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stent, and (left) stent introducer set (guiding tip, compressed stent,

Notice the coaxially inserted covered stent (arrows) into the tubular

Gastric carcinoma in a 72-yearold man. A.

2 Fig. 1. Photograph of (right) a newly designed complex expandable nitinol stent, and (left) stent introducer set (guiding tip, compressed stent, pusher catheter, introducing tube). Notice the coaxially inserted covered stent (arrows) into the tubular uncovered stent (arrowheads). Fig. 2. Gastric carcinoma in a 72-yearold man. A. Upper gastrointestinal study performed before stent placement shows stenosis (arrow) in the antrum of the stomach. B. Upper gastrointestinal study performed after stent placement shows good barium flow through the stent (arrows). A B 412

3 Fig 3. Food intake capacity before(black bars) and after(gray bars) stent placement. Grade 0= able to tolerate solid food. Grade 1= able to tolerate soft food. Grade 2= able to tolerate thick liquids. Grade 3= able to tolerate water or clear fluids. Grade 4= unable to tolerate anything perorally. 413

정미희 외: 새로 고안된 복합형 팽창성 나이티놀 스텐트를 이용한 악성 위 십이지장 협착의 치료 A B C D Fig. 4. Pancreatic carcinoma in a 66year-old man. A. Upper gastrointestinal study performed before stent placement shows obstruction in the second portion of the duodenum.

Percutaneous transhepatic choangiogram obtained 26 days after stent placement shows obstruction of bile duct at mid CBD level. D.

Note reflux of contrast media through the patent duodenal stent (arrow). 텐트 설치도 두 번을 해야하는 번거로움이 있었다.

저자들의 연구에서의 스텐트 전위의 빈도는 3% 로 낮았으며, 그 이유는 Jung 등(18)의 연구에서와 마찬가지 로 바깥쪽의 비피복형 스텐트가 종양 또는 조직 내에 스며들 면서 비교적 안정성 있게 고정되고 이와 함께 내부의 피복형 스텐트의 전위를 막아주는 역할을 하는 것으로 생각된다.

4 정미희 외: 새로 고안된 복합형 팽창성 나이티놀 스텐트를 이용한 악성 위 십이지장 협착의 치료 A B C D Fig. 4. Pancreatic carcinoma in a 66year-old man. A. Upper gastrointestinal study performed before stent placement shows obstruction in the second portion of the duodenum. B. Upper gastrointestinal study performed 1 day after stent placement shows good barium flow through the stent. C. Percutaneous transhepatic choangiogram obtained 26 days after stent placement shows obstruction of bile duct at mid CBD level. D. Percutaneous transhepatic choangiogram obtained just after biliary stent placement shows flow of the contrast media through biliary stent. Note reflux of contrast media through the patent duodenal stent (arrow). 텐트 설치도 두 번을 해야하는 번거로움이 있었다. 이에 저자 들은 피복형 스텐트와 비피복형 스텐트를 결합시켜 일체형으 로 제작함으로써, 시술의 번거로움을 줄일 수 있을 뿐만 아니 라 스텐트의 안정성도 더 증가시킬 수 있다는 가정 하에 연구 를 시행하였다. 저자들의 연구에서의 스텐트 전위의 빈도는 3% 로 낮았으며, 그 이유는 Jung 등(18)의 연구에서와 마찬가지 로 바깥쪽의 비피복형 스텐트가 종양 또는 조직 내에 스며들 면서 비교적 안정성 있게 고정되고 이와 함께 내부의 피복형 스텐트의 전위를 막아주는 역할을 하는 것으로 생각된다. 따 라서 저자들이 사용한 스텐트가 피복형 스텐트의 안정성을 높 이는 한 방법으로 사용될 수 있을 것으로 생각되며, 더 많은 환자들을 대상으로 계속 연구할 가치가 있다고 생각된다. 위 십이지장 협착의 스텐트 설치 시에는 식도와 위유문부 사이, 그리고 위유문부와 십이지장 사이에 형성된 심한 굴곡 으로 인해 스텐트 유도기구의 삽입 시에 팽만된 위강 내에서 유도기구가 빈번히 만곡형성을 함으로써 시술이 어렵다. 따라 서 이 부위에서는 스텐트 유도기구의 직경이 작을수록 시술이 쉽고 안전하다. Song 등(17)은 이러한 목적을 위해 외경 3.8 mm의 유도기구에 장착할 수 있는 새로운 이중 스텐트(dual stent)를 개발하였으며, 기존의 6 mm 유도기구를 사용하는 스 텐트에 비해 시술의 편리성과 안전성을 보고하였다. 그러나 이 들의 방법도 Jung 등(18)의 방법과 마찬가지로 스텐트 설치 를 동시에 두 번을 해야 하는 번거로움이 있다고 보고하였다 (17). 저자들의 연구에서는 기존의 스텐트와 마찬가지로 외경 6 mm의 유도기구를 사용하였으나 전예에서 스텐트를 성공적 으로 설치하였으며 기술적으로도 큰 어려움이 없었다. 저자들 은 시술 전에 비위관을 삽입하여 위내강을 충분히 감압한 후 에 시술을 하였으며 이것이 시술 성공률을 높인 원인의 하나 라고 생각된다. 저자들의 경험으로는 위협착보다 십이지장 협 착에서 위내강의 확장이 더 심했으며 따라서 십이지장 협착 환자에서 시술 전에 감압을 더 충분히 해야 기술적 성공률을 높일 수 있을 것으로 생각된다. 저자들은 십이지장 협착 환자 에서는 비위관을 삽입한 후 가능한 3일 이상 위내강을 감압한 후에 스텐트 설치 시술을 하였다. 스텐트 설치 후 97%의 환 자에서 증상호전을 보였으며, 대부분의 환자에서 추적기간동 안 증상호전이 유지되었다. Jung 등(18)은 장기 개통성을 저해하는 가장 흔한 요인은 스텐트 양 끝단에서의 종양 성장에 의한 스텐트 재협착으로 약 15%에서 발생하였다고 보고하였다. 저자들의 연구에서도 장기 생존자들에서 증상 재발의 흔한 원인이 스텐트 양 끝단 414

5 stenoses of the stomach and duodenum: treatment with self-expanding metallic endoprostheses. Radiology 1996;199: Feretis C, Benakis P, Dimopoulos C, Georgopoulos K, Milas F, Manouras A, et al. Palliation of malignant gastric outlet obstruction with self-expanding metal stents. Endoscopy 1996;28: Pinto IT. Malignant gastric and duodenal stenosis: palliation by peroral implantation of a self-expanding metallic stent. Cardiovascular Intervent Radiol 1997;20: Yates MR III, Morgan DE, Baron TH. Palliation of malignant gastric and small intestinal strictures with self-expandable metal stents. Endoscopy 1998;30: Bethge N, Breitkreutz C, Vakil N. Metal stents for the palliation of inoperable upper gastrointestinal stenoses. Am J Gastroenterol 1998;93: de Baere T, Harry G, Ducreux M, Elias D, Briquet R, Kuoch V, et al. Self-expanding metallic stents as palliative treatment of malignant gastroduodenal stenosis. AJR Am J Roentgenol 1997;169: Soetikno RM, Lichtenstein DR, Vandervoort J, Wong RC. Roston AD, Slivka A, et al. Palliation of malignant gastric outlet obstruction using an endoscopically placed Wallstent. Gastrointest Endosc 1998;47: Nevitt AW, Vida F, Kozarek RA, Traverso LW, Raltz SL. Expandable metallic prostheses for malignant obstructions of gas- outlet and proximal small bowel. Gastrointest Endosc 1998;47: tric Morgan R, Adam A. Use of metallic stents and balloons in the esophageal and gastrointestinal tract. J Vasc Interv Radiol 2001;12: Mauro MA, Koehler RE, Baron TH. Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology 2000;215: Jung GS, Song HY, Kang SK, Huh JD, Park SJ, Koo JY, et al. Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience. Radiology 2000;216: Park KB, Do YS, Kang WK, Choo SW, Han YH, Suh SW, et al. Malignant obstruction of gastric outlet and duodenum: palliation with flexible covered metallic stent. Radiology 2001;219: Jeong JY, Han JK, Kim AY, Lee KH, Lee JY, Kang JW, et al. Fluoroscopically guided placement of a covered self-expandable metallic stent for malignant antroduodenal obstructions. AJR Am J Roentgenol 2002;178: ,,,,,. :. 2002;46: Adam A, Morgan R, Ellul J, Mason RC. A new design of the esophageal wallstent endoprosthesis resistant to distal migration. AJR Am J Roentgenol 1998;170: Song HY, Do YS, Han YM, Sung KB, Choi EK, Sohn KH, et al. Covered, expandable esophageal metallic stent tubes: experiences in 119 patients. Radiology 1994;193: Song HY, Shin JH, Yoon CJ, Lee GH, Kim TW, Lee SK, et al. A dual expandable nitinol stent: experience in 102 patients with malignant gastroduodenal strictures. J Vasc Interv Radiol 2004;15: Jung GS, Song HY, Seo TS, Park SJ, Koo JY, Huh JD, et al. Malignant gastric outlet obstructions: treatment by means of coaxial placement of uncovered and covered expandable nitinol stens. J Vasc Interv Radiol 2002;13: Monson, JR, Donohue JH, Mcllrath DC, Farnell MB, Ilstrup DM. 1. Binkert CA, Jost R, Steiner A, Zollikofer CL. Benign and malignant Total gastrectomy for advanced cancer: a worthwhile palliative 415

6 procedure. Cancer 1991;68: Kikuchi S, Tsutsumi O, Kobayashi N, Tsukamoto H, Shimao H, Sakakibara Y, et al. Does gastrojejunostomy for unresectable cancer of the gastric antrum offer satisfactory palliation? Hapatogastroenterology 1999;46: Song HY, Yang DH, Kuh JH, Choi KC. Obstructing cancer of the gastric antrum: palliative treatment with covered metallic stents. Radiology 1993;187: Maetani I, Ogawa S, Hoshi H, Sato M, Yoshioka H, Igarashi Y, et al. Self expanding metal stents for palliative treatment of malignant biliary and duodenal stenoses. Endoscopy 1994;26: Treatment of Malignant Gastroduodenal Obstruction with Using a Newly Designed Complex Expandable Nitinol Stent: Initial Experiences 1 Mi Hee Jung, M.D., Gyoo Sik Jung, M.D. 2, Ji Ho Ko, M.D., Eun Jung Lee, M.D., Kyeng Seung Oh, M.D., Jin Do Huh, M.D., Young Duk Cho, M.D., Seun Ja Park, M.D. 3 1 Department of Diagnostic Radiology, Gospel Hospital, College of Medicine, Kosin University 2 Department of Diagnostic Radiology, Ulsan Hospital 3 Department of Internal Medicine, Gospel Hospital, College of Medicine, Kosin University Purpose: We wanted to evaluate the usefulness of a new type of a complex expandable nitinol stent that was designed to reduce the stent s propensity to migration during the treatment of malignant gastroduodenal obstructions. Materials and Methods: Two types of expandable nitinol stent were constructed by weaving a single thread of 0.2mm nitinol wire in a tubular configuration: an uncovered stent 18mm in diameter and a covered stent 16mm in diameter. Both ends of the covered stent were fabricated by coaxially inserting the covered stent into the tubular uncovered stent and then attaching the two stents together with using nylon monofilament. Under fluoroscopic guidance, the stent was placed in 29 consecutive patients (20 men and 9 women, mean age: 65 years) who were suffering with malignant gastric outlet obstruction (n=20), duodenal obstruction (n=6) or combined obstruction (n=3). Clinical improvement was assessed by comparing the food intake capacity before and after the procedure. The complications were investigated during the follow up period. Results: Stent placement was successful in all the patients. After stent placement, the symptoms improved in all but one patient. During the follow up, stent migration occurred in one patient (3%) at 34 days after the procedure. Despite the stent migration, the patient was able to resume a soft diet. Six patients developed recurrent symptoms of obstruction with tumor overgrowth at a mean of 145 days after the procedure; all the patients underwent coaxial placement of an additional stent with good results. One patient showed recurrence of obstruction due to tumor in-growth, and this was treated by placement of a second stent. Two patients with stent placement in the duodenum suffered from jaundice 26 days and 65 days, respectively, after their procedures. Conclusion: Placement of the newly designed complex expandable nitinol stent seems to be effective for the palliative treatment of malignant gastroduodenal obstructions. The new stent also seems to help overcome the disadvantage of the increased migration observed for the covered stent. Index words : Duodenum, stenosis or obstruction Gastrointestinal tract, interventional procedure Stents and prostheses Stomach, stenosis or obstruction Address reprint requests to : Gyoo Sik Jung, M.D., Department of Radiology, Ulsan Hospital, Sinjeong 5-dong, Nam-gu, Ulsan , South Korea. Tel Fax gsjung@medimail.co.kr 416

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical