대한방사선의학회지 1993; 29 (4) : 742~746 Journal of Korean Radiological Society, July, 1993 위공장문합부위협착의풍선확장술을이용한치료 전북대학교의과대학진단방사선과학교실 -Abstract - 최연화 * 송호영 **

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1 대한방사선의학회지 1993; 29 (4) : 742~746 Journal of Korean Radiological Society, July, 1993 위공장문합부위협착의풍선확장술을이용한치료 전북대학교의과대학진단방사선과학교실 -Abstract - 최연화 * 송호영 ** 한영민 전수빈 정경호 김종수 최기절 Balloon Dilatation for the Treatment of Stricture of Gastrojejunostomy Yeon Hwa Choi, M.D 긴 Ho Young 80ng, M.D.**, Young Min Han, M.D., 8u Bin Chon, M.D., Gyung Ho Chung, M.D., Chong 800 Kim, M.D., Ki Chul Choi, M.D. Deþartment 01 Radiology, College 01 Mediciη e, Chonbuk National University Enteroenteric anastomotic strictures of UGI tract are common and require treatment if significant obstruction occurs. We performed fluoroscopic guided balloon dilatation in 6 patients who had symptomatic stricture of gastrojejunostomy. The stricture was successfully resolved in 4 patients with benign stricture. But 2 patients with malignant stricture had recurrence of obstructive symptom 2 weeks later, and they required a stent. Asymptomatic balloon rupture was seen in one patient, but other procedural complications did not occur. We found that fluoroscopic guided balloon dilatation is an effective and safe method in the treatment of anastomotic stricture of gastrojejunostomy. We 허 so found transient effect in malignant gastrojejunal anastomotic strictures, which required an interventional procedure, such as placement of a stent. Index Words: Gastrointestinal tract, obstruction Intestines, surgery Intestines, transluiiùnal angioplasty 서 론 없다 (5, 8). 이에저자들은위공장문합부위협착환자에서 풍선확장술을시행하여이의안정성및효과를알아보고 위암또는위궤양으로위를부분적으로절제한후위공장문합부위에발생하는협착은 4-6% 로보고되고있다 (1, 2). 대부분의경우보존적치료방법으로호전이되나 폐쇄증상을초래하는심한협착의경우는재수술로써치료해왔다. 1974년 Gruntzig와 Hopff ( 3) 가카테타를이용하여동맥의확장을시도한이후최근에는소화기관의협착병변을확장시키는데국내외적으로좋은결과를보이고있다 (4 - 끼. 그러나위공장문합술후발생한접합부협착증을풍선확장술로치료한보고는적으며국내에서는 자하였다. 대상및방법지난 7년동안풍선카테타를이용하여위공장문합부위협착을치료한 6명의환자를대상으로총 1 8회의확장술을실시하였다. 환자의연령분포는 48세에서 69세였고 ( 평균, 58) 세모두남자였다. 위공장문합술을받게된원인질환은위암 5예, 만성십이지장궤양 1예였으며모두연 * 청주리라병원진단방사선과 * Department 01 Radiology, Lee Rha Hospital, Chμng Iμ. ** 울산대학교의과대학진단방사선과학교실 ** Dφartmeη t 01 Radiology, Asan Medical Ceη ter, University 01 Ulsaη College 01 Mediciηe 이논문은 1993 년 1 월 5 일접수하여 년 3 월 12 일에채택되었음

2 최연화외 : 위공장문합부위협착의풍선확장술 Table 1. Data in 6 Patients of Gastrojejunostomic Stricture Case Cause Agej Sex No.of Ballon trial size (mm) Gastric cancer 57j M * Gastric cancer 57jM Chronic duodenal 48jM 2 15 ulcer 4 Gastric cancer 48jM * Gastric cancer 69j M Gastric cancer 61 jm 3 15 * malignant stricture Interval #: Duration between gastr 이 ejunostomy and symptomatic recurrence. Interval*: Duration between symptomatic recurrence and balloon dilatation. Inteπal# (month) Mωm 6 Interval* (day) 얘Umm % 하곤란, 위팽만감, 잦은구토를주소로내원하였다. 모든 환자는내시경을통하여협착의양상을보고, 재발유무 환자의인후부에국소적마취제인리도카인 (Lidocaine) 을살포하고 10cc 정도의회석된바륨을삼키게 및악성변화를확진하기위하여조직검사를시행하였다. 내시경소견및조직검사상양성협착이 4예, 악성협착이 2예였다. 시술전위장관촬영상문합부협착을확인하였다. 수술후첫증상이발현하기까지기간은 1개월에서 30 개월까지다양하였고, 증상발현후풍선카테타에의한확장술실시사이의기간은 5일에서 30일까지였다 ( Tab l e 1). 한후구강을통하여안내철사를따라협착부위에풍선카테타를위치하여풍선의허리 ( waist) 가없어질때까지 2 회내지 3회정도반복하여확장시켰다. 풍선의팽창은 l 회에 30초에서 1분정도유지하였으며풍선을팽창시켜확장하는중간에 1분정도의풍선의압력을빼는간격을유지하였다. 협착부위가좁아서안내철사의삽입이힘든경우는 7Fr Head Hunter 카테타 ( Cook, Bloomington, a b c Fig. 1. Case 3: Benign stricture a. UGI series shows abrupt narrowing of anastomotic site after subtotal gastrectomy. b. Dilatation with a balloon catheter of 20mm diameter and 4cm in length shows full dilatation at the level of the stricture c. UGI series obtained after one session balloon dilatation shows good flow of barium. 짧

대한방사선의학회지 1993; 29(4) : 742~746 a b c Fig. 2. Case 5: Malignant stricture a. UGI series shows irregular narrowing of anastomotic site after subtotal gastrectomy b.

3 대한방사선의학회지 1993; 29(4) : 742~746 a b c Fig. 2. Case 5: Malignant stricture a. UGI series shows irregular narrowing of anastomotic site after subtotal gastrectomy b. Dilatation with a balloon catheter of 20mm diameter and 8cm in length shows full dilatation at level of the stncture. c. UGI series after stent placement with 18mm diameter and 6cm in length shows good f10w of the barium. U.S.A ) 를이용하였다. 풍선 ( Meditech, Boston, U.S.A) 의직경은 8mm- 20mm, 길이는 3cm-8cm까지사 용하였으며부풀리지않은 15mm 흉선의삽입이힘든정도로협착이심한경우는직경이적은풍선부터시작하여점차큰풍선을이용하였고협착이심하지않은경우는처음부터 15mm 풍선을사용하여허리 ( waist) 가없어질때까지확장시켰다. 15mm 풍선으로넓히는데별어려움이없는경우는 20mm 풍선까지사용하였다. 시술이끝난직후위장관촬영을시행하여협착부위의확장정도를관찰하였다. 불구하고증상의호전이없어 팽창성금속스댄트 (Sewon Medical, Seoul, Korea) 를삽입하였다 ( Fig. 2). 풍선카테타확장술의시술도중천공이나유출등의심 한합병증은발생하지않았다. 그러나악성협착을가진 1 예에서 20mm 직경, 4cm 길이의풍선카테타 (Meditech. Boston, U.S.A) 를사용하여시술중풍선이파열된경우 가있었으나환자가통증등의증상을호소하지않았고확 장후바로실시한위장관촬영상장파열의증거가보이지 않아다른 20mm 풍선 (Meditech, Boston, U.S.A) 을 이용하여실시하였다. 결 과 고 찰 총 6명의환자에서환자당 2회에서 4회까지풍선카테타를이용하여, 총 18회에걸쳐확장을실시하였다. 풍선카테타에의한확장후양성협착을가진 4명의환자에서는방사선학적으로직경의증가와임상증상의호전을보여고형식을섭취할수있었다 (F ig. 1). 이중 1예는 4개월후에재발하여풍선확장술을반복실시하여임상증상이호전되었다. 악성협착을가진 2명의환자에서는시술직후에는고형식을섭취할수있었으나모두 2주이내에연하곤란을호소하여풍선확장술을반복실시하였는데도 상부위장관협착의비수술적치료는 1821년 Hildreth ( 9 ) 가식도협착의치료로써부지법을도입한후시작되었다. 1981년 London등 ( 10 ) 은 x -선투시하에서의풍선카테타를협착의치료에처음사용하였으며적은탄성의이중내경 ( double lumen) 카테타가 Gruntzig 등 ( 3) 에의해개발됨으로써더욱기술적인진보를할수있었다 (11). 그이후식도뿐만아니라상부위장관의다양한협착치료로써효과적이고안전한시술법으로널리이용되고있다 ( ) _ 744 -

4 최연화오1: 위공장문합부위협착의풍선확장술 풍선카테타의장점은첫째, 확장시술도중협착부위에 고정적위치에서단지방사상의힘만을가하여협착부위 에만그힘이전달되어장파열의위험이감소한다. 둘째, 풍선카테타확장은지속적인 x - 선투시하에서조영제를 이용하여협착부위뿐만아니라그상하부위를볼수있기 때문에풍선의위치와팽창의정도를눈으로보면서시행 하기때문에시술중의모든과정의관찰이가능하여안전 하다고하였다 ( 5; 17). Gotb erg등 (1 7) 은위장관문합술후문합부위에서발 생한협착은환상협착이므로약간의직경의증가만있어 도횡단면적에서는이와비례해서큰효과를가지기때문 에음식물통과가가능하다고하였다. 비록협착직경의 변화가중요하지만풍선확장술의성공여부의판정은임상 적반응이가장중요한것으로여러저자들에의해생각 되어져왔다 ( ). 그러므로성공적인확장은환자의 폐쇄증상의개선으로서, 정하였다. 재발은폐쇄증상의발생으로확 McLean 등은위공장문합부위협착의경우 15mm 직 경의풍선이가장유효하다고하였으며, 식도협착의경우 내경 20mm 이상인경우는대부분의환자에서증상없이 정규적인식사를할수있다고하였다 ( 5, 2 0 ). 저자들은 첫시술시국내외보고가없어식도협착의확장술과동일 하게협착부위확장의효과를증대키위해점차적으로풍 선의직경을증가시켜 20mm 직경의풍선까지사용하였 다. 확장은풍선의허리 ( waist) 가없어질때까지시행하 였으나풍선의파열이나환자가심한통증을호소할때는 풍선확장술을중단하였다 ( 20). 결론적으로위공장문합부협착중악성협착에서는풍선 확장술후 2 주이내에연하곤란, 위팽만감등의증상이재발 하여효과가일시적이므로스멘트와같은다른중재적시 술이필요할것으로생각된다 ( 23). 그러나양성협착경우 모두에서협착부위의성공적인확장을보여안전하고효 과적인시술이라생각된다. 참고문헌 l. Coben WN. Mason EE, Biommers TJ. Gastric bypass for morbid obesity. Radiology 1977; 122: Griffen WO JR, Bell RM. Surgical approaches to morbid obesity. Contemp Surg 1983; 23: Gruntzig A, Hopff H. Perkutane rekanalisation chronisch arterieller verschlusse mit einen dilata- tion katheter. Dtsch med wochs 1974; 99: 이길우, 임효근, 주인옥등. 상부소화관협착에서풍선카 테타확장의결과. 대한방사선의학회지 1990 ; Edward E. ed range, Shaffer HA J R. Anastomotic stricture of UGr tract: Results of balloon dilatation. Radiology 1988; 167: 서정진, 정선관, 김재규, 정연대. 풍선카테타를이용한 식도성형술. 대한방사선의학회지 1990 ; 26 : Steven LD, Peter RM, Joseph TF, James MR. et al. Severe esophageal stricture; Indication for balloon catheter dilatation. Radiology 1984; 153: Gordon KM, Gregory SC, Williams HH, et 머. Radiologically guided balloon dilatation of gastrointestinal stricture. Radiology 1989; 165: Hildreth CT. Stricture of esophagus. N Engl J Med Surg 1821; 10: London RL, Trotman BW, Di Marino AJ. et 외. Dilatation of severe esophageal stricture by an inflatable balloon catheter. Gastroenterology 1981; 80: Pattersonn DJ, Graham DY. Natural histoiγ of beni 망 1 esophageal stricture treated by dilatation. Gastroenterology 1983; 85: Maynar M, Guerra C, Reyes R. et al. Esophageal stricture; balloon dilatation. Radiology 1988; 167: G 이 dtham JF, Ball WS, Wilkinson LG, et 떠. Esophageal stricture in children; Treatment by serial balloon catheter dilatation. 1984; 153: Radiology 14. McLean GK, Cooper GS, Hartz WH, Burke, Meranze SG. Radiologically guided balloon dilatation of gastrointestinal stricture. Radiology 1987; 165: Ho Young Song, Young Min Han, Hak Nam Kim, Chong Soo Kim, Ki Chul Choi. Corrosive esophageal stricture; sefety and effectiveness of balloon dilatation. Radiology 1992; 184: 전동권, 송호영, 한영민, 김학남, 김종수, 최기철. 풍 선식도확장술 : 100 예에서의경험. 지 1991 ; 27(6) : 대한방사선의학회 % 에

5 대한방사선의학회지 1993 ; 29 (4) : 742~ Gotberg S, Afzelius LE, Hamcraeus G. Balloon catheter dilatation of stricture in upper digestive tract. Radiology 1982; 22: Starck E, Paolucci VP, Heszer M. Esophageal stenosis: treatment by balloon catheters. Radiology 1984; 153: Dawson SC, Mueller PR, Ferrucci JJ. Severe esophageal stricture: indication for balloon cath eter dilatation. Radiology 1984; 153: McLean GK, Cooper GS, Hartz WH. et al. Radiologically 밍 Iided balloon dilatation of gastrointestinal stricture 1. technique and factors influencing procedural success. Radiology 1987; 165: Kollath J, Starck E, Vittorio D. Dilatation of esophageal stenosis by balloon dilatation Cardiovas Interven Radiology 1984; 7: Kozzrek, RA. Hydrostatic balloon dilatation of gastrointestinal stenoses. A national Survey Gastrointes endosc 1986; 32: Ho Young Song, Ki Chul Choi, Baik Hwan Cho. et al. Esophagogastric neoplasm; Palliation with a modified Gianturco stent. Radiology 1991; 180:

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar