥류근절을시도하고, 활동출혈은없으나위정맥류출혈의확실한증거가있는급성출혈환자는응급및대기내시경지혈술의적응이되며, 내시경치료후잔존및재발위정맥류, 정맥류출혈의병력이있으면서적색징후나점막미란이관찰되는경우 F2, F3의위정맥류와단기간에커지는위정맥류는예방치료술의적응이될수있다. Histoacryl R 은혈액이나조직수분같은생리적인매개체 Vol. 57 No. 5, May 2011

5 306 민슬기등. 위정맥류출혈에대한치료법간의효과비교 와접촉했을때바로중합체를이루면서고형화되어정맥류를폐쇄시키기때문에활동성출혈을멈추게할뿐만아니라정맥류의근절을유도하여재출혈을줄이는효과가있다. 25 이러한 Histoacryl R 주입법을다른약제를이용한경화요법, 밴드결찰술과비교하는많은연구들에서 16개월동안재출혈은 16.7% 를보이는등재출혈률, 생존율에서모두나은결과를보였다 Ethanolamine oleate 등과같은다른경화제는위정맥류내의혈류가빨라서혈전을형성하는것이어려웠으나, Histoacryl R 을이용한폐색술은혈류와무관하게혈전을빠르게형성할수있는이점이있어다른경화제에비해서높은지혈률이보고되고있고, 반복적인시술을통해정맥류의완전소실과재출혈의예방에도우수한효과가있는것으로알려지고있다. 10 그러나지혈실패나전신색전증과같은심각한합병증과내시경기구손상등의문제점 29,30 이있으며이차예방의효과에대해서는논란의여지가있다. 31,32 EVL은정맥류를흡인한후에 O형고무밴드를이용하여정맥류를기계적으로결찰하는방법이며결찰된조직은고무밴드에의한압박으로괴사되어궤양을형성한후에섬유화를유발하여반흔이만들어지는원리를이용하는것으로경화요법에비해재출혈의상대위험도의 37% 감소와절대위험도의 13% 감소를보여줬다. 33 또한비선택적베타차단제와의병용은 EVL 단독치료보다우월하다는보고도있다. 34 그러나최근에 Histoacryl R 을이용한폐색술이더효과적이라는보고가있어추가적인연구가필요할것으로보인다. 27 위신단락을동반하고간문맥압차가높지않은위정맥류출혈환자에서위신단락을통해경화제를주입하여정맥류를폐쇄시키는 BRTO는 1996년 Kanagawa 등 13 에의해출혈이없는환자에대한예방적시술로시도되어 75% 의성공률을보였으며, 이후출혈성위정맥류의치료에도사용되어높은지혈률, 정맥류소실률을보였다. 14,16,35 또단락을인위적으로소실시키기때문에간문맥압이상승하며이로인해기존의식도정맥류가악화하거나새로운식도정맥류를생성할수있다. 14,16,35 그러나 BRTO는 TIPS나 EVO에비해재발이드물고거의대부분의위정맥류를소실시킬수있다는장점을가지고있어위정맥류출혈의이차예방에가장적절한치료법이라할수있다. 14,16,35 BRTO는 TIPS와의비교연구 15 에서재출혈률에서는차이가없었으며, 합병증이나위정맥류소실에서는통계적인차이는없었으나더나은결과를보여주었다. 그러나아직은 BRTO에대한장기추적결과가부족하며다른치료법과의비교연구도부족하므로이에대한더많은전향적임상연구가필요할것이다. 일반적으로간정맥류출혈의예방에대한연구는두가지방법을비교하는것이대다수이며 BRTO에대한연구는주로 TIPS와비교되어있고내시경적출혈예방법과의비교는더욱 적은형편이다. 이번연구에서는위정맥류출혈의이차예방에대한세가지치료법에대해재출혈률및생존율을동시에비교하였다. 이는통계상의제1종오류를줄이기위한것으로세치료법을비교하기위해 t-test를 3회시행할경우 95% 의신뢰도이므로알파값을 0.05로설정한의학연구에서는 으로알파값이증가하며, 귀무가설일확률이 95% 에서 85.7% 로감소하여귀무가설을받아들일확률이줄어들게된다. 이에세변수를동시에비교하는 one-way ANOVA나 Kruskal- Wallis 검정을시행한이번연구필요성이나타나게되었다. 이번연구에서세치료법간의재출혈까지의기간및생존기간을동시에비교해보았으나통계적으로의미있는차이는나타나지않았다. 또한두치료법씩다시짝지어사후분석을해보아도치료법간에차이는보이지않았다. 과거 EVO가 EVL에비하여더우월하다는여러연구의결과와상반된것으로이는이번연구가전향적무작위연구가아닌후향적분석이며대상환자수가적고, 기저특성면에서차이가있기때문일수있으며세군을비교하는경우는두군간의비교에비해통계학적인차이가나타날가능성이낮은것도이유로생각된다. 그리고 EVO군과 EVL 간에위정맥류의크기에대해통계적으로의미있는차이는보이지않았으나 GOV1 및 F1의정맥류가더많이포함된경향을보였다. 이는정맥류의크기가큰경우밴드결찰로정맥류를완전히결찰하기가어려운경우가많아 EVO군에서고위험군이더포함되었을가능성이있다. BRTO군에는위정맥류의크기가 F2 또는 F3인환자빈도가다른두치료법에비해많아세치료법중고위험군의빈도가가장높음을보여주며이는정맥류의크기가크거나환자와의협조가어려워 EVO를시행하기어렵거나불가능한경우에 BRTO가많이시행되었을가능성을보여준다. 이러한선택편견의존재로인해이번연구에서 BRTO 환자군의재출혈까지의기간과생존기간이짧게측정되었을수있다. EVO군과 EVL군은추적관찰중환자가소실되는좌측중도절단의빈도가높았으나 BRTO군에서는사건이발생한시간이중도절단시기보다긴우측중도절단의빈도가높았다. 이또한 BRTO의효과를과소평가하게하는원인의하나로생각할수있다. 이의극복을위해지속적인추적관찰을통한장기연구가필요할것으로보인다. 세치료법간의재출혈의빈도는 BRTO가 EVO나 EVL에비해낮게나타났으나재출혈까지의기간은다른치료법에비해짧은것으로나타났다. 이또한 BRTO군에서는다른치료법에비해우측중도절단된환자가많았기때문으로생각된다. 재출혈에영향을주는다른인자로는 Sarin 분류법에따른 GOV2가재출혈이높은경향이있었으나통계적으로의미는없었다. 이는 GOV2가 GOV1에비해정맥류가넓게위치하여폐쇄가쉽지않았을가능성과 GOV1의다수가식도정맥류의 The Korean Journal of Gastroenterology

6 Min SK, et al. Comparison of Treatments for Gastric Variceal Bleeding 307 치료에의해자연적으로소실되기때문에재출혈률이높은경향을보였을가능성이있다. 그외위정맥류의형태나원인, 간기능등은재출혈률과관련은보이지않았다. 결론으로, 위정맥류출혈의치료및재출혈예방에있어세치료법간에의미있는차이는보이지않았으며향후지속적인추적관찰을통한전향적인장기연구가필요할것으로생각된다. 요약 목적 : 위정맥류출혈에대한치료는약물적, 내시경적, 방사선적, 그리고수술적치료가제시되고있으며이중에서내시경적정맥류폐색술 (endoscopic variceal obliteration, EVO), 내시경적정맥류결찰술 (endoscopic variceal ligation, EVL), 그리고역행성경정맥위정맥류폐색술 (balloon- occluded retrograde transvenous obliteration, BRTO) 등의내시경및방사선적치료가우선적으로고려되고있다. 그러나아직까지세치료법의간의치료효과에대한명확한비교한연구가없는실정으로이에저자들은위정맥류출혈에있어 EVO, EVL 그리고 BRTO 간의치료효과를비교하였다. 대상및방법 : 2001년 7월부터 2009년 5월까지순천향대학교부천병원에위정맥류출혈로내원한환자들가운데치료를시행한환자 (EVO 52명, EVL 36명, BRTO 환자 15명 ) 를후향적으로분석하였다. 시술전환자의간기능검사및활력징후를측정하였으며 Child score, model for end stage liver disease (MELD) score 및 Child-Pugh Score을기록하였다. 시술후새로발생된토혈, 혈변, 흑색변또는내시경으로확인된출혈이있는경우재출혈로정의하였다. 결과 : 세환자군간에연령, 성별, Child score, MELD score, 간암유무, 기저질환, 간기능장애정도, 사망원인등에서통계적으로유의한차이는보이지않았다. 평균 65.13개월의추적기간중 17명 (13%) 에서재출혈이발생하였으며 EVO군, EVL 군, 그리고 BRTO군에서각각 11명 (21.2%), 5명 (13.9%), 1명 (6.7%) 이었다. 재출혈까지의평균기간은각각 63.59개월, 75.79개월, 51.41개월이었으며통계적으로유의한차이를보여주지는않았다 (p-value=0.515). 생존기간은각군 77.42개월, 70.14개월, 42.79개월이었으며통계적으로유의한차이를보이지않았다 (p-value=0.978). 결론 : 누적지혈률및누적생존율에있어 EVO, EVL 그리고 BRTO 치료법간에의미있는통계적효과의차이는보이지않았다. 이는이번연구가후향적으로시행되어발생한선택편견의가능성과충분한환자군이포함되지못했을가능성이있으므로향후전향적인비교연구가필요할것으로보인다. 색인단어 : 식도위정맥류 ; 위장관출혈 ; 간경변 ; 치료 REFERENCES 1. Sarin SK, Kumar A. Gastric varices: profile, classification, and management. Am J Gastroenterol 1989;84: Greig JD, Garden OJ, Anderson JR, Carter DC. Management of gastric variceal haemorrhage. Br J Surg 1990;77: Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16: Hashizume M, Sugimachi K. Classification of gastric lesions associated with portal hypertension. J Gastroenterol Hepatol 1995;10: Ohnishi K, Saito M, Sato S, et al. Direction of splenic venous flow assessed by pulsed Doppler flowmetry in patients with a large splenorenal shunt. Relation to spontaneous hepatic encephalopathy. Gastroenterology 1985;89: Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988;95: Arakawa M, Masuzaki T, Okuda K. Pathomorphology of esophageal and gastric varices. Semin Liver Dis 2002;22: Wu CY, Yeh HZ, Chen GH. Pharmacologic efficacy in gastric variceal rebleeding and survival: including multivariate analysis. J Clin Gastroenterol 2002;35: Lo GH, Liang HL, Chen WC, et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy 2007;39: Soehendra N, Nam VC, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 1986;18: Japanese Research Society for Portal Hypertension. The general rules for recording endoscopic findings on esophageal varices. Jpn J Surg 1980;10: Feretis C, Tabakopoulos D, Benakis P, Xenofontos M, Golematis B. Endoscopic hemostasis of esophageal and gastric variceal bleeding with Histoacryl. Endoscopy 1990;22: Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 1996; 11: Hirota S, Matsumoto S, Tomita M, Sako M, Kono M. Retrograde transvenous obliteration of gastric varices. Radiology 1999; 211: Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: Its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003;4: Baik GH, Kim DJ, Lee HG, et al. Therapeutic efficacy of balloon-occluded retrograde transvenous obliteration in the treatment of gastric varices in cirrhotic patients with gastrorenal shunt. Korean J Gastroenterol 2004;43: Vol. 57 No. 5, May 2011

7 308 민슬기등. 위정맥류출혈에대한치료법간의효과비교 17. Garcia-Pagán JC, Bosch J. Endoscopic band ligation in the treatment of portal hypertension. Nat Clin Pract Gastroenterol Hepatol 2005;2: Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K. Endoscopic classification of gastric varices. Gastrointest Endosc 1990;36: Ramond MJ, Valla D, Mosnier JF, et al. Successful endoscopic obturation of gastric varices with butyl cyanoacrylate. Hepatology 1989;10: Hou MC, Lin HC, Kuo BI, Lee FY, Schmidt CM, Lee SD. Clinical implications of the white nipple sign and its role in the diagnosis of esophageal variceal hemorrhage. Am J Gastroenterol 1996; 91: Mitchell KJ, MacDougall BR, Silk DB, Williams R. A prospective reappraisal of emergency endoscopy in patients with portal hypertension. Scand J Gastroenterol 1982;17: Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices. Part 1. Anatomic classification. Radiographics 2003;23: Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol 1996; 167: Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg 2001;18: Binmoeller KF, Soehendra N. "Superglue": the answer to variceal bleeding and fundal varices? Endoscopy 1995;27: Huang YH, Yeh HZ, Chen GH, et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000;52: Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 2001;33: Sarin SK, Jain AK, Jain M, Gupta R. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices. Am J Gastroenterol 2002;97: Tan YM, Goh KL, Kamarulzaman A, et al. Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate. Gastrointest Endosc 2002;55: Roesch W, Rexroth G. Pulmonary, cerebral and coronary emboli during bucrylate injection of bleeding fundic varices. Endoscopy 1998;30:S89-S Akahoshi T, Hashizume M, Shimabukuro R, et al. Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience. Surgery 2002;131(1 Suppl):S176-S Evrard S, Dumonceau JM, Delhaye M, Golstein P, Devière J, Le Moine O. Endoscopic histoacryl obliteration vs. propranolol in the prevention of esophagogastric variceal rebleeding: a randomized trial. Endoscopy 2003;35: Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995;123: Lo GH, Lai KH, Cheng JS, et al. Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial. Hepatology 2000;32: Kim ES, Park SY, Kwon KT, et al. The clinical usefulness of balloon occluded retrograde transvenous obliteration in gastric variceal bleeding. Korean J Hepatol 2003;9: The Korean Journal of Gastroenterology

Original Article pissn J Korean Soc Radiol 2011;65(4): Comparison of Coil Embolization and Slcerotherapy of Collateral Veins during B

Original Article pissn J Korean Soc Radiol 2011;65(4): Comparison of Coil Embolization and Slcerotherapy of Collateral Veins during B Original Article pissn 1738-2637 J Korean Soc Radiol 2011;65(4):357-363 Comparison of Coil Embolization and Slcerotherapy of Collateral Veins during Balloon Occluded Retrograde Transvenous Obliteration: