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1 대한내시경복강경외과학회지 Vol. 10. No. 1, 2007 거대총담관결석환자에서선택적으로시행된복강경총담관탐색술 원저 을지대학교을지병원외과학교실 김동희 Selective Performed Laparoscopic Common Bile Duct Exploration for Patients with Large CBD Stones Dong Hee Kim, M.D. Department of Surgery, Eulji General Hospital, Eulji University College of Medicine, Seoul, Korea Purpose: Although application of laparoscopic common bile duct exploration (LCBDE) has been growing, the initial treatment during recent decades for large common bile duct (CBD) stones has been endoscopic sphincterotomy (EST) or endoscopic papillary ballon dilatation (EPBD). However, performing EST or EPBD for patients with large CBD stones requires a prolonged time or repeated sessions for removal of large CBD stones. The aim of this study was to evaluate the clinical benefits of LCBDE for patients with large CBD stones. Methods: From January 2003 to December 2006, we conducted a retrospective study to compare LCBDE (n=37) with EST or EPBD (n=55) for the management of patients with large CBD stones that were more than 15 mm in maximum diameter. Result: All the LCBDEs were performed via choledochotomy with T-tube placement. The mean operation time was 134.1±15.7 minutes. The postoperative hospital stay was statistically shorter in the LCBDE (8.35±3.2 days) group than in the EST or EPBD (10.7±3.1 days) groups (p<0.003). The difference in the average number of sessions needed for complete clearance of choledocholithiasis in each group was statistically significant (LCBDE, 1.1±0.1; EST or EPBD, 2.8±0.8; p<0.001). Only 2 patients (5.4%) required postoperative choledochoscopy to clear residual stones through the T-tube tract in the LCBDE group. The morbidity rate was not statistically different between the LCBDE group and the EST or EPBD groups (p>0.05). Conclusion: The above results suggested that LCBDE for patients with large CBD stones tended to require a shorter postoperative hospitalization and less sessions for complete removal of larger CBD stones than did endoscopic treatment. Key words: Laparoscopy, Surgery, Common bile duct stones 중심단어 : 복강경, 수술, 총담관결석 서 1980년대후반에복강경담낭절제술이처음시행된이래로오늘날에는담석증및담낭염환자에서일차적으로고려할수있는표준치료방법으로인정되고있다. 1 반면에담낭결석환자의 10% 전후에서동반되는총담관결석의치료방법은내시경기술의발달로과거의고전적인개복술을대신하여내시경역행성췌담관조영술및유두괄약근절개술이도입되어내시경을이용한총담관결석의제거후이차적으로복강경담낭절제술을시행하는방법이일반적인추세이다. 2,3 그러나최근 10 여년간외과적인복강경술기의발달로복강경총담관탐색술이안전하게시행되고있으며내시경괄약근절개술보다우수하다는몇몇 통신저자 : 김동희, 서울시노원구하계 1 동 우편번호 : , 을지대학교을지병원외과 Tel: , Fax: kdh2109@eulji.ac.kr 론 보고들도나오고있다. 4,5 그러나현재총담관결석환자에대한치료는각기관마다담당하는치료자의선호도및숙련도와그치료기관의특성에따라복강경시술과내시경시술이차지하는비율이다양하다. 문헌상내시경을이용한총담관결석제거가어려운위험인자로총담관결석의크기가 15 mm 이상, 결석의모양이술통혹은각진모양, 해부학적으로총담관원위부가좁아진경우등을보고하고있다. 6 그밖에환자의협조가되지않은경우와유두부주위의게실, 유두부협착, situs inversus 등이위험인자로보고되고있다. 7 이에저자는내시경을이용한총담관결석제거가어려운위험인자중총담관결석의크기가 15 mm 이상인환자군에대하여선택적으로복강경총담관탐색술 37예를시행하였기에같은시기에내시경을이용하여총담관결석을제거한후이차적으로복강경담낭절제술을시행받은 55 예와임상결과를비교하여문헌고찰과함께보고하는바이다. 22

choledochotomy) 을시행하였으며간내담석증이의심되는경우는배제하였다 (Fig. 1).

2 김동희 : 거대총담관결석환자에서선택적으로시행된복강경총담관탐색술 23 대상및방법 1) 대상및방법 2003년 1월부터 2006년 12월까지을지대학교을지병원에서입원후방사선검사상총담관결석이 15 mm 이상으로진단된총담관결석증환자 37명을대상으로하였다. 환자는본원외래와응급실에서복부초음파 (SONO), 복부전산화단층촬영 (CT), 자기공명담췌조영술 (MRCP) 등을통하여총담관의확장및총담관석의크기가 15 mm 이상인환자에대하여환자및보호자의동의하에복강경총담관탐색술및결석제거와 T자배액관삽입술 (Laparoscopic common bile duct exploration with T-tube choledochotomy) 을시행하였으며간내담석증이의심되는경우는배제하였다 (Fig. 1). 또한같은시기에거대총담관결석을내시경역행성담도조영술 (endoscopic retrograde cholangigraphy, ERC) 과괄약근절개술 (endoscopic sphincterotomy, EST) 및풍선을이용한유두확장술 (endoscopic papillary balloon dilatation, EPBD) 을통한내시경적제거를한후복강경담낭절제술을이차적으로시행받은 55예를대조군으로비교하였다. 저자는두그룹의환자들에대하여성별, 나이, 내과적동반질환유무, 총담관결석의크기및갯수, 입원기간, 합병증유무, 잔류담석유무및시술횟수등의임상결과를비교하였으며모든자료는의무기록지를이용하여후향적으로조사하였고통계분석은 SPSS 12.0을이용한 Paired- Samples T Test로분석하였다. p-value가 0.05 이하인경우를통계적으로유의한것으로평가하였다. 2) 수술방법수술은전신마취하에환자를앙와위 (supine position) 로눕히고 4 공식방법으로제대부직하방과검상돌기하방 10 cm 부위및우상복부늑하연에 10 mm 포트 (port) 를사용하 였고우하복부에담낭견인을위하여 5 mm 포트를삽입하여시행하였다. 이산화탄소로기복을형성한후역트렌델렌버그 (reverse Trendelenburg) 자세를취하였으며수술자가좌측에서우상복부및검상돌기하방의포트를이용하여먼저칼로삼각 (Calot's triangle) 과총담관을노출하고담낭관을 Vicry 1.0으로결찰절단을시행한후, 담낭동맥을 5 mm 클립으로결찰후절단하였다. 총담관탐색을용이하게하기위하여담낭을우상방으로견인한자세를유지하였으며총담관의절개는전방벽에수직절개를약 20 mm 정도전기소작기를이용하여시행하였다. 총담관경 (Choledochoscope) 을이용하여총담관절개창을통해삽입하여탐색한후 Dormia basket, Fogarty catheter 또는전기유압식쇄석술 (electrohydraulic lithotripsy, EHL) 등을이용하여결석을제거하였다. 결석이어느정도제거되었다고판단되면총담관경으로원위부와근위부에잔존결석의유무를확인한후만약잔존결석이존재하면다시결석제거를시도하였으며최종적으로잔존결석이없음을확인한후담즙배액및향후추적관찰을위하여모든예에서 T자배액관을삽입하고 Vicry 3.0으로단절봉합하였다. 그다음담낭와에부착되어있는담낭을절제한후 T자배액관을우상복부하연의포트를통해빼낸후수술을마쳤다. 수술후합병증발생이없는경우 24시간이후에식이를섭취하였으며수술후 7일째에 T자배액관을통하여방사선검사를시행한후잔존결석이없을경우 T자배액관을결찰후퇴원시켰다. 내시경적총담관결석제거를시행한경우전신마취의금기가되지않는한모든예에서외과로전과후조기에복강경담낭절제술을시행하였으며수술후특이합병증이없을경우 3일이내에조기퇴원하였다. 결과 1) 환자의특징및임상양상본원에서거대총담관결석으로진단을받은환자는총 Fig. 1. (A) Preoperative computed tomography image. Large stone (max. diameter: mm) was impacted in the common bile duct (black arrow). (B) Postoperative T- tube cholangiography. There is no remnant stone in common bile duct (black arrow). Previous trocar insertion site was noted in a state of closure with metallic staples (white arrow).

3 24 대한내시경복강경외과학회지제 10 권제 1 호 명으로복강경총담관탐색술을받은환자는 37예 (40.2%) 였다. 이중 12예 (13.0%) 는초기에내시경시술을시도하였으나실패한경우이며 25예 (27.2%) 는일차적으로복강경총담관탐색술을시행받았다. 환자군의연령은 48세에서 82세까지다양하였으며평균연령은 64.5±9.5세였다. 남녀비는남자가 23예 (62.3%), 여자가 14예 (37.8%) 로남자가두배가량많았으며수술전내과적전신질환을동반한경우는 8예 (21.6%) 로고혈압 6예 (16.2%), 당뇨 4예 (10.8%), 만성폐쇄성폐질환이 2예 (5.4%), 허혈성심질환이 1예 (8.3%) 있었으며그밖에간경변증 2예 (5.4%), 만성신부전증 1예 (2.7%) 가있었다. 상복부수술기왕력을가진경우가 2 예 (5.4%) 로모두위십이지장궤양천공으로 1예 (2.7%) 는일차봉합술, 다른 1예 (2.7%) 는미주신경절단술및유문성형술을시행받은경우로 2예모두초기에내시경을이용한총담관결석제거를시도하였으나실패하여복강경총담관탐색술을시행받은경우이다. 수술전진단된거대총담관결석의평균최대직경은 22±2.1 mm ( 범위 15 28) 였고결석의수는 9예 (24.3%) 에서 1개, 11예 (29.7%) 에서 2개, 17예 (46.0%) 에서 3개이상으로평균 2.1±1.1개였다. 반면에내시경시술을통해총담관결석을제거한경우는 55예 (59.8%) 로이중 34예 (61.8%) 에서입원기간중외과로전과되어복강경담낭절제술을받았으며 21예 (38.2%) 는증상의재발이나혹은적극적으로수술의안전성및필요성을환자에게권유하여재입원후복강경담낭절제술을시행하였다. 환자의연령은 42세에서 77세사이에분포하였으며평균연령은 62.5±8.4세였다. 남녀비는남자가 25예 (45.5%), 여자가 30예 (54.5%) 로여자가약간많았으며전신질환을동반한경우는 14예 (25.5%) 로고혈압 8예 (14.5%), 당뇨 14예 (25.5%) 였고평균결석의최대직경은 18±0.3 mm ( 범위 15 28) 였으며결석의수는 20예 (36.4%) 에서 1개, 26 예 (47.3%) 에서 2개, 9예 (16.4%) 에서 3개이상의결석을가지고있었으며평균 1.9±0.8개였다. 두환자군간의연령, 성비, 기저질환유무및총담관결석의크기와갯수는통계적으로유의한차이를보이지않았다 (p>0.05)(table 1). 2) 임상결과복강경총담관탐색술을시행받은 37예중 1예 (2.7%) 에서술통모양의거대담석이원위부담도에매복되어제거가불가능하여수술중개복으로전환하였고나머지 36예 (97.3%) 는성공적으로복강경수술이가능하였다. 평균수술시간은 134.1±15.7 ( ) 분으로점차횟수를거듭할수록수술시간은짧아지는경향이었다. 수술후평균재원기간은 8.35±3.2일 (7 25일) 로특별한합병증이없을경우보통수술후 7일째에 T 자관을통한담도조영술을시행하여담즙누출이나잔류담석이없음을확인한다음담즙배액관을짧게결찰한후당일이나그다음날퇴원하였다. 수술후잔류담석이있는경우는 2예 (5.4%) 로퇴원 4주 후에 T 자관을제거한후국소마취하에담도경을이용하여추가로총담관결석을제거하였으며, 그중 1예 (2.7%) 의경우 3차례에걸쳐잔류총담관석을제거하였다. 그외에 35예 (94.6%) 는수술중총담관석을모두제거할수있었으며평균시술횟수는 1.1±0.1(1 4) 회였다. 합병증은 6예 (16.2%) 에서발생하였으며개복으로전환한 1예 (2.7%), 잔류담석이있던 2예 (5.4%) 를제외하고 2예 (5.4%) 에서수술후 3일째에담즙누출이있었으나양이많지않아 2주이내에자연폐쇄되었으며, 그밖에 2예 (5.4%) 에서창상감염이있었으나경미한경우로입원기간등임상결과에큰영향을주지않았다. 반면에내시경을이용한거대총담관결석을제거한후복강경담낭절제술을시행받은경우첫내시경치료시기부터외과로전과되어수술을받기전까지의평균입원기간은 10.7±3.1일 (7 23일) 로복강경시술을받은환자보다 2일정도평균입원기간이길었으며평균시술횟수도 2.8±0.8 (1 6) 회로거대총담관결석을제거하기위하여평균 2회이상의내시경시술이필요하였다. 내시경시술을시행받은환자군이복강경수술을받은환자군보다통계적으로유의하게긴입원기간과반복적인시술횟수등을보였다 (p<0.05). 입원기간중발생한합병증은 6예 (10.9%) 에서발생하였으며 5예 (9.0%) 에서내시경시술후췌장염 Table 1. Demographic characteristics of the laparoscopic common bile duct exploration (LCBDE) and endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation (EPBD) patients LCBDE EST or EPBD p-value Number of patients (%) 37 (40.2) 55 (59.8) Mean age 64.5± ±8.4 NS* (range) (48 82) (42 77) Gender NS* Male (%) 23 (62.3) 14 (37.8) Female (%) 25 (45.5) 30 (54.5) Comorbid disease (%) 8 (21.6) 14 (25.5) NS* HTN 6 (16.2) 8 (14.5) NIDDM 4 (10.8) 14 (25.5) IHD 1 (8.3) 0 COPD 2 (5.4) 0 Others 3 (8.1) 0 Previous upper abdomen operation 2 (5.4) 0 Diameter of stones (mm) 22±2.1 18±0.3 NS* (range) (15 28) (15 28) Mean, number of stones 2.1± ±0.8 NS* *NS = not significant; HTN = hypertension; NIDDM = noninsulin-dependent diabetes mellitus; IHD = ischemic heart disease; COPD = chronic obstructive pulmonary disease; Includes LCBDE group: liver cirrhosis (n=2) and chronic renal failure (n=1).

4 김동희 : 거대총담관결석환자에서선택적으로시행된복강경총담관탐색술 25 Table 2. Clinical results of the laparoscopic common bile duct exploration (LCBDE) and endoscopic sphicterotomy (EST) or endoscopic papillary balloon dilatation (EPBD) patients LCBDE EST or EPBD p-value (n=37) (n=55) Mean operation time 134.1±15.7 (min) ( ) Mean postoperative 8.35± ±3.1 p<0.003 hospital stay (day) (7 25) (7 23) Average sessions 1.1± ±0.8 p<0.001 (1 4) (1 6) Complicaton (%) 6 (16.2) 6 (10.9) Pancreatitis 0 5 (9.0) Wound infection 2 (5.4) 0 Bleeding 0 1 (1.8) Bile leakage 2 (5.4) 0 Retained stone 2 (5.4) Conversion 1 (2.7) 이발생하였고 1예 (1.8%) 에서담도출혈이있었으나보존적치료로회복되었다. 복강경수술을받은환자군과내시경시술을받은환자군간의입원기간중발생한합병증발생율은통계적으로유의한차이를보이지않았다 (p> 0.05)(Table 2). 고 총담관결석은담석증환자의 10 15% 에서발견되며최근까지총담관결석의치료는내시경적역행성췌담관조영술을이용하여결석을제거하는방법이중요한치료방법으로여겨지고있다. 8 그러나대부분의총담관결석환자가담낭결석을동반하여이차적으로복강경담낭절제술을시행받아야한다는점에서복강경을이용하여한번의시술로치료가이루어진다는장점과더불어복강경술기의발달로점차복강경총담관탐색술이증가추세에있다. 최근에는국내에서도복강경총담관탐색술의안정성과효율성이내시경치료보다우수하다는보고가나오고있다 Libermann 등 13 은총담관결석이존재할경우복강경을이용한총담관결석의제거가이환율, 입원기간및의료비용측면에서내시경시술을받은환자군보다우수하다고보고하였으며, European Association of Endoscopic Surgeon (EAES) 14 의보고에의하면복강경총담관탐색술의이환율은 10% 정도로내시경괄약근절개술을시행받은환자군보다낮은합병증발생률을보인다고보고하였다. 그러나아직까지전신마취하에시행되는수술이라는점에서환자의거부감으로쉽게초기치료방법으로선택하기가어려우며, 치료자의복강경수술과내시경시술의숙련도차이로치 찰 료기관에따라복강경수술이차지하는비율이다양하다. 특히담낭결석이동반되지않은원발성총담관결석의치료의경우내시경괄약근절개술을이용한결석제거가일차적치료방법으로선택되어지고있다. 원발성총담관결석은서구보다우리나라와같은동북아에서흔하게나타나는질환으로병인기전상과거담도계내에기생충감염등이있은후총담관의반복적인염증반응으로총담관의확장을동반하며다발성의거대총담관결석이흔하게나타난다. 15 이러한거대총담관결석은내시경을이용한총담관결석제거성적에영향을주는위험인자로문헌보고상괄약근절개술후거대총담관결석의기계적쇄석술의경우 80% 이상의성공률을보이나담관손상등시술에따른합병증이보고되어최근에는풍선유두확장술을이용하여거대총담관결석을제거할경우시술시간의단축과합병증발생률을감소시킬수있다고보고하고있다. 16 그러나이방법역시유두부확장으로인한유두부기능부전이발생하여췌장염의발병을흔하게유발하여아직까지논란의여지가있다. 16,17 이에본원에서는내시경의사와사전협의하에 15 mm 이상의거대총담관결석의경우환자와보호자에게내시경을이용한결석제거방법과복강경총담관탐색술에대하여설명한후치료방법을선택하게하였다. 그러나대부분환자에서내시경시술을원하여전체 92예중 25예 (27.2%) 에서만일차적으로복강경총담관탐색술을시행하였고내시경시술을시도한 67예 (72.8%) 중 12예 (13.0%) 에서거대총담관결석제거의실패로복강경총담관탐색술을이차적으로시행받았다. 내시경을이용한결석제거의실패요인은대부분 70세이상의고령환자에서오랜시술시간및반복적인내시경삽입에대하여환자의협조가되지않아전신마취하에복강경총담관탐색술을시행하게되었다. 복강경수술시총담관결석의제거방법으로는담낭관을통한접근방법과총담관절개를통한접근방법이있는데담낭관을통한접근방법은총담관의절개와봉합등으로인한시간을절약할수있는등여러장점이있으나다발성결석이거나거대총담관결석의경우적용하기어렵다. 저자의경우모든예에서총담관을 20 mm 이상절개하고거대총담관결석을제거할수있었다. 이것은내시경을이용하여총담관결석을제거할경우발생할수있는출혈, 담관손상, 유두부기능부전, 췌장염의위험을막을수있었다. 18,19 결석의제거방법으로는 Forgaty 카테터를이용하여효과적으로결석을제거할수있으나만약제거가되지않을경우투시검사유도결석제거술 (fluoroscopy guided basket extraction) 이나총담관경을이용한결석제거술등이보고되고있다. 20,21 저자의경우도 Forgaty 카테터를이용하여일차적으로결석제거를시도하였으나술통모양의거대총담관결석의경우원위부담관에매복되어카테터가통과

5 26 대한내시경복강경외과학회지제 10 권제 1 호 2007 하지못하는경우 fluoroscopy나혹은총담관경을이용하여카테터에와이어 (wire) 를장착한후거대총담관결석이매복되어있는원위부담관을통과한후총담관결석을총담관절개창부위까지밀어올려복강경용겸자를이용하여결석을제거할수있었다. 그러나 1예에서술통모양의결석이원위부담도협착으로이루어진담도주변게실에매복되어담도손상의우려가있어개복술로전환한후결석겸자를사용하여결석을분쇄한후제거하였다. 총담관결석을제거한후배액술로는 T자관삽입법, ENBD, PTBD 및일시적인내부담관스텐트를이용하는방법이있다. 최근에 Decker 등 4 은담관배액술을사용하지않고단순봉합만으로도좋은수술결과를보고하고있으며특히총담관이확장된경우담도협착의가능성은희박하여유용하리라본다. 그러나유두부종으로압력이증가할경우봉합부전의가능성이있으며무엇보다도다발성총담관결석일경우잔류담석을간과할수있으리라본다. 저자의경우모든예에서 No. 4이나 No. 5 T자관을삽입하였다. T자관배액술은복강내담즙이고이는것을피하고, 총담관내담즙저류를예방하며, 담관내감압으로감염의위험성이적고특히수술후발생하는잔류담석의효과적인처치가가능하다. 복강경총담관탐색술을시행한 37예중수술후시행한담도조영술상 2예 (5.4%) 에서잔류담석이있었으나효과적으로경피총담관경을이용하여잔류담석을제거할수있었다. T자관배액술로인한출혈, 담즙성복막염등의합병증이증가한다고보고하였으나오히려저자의경우 2예 (5.4%) 에서발생한담즙누출의경우 T자관을통한담도내감압으로쉽게누출부위가폐쇄되어입원기간을줄일수있었다. 22,23 T자관을유치한상태로퇴원후사회생활로의복귀가어려워지는문제점도담도조영술후 T자관을결찰한후몸에서짧게하였을경우큰불편감없이생활할수있었다. 이상과같이복강경총담관탐색술은복강경수술을시행할때담낭결석과총담관결석을동시에치료할수있다는장점과함께총담관결석의치료에서내시경을이용한결석제거의위험인자중하나인 15 mm 이상의거대총담관결석제거에효과적이라사료된다. 다만이번연구에서몇가지보완해야할문제가있는데첫째, 대조군으로비교한내시경시술을받은환자중결석제거후이차적으로복강경담낭절제술을시행받지않고퇴원한환자의경우본원에서는거대총담관결석군에해당한경우담낭결석이없더라도만성담낭염으로간주하여입원기간중혹은차후에적극적으로복강경담낭절제술을권유하여모든예에서수술을시행하였다. 그러나차후에수술을받지않은경우의자연경과에대한전향적연구가필요하리라본다. 둘째, 복강경환자군의경우단일수술자에의하여시행되었으나내시경시술을시행받은환자군의경우다수의내시경의사에의하여시행된점으로보아숙련도의오차로 내시경시술의실패율 12/67 (17.9%) 이비교적높아보이나문헌보고상 24,25 거대총담관결석의내시경적제거의실패율은기관마다다양하나대략 3 27% 정도로보고하고있어본원과큰차이는없었다. 결 최근복강경총담관탐색술의시행이확대되고있으나아직까지총담관결석제거의일차적인치료방법은내시경을이용한방법이다. 하지만총담관결석제거가어려운 15 mm 이상의거대총담관결석의경우괄약근절개술및풍선을이용한유두부확장을통한내시경적결석제거시발생할수있는합병증, 잦은시술횟수및입원기간을고려할때복강경총담관탐색술을초기치료방법으로선택할수있으리라보며앞으로이에대한많은연구가필요하겠다. 론 참고문헌 1) The Southern Surgeon Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324: ) Sherman S, Gottlieb G, Lehhman A. Therapeutic biliary endoscopy. Endoscopy 1994;26: ) Wojtun S, Gil J, Gietka W, Gil M. Endoscopic sphincterotomy for choledocholithiasis: a prospective single center study on the shorterm and long-term treatment result in 483 patients. Endoscopy 1997;29: ) Decker G, Bori F, Milat B, et al. One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc 2003;17: ) Kim WW, Chun SW, Kim EK, Kim SN. Managing choledocholithiasis in the laparoscopic Era. J Korean Soc Endosc Laparosc Surg 1998;1: ) Siegel JH, Ben-Zvi JS, Pullano WE. Mechanical lithotripsy of common bile duct stones. Gastrointest Endosc 1990;36: ) Mathuna PM, White P, Clarke E, Merriman R, Lennon JR, Crowe J. Endoscopic balloon sphicteroplasty (papillary dilatation) for bile duct stones: efficacy, safety, and follow-up in 100 patients. Gastrointest Endosc 1995;42: ) Fink AS. Current dilemmas in management of common duct stones. Surg Endosc 1993;7: ) Park IY, Sung GY, Song MH, Lee DS, Kim W, Won JM. Primary common bile duct closure and antegrade stent insertion in choledocholithiasis patients. Korean J HBP Surg 2001;5: ) Lee JR, An HT. The safety and feasibility of laparoscopic exploration of common bile duct and choledochoscope in management of patients with choledocholithiasis. J Korean

6 김동희 : 거대총담관결석환자에서선택적으로시행된복강경총담관탐색술 27 Surg Soc 2005;69: ) Sung CW, Moon JH, Park SY, Kim WY. Comparison of open and laparoscopic common bile duct exploration for CBD stones. J Korean Soc Endosc Laparosc Surg 2005;7: ) Park JH, Choi IS, Choi WJ, Go DJ, Yoon DS. Laparoscopic CBD exploration without T-tube. J Korean Soc Endosc Laparosc Surg 2005;7: ) Liebermann MA, Phillips EH, Carroll BJ, Fallas MJ, Rosenthal R, Hiatt J. Cost-effective management of complicated choledocholithiasis: Laparoscopic transcystic duct exploration or endoscopic shphicterotomy. J Am Coll Surg 1996;182: ) Cushier A, Lezoche E, Morino M, et al. EAES multicenter prospective trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;17: ) Tazuma S. Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 2006;20: ) Hwang SJ, Kim YG, Lee KC, et al. Endoscopic sphicterotomy plus endoscopic papillary large balloon dilatation for large bile duct stone. Korean J Gastrointest Endosc 2006;32: ) Yoo BM. Endoscopic papillary balloon dilatation. Korean J Gastrointest Endosc 2005;31: ) Sugiyama M, Atomi Y. Follow up of more than 10 years after endoscopic sphincterotomy for choledocholithiasis in young patients. Br J Surg 1998;85: ) Bader MGJ, Hogan W. Endoscopic balloon dilatation of the sphincter of Oddi in patients with suspected biliary dyskinesia: results of a prospective randomized trial. Gastrointest Endosc 1986;32: ) Petelin JB. Laparoscopic common bile duct exploration. Surg Endosc 2003;17: ) Duensing RA, Williams RA, Collins JC, Wilson SE. Managing choledocholithiasis in the laparoscopic era. Am J Surg 1995; 70: ) Lygidaski NJ, Hazards following T-tube removal after choledochotomy. Surg Gynecol Obstet 1986;163: ) Corbett CRR, Fytfe NCM, Nichlls RJ, Jackson BT. Bile peritonitis after removal of T-tube from the common bile duct. Br J Surg 1986;73: ) Ponsky JL, Shreeres DE, Simmon I. Endoscopic retrograde cholangioscopy. A adjunction to endoscopic exploration of the common bile duct. Am Surg 1990;56: ) Neoptolemos JP, London N, Bailey I, Shaw D, Carr-Locke DL, Fossard DP, Moossa AR. The role of chemical and biochemical criteria and endoscopic retrograde cholangiopancreatography in the urgent diagnosis of common bile duct in acute pancreatitis. Surgery 1986;100:

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic