총담관결석의 진료 가이드라인 Korean Clinical Practice Guidelines for Common bile duct stones 대한췌담도학회

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1 총담관결석의 진료 가이드라인 Korean Clinical Practice Guidelines for Common bile duct stones 대한췌담도학회

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3 Contents I. 개발목적과과정 II. 총담관결석의진단 III. 총담관결석의내시경치료 IV. 난치성, 재발담관결석의내시경적치료

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5 I I. 개발목적과과정 개발목적과과정 ,,,,...,, 가이드라인개발취지와목적,., (endoscopic retrograde cholangiopancreatography, ERCP) (Magnetic resonance cholangiopancreatogram, MRCP), (Endoscopoic ultrasound, EUS),. ERCP, 2, 3..,,,, 5-10%. Korean Pancreatobiliary Association 3

6 .,,,... (adaptation) 가이드라인을적용할대상집단및가이드라인이용자,,,,,. 1, 가이드라인의개발과정 ( ).. 9 (,,,,,,,, ) 9 (,,,,,,,, ) (,, ).,.,, 3..,, 대한췌담도학회

7 I. 개발목적과과정 MEDLINE, MEDLINE Systematic Review, MEDLINE Clinical Study, Ovid MEDLINE, EMBASE, Web of Science Cochrane Library, KoreaMed,,,, Google Scholar, Scopus National Guideline Clearinghouse, Guidelines International Network (GIN) International Guideline Library, Canadian Medical Association (CMA) Infobase ,,,..,. PICO. P (population), I (intervention), C (comparison), O (outcome).. 1)? 2) ERCP? 3)? 4) ERCP? 5)? 6)? 7) ERCP,? 8) ERCP? 9)? 10) ERCP? 11)? 12)? Korean Pancreatobiliary Association 5

8 13)? 14)? 15)? GRADE (Table 1). 6 (A), (B), (C),,,,. (1, strong recommendation) (2, weak recommendation).,...,. Table 1. Level of evidence and grage recommendation Items Definitions Level of evidence A. High-quality evidence Further research is unlikely to changes our confidence in the estimate of effect. Consistent evidence from RCTs without important limitations or exceptionally strong from observational studies. B. Moderate-quality evidence Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Evidence from RCTs with important limitation (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence from observational studies. C. Low-quality evidence Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Evidence for at least one critical outcom from observational studies, case series, or from RCTs with serious flaws, or indirect evidence, or expert s consensus. Strength of recommendation 1. Strong recommendation Recommendation can apply to most patients in most circumstances. 2. Weak recommendation The best action may differ depending on circumstances or patient or society values. Other alternatives may be equally reasonable. RCT, randomized controlled trial 6 대한췌담도학회

9 I. 개발목적과과정..,.. 참고문헌 1. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States Part III: Liver, biliary tract, and pancreas. Gastroenterology 2009;136: Fervers B, Remy-Stockinger M, Graham ID, et al. Guideline adaptation: an appealing alternative to de novo guideline development. Ann Intern Med 2008;148:563-4; author reply Maple JT, Ben-Menachem T, Anderson MA, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastointest Endosc 2010;71: Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M. Guidelines on the management of common bile duct stones (CBDS). Gut 2008;57: Maple JT, Ikenberry SO, Anderson MA, et al. The role of endoscopy in the management of choledocholithiasis. Gastointest Endosc 2011;74: Schunemann HJ, Oxman AD, Brozek J, et al. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 2008;336: Korean Pancreatobiliary Association 7

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11 II. 총담관결석의진단 II 총담관결석의진단 1. 임상양상 1) 임상증상권고사항 병력청취와신체검진, 혈액검사를통해서총담관결석의소견이있는지살펴야한다. - 근거수준및권고등급 : 1B,,,. 1,. 30,. 2,, Charcot triad % (95.9%) (26.4%). 3,4 91.8%, 77.7%. 4 2) 혈액검사. 69%, 88%, 57%, 86%. 5 97% 15% Korean Pancreatobiliary Association 9

12 . 6,, 25-50%. 6-9,. 1.7 mg/dl 60%, 4.0 mg/dl 75% 영상검사 1) 복부초음파권고사항 복부초음파검사는총담관결석진단을위한초기검사로고려해볼수있다. - 근거수준및권고등급 : 1B,. 10, %, mm 77-87% ,. 2) 복부전산화단층촬영권고사항 복부전산화단층촬영 (CT) 은총담관결석및합병증진단을위한유용한검사이다. - 근거수준및권고등급 : 1C (CT),. 1 (Helical CT) 65-88%, 73-97% 대한췌담도학회

13 II. 총담관결석의진단 (multidetector computerized tomography, MDCT),.. 23,24, 25,,,.,,. 26 3) 자기공명담췌관조영술 (MRCP) MR T2.,,. 27,28,, (Pneumobilia),. 29 (systemic review), 85-92%, 93-97%. 30,31 6 mm 33-71% ,. 26,29 3. 내시경검사 1) 내시경초음파.,., %, 94-95%, 35,36 5 mm ,,,, Korean Pancreatobiliary Association 11

14 . 31 2) 내시경역행성담췌관조영술 (Endoscopic sphincterotomy). ( %), ( %), ( %), ( %) X-,., 25, 위험도평가,..,, (CT) (stratification) (risk groups) (Table 1). 26, Table 1. A proposed strategy to assign risk of choledocholithiasis in patients with symptomatic cholelithiasis based on clinical predictors 26 Predictors of choledocholithiasis Very strong CBD stone on transabdominal US Clinical ascending cholangitis Bilirubin >4 mg/dl Strong Dilated CBD on US (>6 mm with gallbladder in situ) Bilirubin level mg/dl Moderate Abnormal liver biochemical test other than bilirubin Age older than 55 y Clinical gallstone pancreatitis Assigning a likelihood of choledocholithiasis based on clinical predictors Presence of any very strong predictor Presence of both strong predictors No predictors present All other patients High High Low Intermediate 12 대한췌담도학회

15 II. 총담관결석의진단 Initial evaluation 1. Clinical findings 2. Laboratory findings 3. Ultrasonography or CT* Further evaluations 1. CT 2. MRCP** 3. EUS** Therapeutic procedures 1. ERCP 2. PTBD 3. Surgery *If needed, can replace US **depend on costs and local expertise Risk stratification 1. Low 2. Moderate 3. High Figure 1. The diagnostic pathway for diagnosis of common bile duct stones. PTBD: Percutaneous Transhepatic Biliary Drainage.. (Figure 1). 1) 저위험군 (low risk) 권고사항 총담관결석의저위험군환자에서내시경역행담췌관조영술 (ERCP) 은진단목적인경우우선시행하지않는다. - 근거수준및권고등급 : 1B 10%.. 5 2) 중등도위험군 (intermediate risk) 권고사항 총담관결석의중등도위험군환자에서는정확한진단을위해자기공명담췌관조영술 (MRCP) 또는내시경초음파검사 (EUS) 를시행할수있다. - 근거수준및권고등급 : 1B Korean Pancreatobiliary Association 13

16 10-50%, , 48,. 3) 고위험군 (high risk) 권고사항 총담관결석의고위험군환자에서내시경역행담췌관조영술 (ERCP) 은진단및치료목적으로시행할수있다. - 근거수준및권고등급 : 1B 50%. 26 참고문헌 1. 이진. 담석의임상양상과진단. In: 정재복, ed. 담도학. 1st ed. p , 서울, 군자출판사, Caddy GR, Tham TC. Gallstone disease: Symptoms, diagnosis and endoscopic management of common bile duct stones. Best Pract Res Clin Gastroenterol. 2006;20: Anciaux ML, Pelletier G, Attali P, et al. Prospective study of clinical and biochemical features of symptomatic choledocholithiasis. Dig Dis Sci 1986; 31(5): Kiriyama S, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Pitt HA, et al. New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci 2012;19: Abboud PA, Malet PF, Berlin JA, Staroscik R, Cabana MD, Clarke JR, Shea JA, Schwartz JS, Williams SV. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 1996;44: Yang MH, Chen TH, Wang SE, et al. Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc 2008;22: Barkun AN, Barkun JS, Fried GM, Ghitulescu G, Steinmetz O, Pham C, et al. Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy. Annals of Surgery 1994;220(1): Onken JE, Brazer SR, Eisen GM, et al. Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 1996;91: Peng WK, Sheikh Z, Paterson-Brown S, et al. Role of liver function tests in predicting common bile duct stones in patients with acute calculous cholecystitis. Br J Surg 2005;92: Barkun JS, Barkun AN. Jaundice. In ACS surgery: principles and practice Einstein DM, Lapin SA, Ralls PW, et al. The insensitivity of sonography in the detection of choledocholi- 14 대한췌담도학회

17 II. 총담관결석의진단 thiasis. AJR Am J Roentgenol 1984;142: Vallon AG, Lees WR, Cotton PB. Grey-scale ultrasonography in cholestatic jaundice. Gut 1979;20: Cronan JJ. US diagnosis of choledocholithiasis: a reappraisal. Radiology 1986;161: O Connor HJ, Hamilton I, Ellis WR, et al. Ultrasound detection of choledocholithiasis: prospective comparison with ERCP in the postcholecystectomy patient. Gastrointest Radiol 1986;11: Lapis JL, Orlando RC, Mittelstaedt CA, et al. Ultrasonography in the diagnosis of obstructive jaundice. Ann Intern Med 1978;89: Baron RL, Stanley RJ, Lee JKT, et al. A prospective comparison of the evaluation of biliary obstruction using computed tomography and ultrasonography. Radiology 1982;145: Mitchell SE, Clark RA. A comparison of computed tomography and sonography in choledocholithiasis. AJR Am J Roentgenol 1984;142: Pedersen OM, Nordgard K, Kvinnsland S. Value of sonography in obstructive jaundice. Limitations of bile duct caliber as an index of obstruction. Scand J Gastroenterol 1987;22: Soto JA, Alvarez O, Munera F, et al. Diagnosing bile duct stones: comparison of unenhanced helical CT, oral-contrast enhanced CT cholangiography, and MR cholangiography. AJR Am J Roentgenol 2000;175: Neitlich JD, Topazian M, Smith RC, et al. Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography. Radiology 1997;203: Tseng CW, Chen CC, Chen TS, et al. Can computed tomography with coronal reconstruction improve the diagnosis of choledocholithiasis? J Gastroenterol Hepatol 2008;23: Anderson SW, Rho E, Soto JA. Detection of biliary duct narrowing and choledocholithiasis: accuracy of portal venous phase multidetector CT. Radiology 2008;247: Anderson SW, Lucey BC, Varghese JC, Soto JA. Accuracy of MDCT in the diagnosis of choledocholithiasis. AJR Am J Roentgenol 2006;187: 김동일ㆍ이홍식등. 총담관결석진단에대한다검출나선전산화단층촬영의역할 : 내시경역행성담췌관조영술과의비교. 대한소화기내시경학회지 2007;35: Kiriyama S, Takada T, Strasberg SM, Solomkin JS, et al. 5. TG13 guidelines for diagnosis and severity grading of acute cholangitis J Hepatobiliary Pancreat Sci 2013;20: ASGE Standards of Practice Committee. The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc 2011;74: Gillams AR, Lees WR. Recent developments in biliary tract imaging. Gastrointest Endosc Clin N Am 1996;6: Becker CD, Grossholz M, Becker M, Mentha G, de Peyer R, Terrier F. Choledocholithiasis and bile duct stenosis: diagnostic accuracy of MR cholangiopancreatography. Radiology. 1997;205: Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut 2008;57: Romagnuolo J, Bardou M, Rahme E, et al. Magnetic resonance cholangiopancreatography: a metaanalysis of test performance in suspected biliary disease. Ann Intern Med 2003;139: Verma D, Kapadia A, Eisen GM, et al. EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc 2006;64: Zidi SH, Prat F, Le Guen O, et al. Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method. Gut 1999;44: Sugiyama M, Atomi Y, Hachiya J. Magnetic resonance cholangiography using half-fourier acquisition for diagnosing choledocholithiasis. Am J Gastroenterol 1998;93: Boraschi P, Neri E, Braccini G, et al. Choledocholithiasis: diagnostic accuracy of MR cholangiopancreatography 3 year experience. MRI 1999;17: Korean Pancreatobiliary Association 15

18 35. Tse F, Liu L, Barkun AN, et al. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc 2008;67: Garrow D, Miller S, Sinha D, et al. Endoscopic ultrasound: a meta analysis of test performance in suspected biliary obstruction. Clin Gastroenterol Hepatol 2007;5: Kondo S, Isayama H, Akahane M, et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Eur J Radiol 2005;54: Aube C, Delorme B, Yzet T, et al. MR cholangiopancreatography versus endoscopic sonography in suspected common bile duct lithiasis: a prospective, comparative study. AJR Am J Roentgenol 2005;184: Sugiyama M, Atomi Y. Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography. Gastrointest Endosc 1997;45: Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335: Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998;48: Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ercp pancreatitis: a prospective, multicenter study. Gastrointest Endosc 2001;54: Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective, multicenter study. Am J Gastroenterol 2001;96: Christensen M, Matzen P, Schulze S, et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004;60: Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP: results of a largescale, prospective multi-center study. Endoscopy 2007;39: Cotton PB, Garrow DA, Gallagher J, et al. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc 2009;70: Sahai AV, Mauldin PD, Marsi V, Hawes RH, Hoffman BJ. Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc 1999;49: Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL. Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc 2001;15: 대한췌담도학회

19 I. 개발목적과과정 III 총담관결석의내시경치료, ERCP 전준비해야할사항 1) ERCP에필요한시설및인력권고사항 총담관결석을내시경으로제거하기위해서는숙련된의사, 간호사, 방사선사로구성된 ERCP팀을구성할것을권장한다. - 근거수준및권고등급 : 1C 80% 200 ERCP. 2 ERCP ,4 1, 1, 1. Korean Pancreatobiliary Association 17

20 2) 시술동의서권고사항 내시경의사는 ERCP를시행하기전에구두혹은서면으로시술후발생할수있는췌장염, 출혈, 천공, 및담도계감염등의합병증에대하여설명하고, 서면으로동의를받을것을권장한다. - 근거수준및권고등급 : 1C ERCP.,,... 3) 시술합병증과관련된환자요인권고사항 내시경의사는 ERCP시술전에관련된합병증의위험요인을파악하고, 그예방법을숙지할것을권장한다. - 근거수준및권고등급 : 1A ERCP,,, (Table 1).,,,. 3-7., ERCP ERCP.,,,,,,,,.,., 50,000-80,000/mm ,8, ERCP,. 18 대한췌담도학회

21 III. 총담관결석의내시경치료 Table 1. the incidence and risk factors of ERCP-related complications Incidence (%, range) Post-ERCP pancreatitis Hemorrhage Perforation Biliary tract infection Risk factors Definite Suspected SOD Young age Normal bilirubin H istory of post-ercp pancreatitis P ancreatic duct injection P ancreatic sphincterotomy Precut sphincterotomy B alloon dilation of biliary sphincter 3.5 ( ) 1.3 ( ) 0.2 ( ) Less than 1 Maybe Female gender Acinarization Absence of CBD stone L ower ERCP case volume Definite Coagulapathy Hemodialysis A nticoagulation <3d after sphincterotomy V isible bleeding during the procedure Higher bilirubin C holangitis before ERCP L ower ERCP case volume Maybe Cirrhosis Dilated CBD CBD stone P eriampullary diverticulum Precut sphincterotomy Definite Malignancy Precut sphincterotomy Maybe T he performance of a sphincterotomy Billroth II anatomy T he intramural injection of contrast P rolonged duration of procedure B iliary stricture dilation Cholangitis U se of combined percutaneousendoscopic procedures S tent placement in malignant strictures P resence of jaundie I ncomplete or failed biliary drainage L ower ERCP case volume Cholecystitis P resence of stones in the GB P ossibly filling of the GB with contrast during the procedure Placement of SEMSs SOD; sphincter of Oddi dysfunction, ERCP; endoscopic retrograde cholangiopancreatography, CBD; common bile duct, GB; gallbladder, SEMS; self-expandable metal stenfs. 4) 시술후췌장염의예방권고사항 환자개개인의시술후췌장염발생의위험도를판단하여예방적약물사용을고려할수있다. - 근거수준및권고등급 : 2B ERCP glycerol trinitrate, gabexate, octerotide, somatostatin, %,. 13, ERCP,. Korean Pancreatobiliary Association 19

22 5) 항응고제와항혈소판제권고사항 혈전색전증의저위험군에서유두괄약근절개술이예정되어있다면, ERCP 전에항응고제를중단해야하며, 저용량의헤파린은유두괄약근절개술의절대적금기가아니다. - 근거수준및권고등급 : 1B 아스피린을제외한항혈소판제는유두괄약근절개술을시행하기약 7일전에중단을고려한다. 다만, 항혈소판제의복용이유두괄약근절개술의절대적금기가아니다. - 근거수준및권고등급 : 1C., 3. 3 INR ,.. 3,8,14 clopidogrel 7. 16,. 6) 예방적항생제권고사항 담도폐쇄가있다거나패혈증의양상을보였던환자혹은면역억제환자에서는예방적항생제사용이권장된다. - 근거수준및권고등급 : 1B ERCP. 17,. 18,19 20 대한췌담도학회

23 III. 총담관결석의내시경치료 2. ERCP 중고려할사항 1) 내시경유두괄약근절개술및담석제거권고사항 내시경유두괄약근절개술은총담관결석을제거하기위한표준술식으로우선적으로권장된다. - 근거수준및권고등급 : 1C. ERCP 90% ,. (blended current),, (pure cutting current) ,. 26 endocut, 27.,,, ,.,.,. 28,29 2) 내시경유두괄약근풍선확장술권고사항 내시경유두괄약근풍선확장술은간경화혹은출혈성향을가진환자, 유두팽대부게실이나수술로인한해부학적변형이있는환자에서내시경유두괄약근절개술의대안적방법으로사용을고려한다. - 근거수준및권고등급 : 2B Korean Pancreatobiliary Association 21

24 .,,. 30,31, 32,33. 34,35,. 3) 담관배액술권고사항 총담관결석이완전히제거되지않아추가적인 ERCP가필요한경우일시적인담관배액술을시행할것을권장한다. - 근거수준및권고등급 : 1B. 36 ERCP ) 예비절개술권고사항 예비절개술은합병증발생의위험인자이므로, 충분한교육과경험을가진숙련된의사가내시경치료가반드시필요한환자에게제한적으로시행할것을고려한다. - 근거수준및권고등급 : 1B , 대한췌담도학회

25 III. 총담관결석의내시경치료 5) 시술후췌장염의예방을위한췌관스텐트권고사항 어려운삽관이나예비절개술등의 ERCP 시술후췌장염의위험이높은환자는짧은기간동안췌관스텐트를유치할것을우선적으로고려한다. - 근거수준및권고등급 : 1A ERCP , 특별한임상상황에서담석의치료 1) 담낭담석을동반한총담관결석권고사항 담낭담석을동반한총담관결석은내시경담석제거술혹은복강경총담관탐색술로제거하며, 각각의병원에서이용도와숙련도를고려하여결정할것을권장한다. - 근거수준및권고등급 : 1A 담낭담석을동반한총담관결석을가진젊은환자에서내시경담석제거술이후복강경담낭절제술을권장한다. - 근거수준및권고등급 : 2B,. 44,45. 2.,,,. 46,.. 47,48, %, Korean Pancreatobiliary Association 23

26 ) 급성담석성췌장염권고사항 급성췌장염환자에서담석성췌장염이강력히의심되는환자에서담도염이있거나, 담도폐쇄가지속되는환자에서조기에 ERCP를시행한다. - 근거수준및권고등급 : 1A ERCP. ERCP, Cochrane library,,. 52 ERCP. 3) 급성담관염권고사항 항생제치료에반응이없거나패혈증의증후를보이는급성담관염을가진환자는응급담도감압술을권장한다. - 근거수준및권고등급 : 1A %, 4-10%. 53,54 ERCP,. 55 참고문헌 1. Yasuda I. Management of the bile duct stone: current situation in Japan. Dig Endosc 2010;22:S Jowell PS, Baillie J, Branch MS, et al. Quantitative assessment of procedural competence. A prospective 24 대한췌담도학회

27 III. 총담관결석의내시경치료 study of training in endoscopic retrograde cholangiopancreatography. Ann Intern Med 1996;125: Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335: Rabenstein T, Schneider HT, Bulling D, et al. Analysis of the risk factors associated with endoscopic sphincterotomy techniques: preliminary results of a prospective study, with emphasis on the reduced risk of acute pancreatitis with low-dose anticoagulation treatment. Endoscopy 2000;32: Christensen M, Matzen P, Schulze S, et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004;60: Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a largescale, prospective multicenter study. Endoscopy 2007;39: Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ercp pancreatitis: a prospective, multicenter study. Gastrointest Endosc 2001;54: Nelson DB, Freeman ML. Major hemorrhage from endoscopic sphincterotomy: risk factor analysis. J Clin Gastroenterol 1994;19: Andriulli A, Leandro G, Niro G, et al. Pharmacologic treatment can prevent pancreatic injury after ERCP: a meta-analysis. Gastrointest Endosc 2000;51: Duvnjak M, Supanc V, Simicevic VN, et a l. Use of octreotide-acetate in preventing pancreatitis-like changes following therapeutic endoscopic retrograde cholangiopancreatography. Acta Med Croatica 1999;53: Arcidiacono R, Gambitta P, Rossi A, et al. The use of a long-acting somatostatin analogue (octreotide) for prophylaxis of acute pancreatitis after endoscopic sphincterotomy. Endoscopy 1994;26: Andriulli A, Clemente R, Solmi L, et al. Gabexate or somatostatin administration before ERCP in patients at high risk for post-ercp pancreatitis: a multicenter, placebo-controlled, randomized clinical trial. Gastrointest Endosc 2002;56: Elmunzer BJ, Waljee AK, Elta GH, et al. A meta-analysis of rectal NSAIDs in the prevention of post- ERCP pancreatitis. Gut 2008;57: Oren A, Breumelhof R, Timmer R, et al. Abnormal clotting parameters before therapeutic ERCP: do they predict major bleeding? Eur J Gastroenterol Hepatol 1999;11: Eisen GM, Baron TH, Dominitz JA, et al. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc 2002;55: Zuckerman MJ, Hirota WK, Adler DG, et al. ASGE guideline: the management of low-molecularweight heparin and nonaspirin antiplatelet agents for endoscopic procedures. Gastrointest Endosc 2005;61: Harris A, Chan AC, Torres-Viera C, et al. Meta-analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1999;31: Thompson BF, Arguedas MR, Wilcox CM. Antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice: is it worth the cost? Aliment Pharmacol Ther 2002;16: Niederau C, Pohlmann U, Lubke H, et al. Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study. Gastrointest Endosc 1994;40: Rhodes M, Sussman L, Cohen L, et al. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 1998;351: Tham TC, Lichtenstein DR, Vandervoort J, et al. Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Gastroin- Korean Pancreatobiliary Association 25

28 test Endosc 1998;47: Arregui ME, Davis CJ, Arkush AM, et al. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis. Surg Endosc 1992;6: Elta GH, Barnett JL, Wille RT, et al. Pure cut electrocautery current for sphincterotomy causes less postprocedure pancreatitis than blended current. Gastrointest Endosc 1998;47: Stefanidis G, Karamanolis G, Viazis N, et al. A comparative study of postendoscopicsphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis. Gastrointest Endosc 2003;57: Gorelick A, Cannon M, Barnett J, et al. First cut, then blend: an electrocautery technique affecting bleeding at sphincterotomy. Endoscopy 2001;33: Verma D, Kapadia A, Adler DG. Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes. Gastrointest Endosc 2007;66: Perini RF, Sadurski R, Cotton PB, et al. Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference? Gastrointest Endosc 2005;61: Stave R, Osnes M. Endoscopic gallstone extraction following hydrostatic balloon dilatation of a stricture in the common bile duct. Endoscopy 1985;17: Binmoeller KF, Schafer TW. Endoscopic management of bile duct stones. J Clin Gastroenterol 2001;32: Bergman JJ, Rauws EA, Fockens P, et al. Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bileduct stones. Lancet 1997;349: Yasuda I, Tomita E, Enya M, et al. Can endoscopic papillary balloon dilation really preserve sphincter of Oddi function? Gut 2001;49: Fujita N, Maguchi H, Komatsu Y, et al. Endoscopic sphincterotomy and endoscopic papillary balloon dilatation for bile duct stones: A prospective randomized controlled multicenter trial. Gastrointest Endosc 2003;57: Weinberg BM, Shindy W, Lo S. Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones. Cochrane Database Syst Rev 2006:CD Arnold JC, Benz C, Martin WR, et al. Endoscopic papillary balloon dilation vs. sphincterotomy for removal of common bile duct stones: a prospective randomized pilot study. Endoscopy 2001;33: DiSario JA, Freeman ML, Bjorkman DJ, et al. Endoscopic balloon dilatation vs. sphincterotomy (EDES) for bile duct stone removal [abstract]. Digestion 1998;59: Maluenda F, Csendes A, Burdiles P, et al. Bacteriological study of choledochal bile in patients with common bile duct stones, with or without acute suppurative cholangitis. Hepatogastroenterology 1989;36: Bergman JJ, Rauws EA, Tijssen JG, et al. Biliary endoprostheses in elderly patients with endoscopically irretrievable common bile duct stones: report on 117 patients. Gastrointest Endosc 1995;42: Sharma BC, Kumar R, Agarwal N, et al. Endoscopic biliary drainage by nasobiliary drain or by stent placement in patients with acute cholangitis. Endoscopy 2005;37: Leung JW, Banez VP, Chung SC. Precut (needle knife) papillotomy for impacted common bile duct stone at the ampulla. Am J Gastroenterol 1990;85: Ramirez FC, Dennert B, Sanowski RA. Success of repeat ERCP by the same endoscopist. Gastrointest Endosc 1999;47: Fazel A, Quadri A, Catalano MF, et al. Does a pancreatic duct stent prevent post- ERCP pancreatitis? A prospective randomized study. Gastrointest Endosc 2003;57: Singh P, Das A, Isenberg G, et al. Does prophylactic pancreatic stent placement reduce the risk of post- 26 대한췌담도학회

29 III. 총담관결석의내시경치료 ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 2004;60: Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc 1990;36: Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13: Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2006:CD Schiphorst AH, Besselink MG, Boerma D, et al. Timing of cholecystectomy after endoscopic sphincterotomy for common bile duct stones. Surg Endosc 2008;22: Hammarstrom LE, Holmin T, Stridbeck H, et al. Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Br J Surg 1995;82: Boerma D, Rauws EA, Keulemans YC, et al. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial. Lancet 2002;360: Pereira-Lima JC, Jakobs R, Winter UH, et al. Long-term results (7 to 10 years) of endoscopicpapillotomy for choledocholithiasis. Multivariate analysisof prognostic factors for the recurrence of biliarysymptoms. Gastrointest Endosc 1998;48: Moretti A, Papi C, Aratari A, et al. Is early endoscopic retrograde cholangiopancreatography useful in the management of acute biliary pancreatitis? A meta-analysis of randomized controlled trials. Dig Liver Dis 2008;40: Petrov MS, van Santvoort HC, Besselink MG, et al. Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials. Ann Surg 2008;247: Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev May 16;5:CD doi: / CD pub Andrew DJ, Johnson SE. Acute suppurative cholangitis, amedical and surgical emergency. A review of ten years experience emphasizing early recognition. Am J Gastroenterol 1970;54: Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992;326: Leung JW, Chung SC, Sung JJ, et al. Urgent endoscopic drainage for acute suppurative cholatis. Lancet 1989;1: Korean Pancreatobiliary Association 27

30 28 대한췌담도학회

31 IV I. 개발목적과과정 난치성, 재발담관결석의내시경적치료 (endoscopic retrograde cholangiopancreatography, ERCP) (endoscopic sphincterotomy, EST) 85-90%. 1, %,,,,, mm EST, 15 mm. 8,9. EST. ERCP 6, 10 ERCP % ,, (15 mm ),,,,,,. 10,13,16-18,, 19,20., Korean Pancreatobiliary Association 29

32 , (Repeat ERCP). I. 내시경적제거가어려운총담관결석의치료 (Management of difficult bile duct stones) 1. 거대총담관결석 1) 기계적쇄석술권고사항 기계적쇄석술은 EST 후바스켓과풍선도관을이용하는통상적인내시경적결석제거술로제거가어려운 3 cm 미만의거대총담관결석에대한일차적인치료로사용될수있다. - 근거수준및권고등급 : 1B.. 19 EST %, cm 3 cm. 24, %. 23,24, ) 담관내전기수압쇄석술, 레이저쇄석술권고사항 담도내시경하에전기수압쇄석술또는레이저쇄석술은 EST 후바스켓과풍선도관을이용하는통상적인내시경적결석제거술로제거가어려운거대총담관결석에대한치료로유용하게사용될수있다. - 근거수준및권고등급 : 1B 30 대한췌담도학회

33 IV. 난치성, 재발담관결석의내시경적치료 (electrohydraulic lithotripsy, EHL) (laser lithotripsy, LL). 20 EHL %, 2,27-30 LL EHL 88-97% LL FREDDY (FRequency Doubled Double Pulse YAG Laser) holmium. FREDDY plasma. 36 Holmium holmium. 37 EHL LL 3-19% ,38 EHL LL (mother-baby scope system) (baby scope). 39 Spy Glass Direct Visualization System (Boston Scientific Corp., Natick, MA, USA) (direct peroral cholangioscopy) ERCP EHL LL.. 43,44 3) 내시경유두큰풍선확장술권고사항 소절개내시경유두괄약근절개술후시행되는내시경유두큰풍선확장술은원위부담관협착이없는환자에서 EST 후바스켓과풍선도관을이용하는통상적인내시경적결석제거술로제거할수없는거대담관결석의치료로유용하게사용될수있다. - 근거수준및권고등급 : 1B 2003 Ersoz 45 EST mm (endoscopic papillary large balloon dilatation, EPLBD), EST EPLBD EPLBD %, 1-27%,, 0-16% EPLBD 0-9%, 45-50,52,53 EST EPLBD 8.3-9%, 45,47 EPLBD EST. EPLBD 0.42% (4/946) Korean Pancreatobiliary Association 31

34 . 54 EST EPLBD (12 mm). EPLBD EPLBD EST. EST EPLBD, 52,53,55. 4) 일시적담관스텐트삽입술권고사항 EST 후바스켓과풍선도관을이용하는통상적인내시경적결석제거술로제거할수없는거대담관결석이있는고령이거나수술에대한고위험군의환자에서일시적플라스틱담관스텐트의삽입은이차적인내시경적시술로결석제거성공률을높일수있는방법으로사용될수있다. - 근거수준및권고등급 : 2B,, mm, % , ursodeoxycholic acid (UDCA) terpene. 66,69 2. 수술로변형된상부위장관의해부학적구조권고사항 Billroth II 수술, Roux-en-Y 문합술로해부학적인변화가발생한총담관결석환자는경험있는숙련가나상급병원에의뢰하는것을고려해야한다. - 근거수준및권고등급 : 1C Billroth II 수술, Roux-en-Y 문합술로해부학적인변화가발생한총담관결석환자에서 ERCP를통한담석제거에실패하는경우에경피적경간담도내시경을통한쇄석술은수술적치료를피할수있는유용한대안으로사용될수있다. - 근거수준및권고등급 : 1B 32 대한췌담도학회

35 IV. 난치성, 재발담관결석의내시경적치료 Billroth II, Roux-en-Y. Billroth II, Roux-en-Y ERCP,, (Treit s ligament). 70 EST. 39 Roux-en-Y 33-67% Billroth II 60-90%. 70, 71, 5-17% Billroth II, Roux-en-Y. 20 (Percutaneous transhepatic cholangioscopic lithotomy, PTCSL) ERCP. 43,44 PTCSL. 77,78 Jeong 77 Billroth II ERCP 20 PTCSL. Billroth II, Rouxen-Y ERCP PTCSL II. 재발성총담관결석의치료 (Management of recurrent bile duct stones) 1. 반복적인내시경역행담관조영술권고사항 반복적인 ERCP는 ERCP 시행후발생한재발성총담관결석에대한일차적인치료로사용될수있다. - 근거수준및권고등급 : 1C ERCP. 8,15,81 ERCP EST. 82 Korean Pancreatobiliary Association 33

36 15 mm. 18,20 Geenen (Surveillance ERC) ,20 참고문헌 1. Cotton PB. Non-operative removal of bile duct stones by duodenoscopic sphincterotomy. Br J Surg 1980;67: Binmoeller KF, Bruckner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy 1993;25: Lauri A, Horton RC, Davidson BR, Burroughs AK, Dooley JS. Endoscopic extraction of bile duct stones: management related to stone size. Gut 1993;34: Kim MH, Lee SK, Lee MH, et al. Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope. Endoscopy 1997;29: Okugawa T, Tsuyuguchi T, K CS, et al. Peroral cholangioscopic treatment of hepatolithiasis: long-term results. Gastrointest Endosc 2002;56: Gluck M, Cantone NR, Brandabur JJ, Patterson DJ, Bredfeldt JE, Kozarek RA. A twenty-year experience with endoscopic therapy for symptomatic primary sclerosing cholangitis. J Clin Gastroenterol 2008;42: Lopes TL, Wilcox CM. Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. Gastroenterol Clin North Am 2010;39: Lai KH, Peng NJ, Lo GH, et al. Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy. Gut 1997;41: Kim HJ, Choi HS, Park JH, et al. Factors influencing the technical difficulty of endoscopic clearance of bile duct stones. Gastrointest Endosc 2007;66: Keizman D, Shalom MI, Konikoff FM. An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction. Surg Endosc 2006;20: Hawes RH, Cotton PB, Vallon AG. Follow-up 6 to 11 years after duodenoscopic sphincterotomy for stones in patients with prior cholecystectomy. Gastroenterology 1990;98: Prat F, Malak NA, Pelletier G, et al. Biliary symptoms and complications more than 8 years after endoscopic sphincterotomy for choledocholithiasis. Gastroenterology 1996;110: Pereira-Lima JC, Jakobs R, Winter UH, et al. Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms. Gastrointest Endosc 1998;48: Costamagna G, Tringali A, Shah SK, Mutignani M, Zuccala G, Perri V. Long-term follow-up of patients after endoscopic sphincterotomy for choledocholithiasis, and risk factors for recurrence. Endoscopy 2002;34: Sugiyama M, Atomi Y. Risk factors predictive of late complications after endoscopic sphincterotomy for bile duct stones: long-term (more than 10 years) follow-up study. Am J Gastroenterol 2002;97: 대한췌담도학회

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