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1 The Korean Journal of Gastrointestinal Endoscopy Review 상부위장관스텐트삽입술의현황과미래 박종재ㆍ양창헌 * 고려대학교의과대학소화기내과학교실, 동국대학교의과대학내과학교실 * The Current Status and the Future of Upper GI Stenting Jong-Jae Park, M.D. and Chang-Hun Yang, M.D., Ph.D.* Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, *Dongguk University College of Medicine, Gyeongju, Korea Stent implantation in the upper gastrointestinal (UGI) tract is now widely accepted for achieving palliative symptom relief of patients who have malignant UGI obstruction and causative symptoms such as nausea, vomiting, malnutrition and acid reflux. With the increased technical progress and clinical experiences, it has become possible to perform this procedure with more safety and convenience. However, clinicians should also focus on the post-procedural management because complications such as stent migration or in-stent tumor growth could occur. On the other hand, temporary stent insertion is an effective treatment option for benign diseases such as pyloric strictures due to benign peptic ulcer, esophageal perforation or leakage on the anastomosis site. In this review, several issues about stent implantation in the UGI tract, such as the main indications, the current status and the expected applications in other fields in the near future, are briefly discussed. (Korean J Gastrointest Endosc 2009;38:61-67) Key Words: Upper GI, Stent, Current indication, Future application 교신저자. 박종재고려대학교의료원구로병원소화기내과 ( ), 서울시구로구구로동길 97 번지전화 : 팩스 : 이메일 : gi7pjj@yahoo.co.kr 접수 년 2 월 18 일승인 년 2 월 19 일 서론 상부위장관의스텐트삽입술은주로근치적수술이불가능한위, 식도, 담도및췌장의악성종양에의한위장관협착환자에서오심, 구토, 칼로리섭취부족, 위액역류등의위장관폐쇄증상완화를위한보존적치료목적으로사용되고있다. 이러한환자들의상당수는전신상태악화등의이유로고식적우회술이불가능한경우가많고, 수술과관련된사망률및이환율도높다. 스텐트삽입술은수기가비교적쉬워어느정도의진단내시경및치료내시경의경험만있어도쉽고안전하게시행할수있다. 시술후빠른증상의호전으로입원기간의단축을기대할수있으며경우에따라서는외래에서도시행가능하다는장점또한있어유용한시술임은자명하다. 초기에는플라스틱스텐트를주로식도에서사용하였으나시술을전후하여천공, 일탈, 출혈, 통증과같은합병증의빈도가높았고, 위유문부및십이지장과같이굴곡이심한부위에서는삽입이어렵다는단점이있었다. 1 이에대한해결책으로개발된자가 팽창형금속스텐트 (self expandable metal stent, SEMS) 는삽입및장착이쉽고안전해졌으며플라스틱스텐트에비하여임상적인효과가우수하였다. 2 최근에는내시경처치공으로삽입이가능한경내시경적스텐트 (through-the-scope, TTS) 가개발되어현재널리이용되고있으며스텐트삽입의임상성적도향상되면서점차고식적수술을대체할수있는효과적이고또비용효과면에서도경제적인치료법으로인정되고있다. 3,4 본종설에서는최근상부위장관에서스텐트삽입술의현황, 그리고앞으로기대되는임상적응용분야에대하여알아보고자한다. 본론 1. 스텐트삽입의적응증 상부위장관에서스텐트삽입술의적응증은위전정부, 십이지장및췌담도의악성종양에의한협착및폐쇄로증상이발생한경우, 림프절종대에의한장관압박이있는경우, 위절제술이나위-공장문합술시행이후에재발한협착이있는경우, Vol. 38, No. 2 February, 2009 (61-67) 61

2 그리고복막전이에의한위장막침범이나다발성질환에서위출구폐쇄가있는경우에도스텐트삽입을고려할수있다. 3,4 그러나기계적폐쇄가동반되지않은 linitis plastica나다발성소장폐쇄의경우는스텐트삽입술이부적절하다. 일반적으로양성병변에의한협착의경우장기간의스텐트유치는적응증이되지않으나일시적으로스텐트를삽입하여폐쇄병변의확장효과를기대할경우는제한적으로시술할수있다 (Table 1) 식도병변의스텐트삽입술 1) 양성질환 : 역류성식도염, 식도절제술후문합부위의협착또는부식성식도협착과같은양성식도협착에대한치료로서풍선확장술이많이시행되고있으나 66% 정도의낮은시술성공률과식도천공과같은합병증이문제점으로지적되었다. 6 이를극복하기위한시도로서양성병변에 SEMS를일시적으로유치하여증상의유의한호전을보인연구결과가보고된바있다. 7 그러나스텐트일탈이나조직과증식등의합병증이발생할경우스텐트의회수가어려워지기때문에양성질환에서 SEMS 삽입술은신중하게고려해야한다. 또한성공적으로스텐트가회수되고기존협착부위는호전되더라도스텐트말단부에의한기계적인점막손상으로새로운협착이발생할수있어아직까지는널리시행되지않고있는실정이며스텐트재질이나도안에해결해야할문제가남아있다. 2) 악성질환 : 식도의악성종양에의한협착이나폐쇄환자의고식적치료로서스텐트삽입술은환자의전신상태가불량하고기대여명이 3개월이하로짧은경우에는일차적으로고려할수있지만환자의예후가양호하여기대여명이 3개월이상인경우에는스텐트유치기간이길어지기때문에스텐트자체에의한합병증을고려해야한다. 특히스텐트말단부에의한식도점막이나벽의손상으로궤양이형성되어동통및출혈이발생될수있고, 좀더진행되면천공이나식도주위의혈 Table 1. Indications of Enteral Stenting for Gastric Outlet Obstruction and Duodenum 3 Stenting indicated Obstructing pancreatic carcinoma and tumors of stomach, duodenum and gallbladder Compressive lymphadenopathy Recurrence after gastrectomy or gastro-jejunostomy Stenting appropriate Serosal involvement from peritoneal spread Possible multifocal disease, but clear obstruction at gastric outlet Stenting inappropriate Linitis platisca without mechanical obstruction Clear evidence of multifocal small-bowel obstruction Benign strictures (unless temporary) 관손상에의한대량출혈이발생하여때로는환자가사망에이를수도있다. 이러한문제점때문에장기간의스텐트유치가필요할때는외부방사선조사치료또는 brachytherapy 가스텐트삽입술보다더효과적일수있다. 8 일반적으로비막성스텐트는일탈의가능성은없지만일단삽입되면제거가불가능하기때문에생존기간이짧은경우에만사용하며, 장기간의스텐트유치가예상되면막성스텐트를삽입하고전술한대로스텐트자체에의한궤양및천공, 대량출혈등이발생할가능성을염두에두고주기적인내시경검사를하여필요시제거하는것이중요하다. 3) 기타식도의특수부위 (1) 상부식도종양의스텐트삽입 ; 스텐트를경부식도에삽입하면지속적인통증이나이물감을호소할수있고천공, 폐흡인, 하인두로의일탈등의위험이높아주의가필요하다. 윤상인두괄약근직하방에스텐트를삽입하면대부분처음 1주일간은이물감을느끼지만점차적응되어불편감이감소한다고알려져있고, 9 특별히고안된직경 16 mm인 Wallstent를상부식도괄약근하방 1 3 cm에위치시켰을때불편감이없다는보고도있다. 10,11 국내에서는근위부 flange의길이를원위부의 20 mm와달리 7 mm로감소시키고확장시의직경을원위부의 22 mm와달리 18 mm로고안하여이물감과스텐트일탈의가능성을낮출수있는스텐트가개발된바있다. 12 또한상부식도괄약근근처에스텐트가삽입되면스텐트가펴지면서기도를압박할수있으므로시술시특별한주의와시술후관찰이필요하다. 13 근위부부터풀리는 Ultraflex 스텐트는병변근위부에정확하게유치시킬수있고원위부로의이동도가능하므로상부식도병변에대한스텐트삽입시유용할수있다. (2) 식도하방, 위분문부종양의스텐트삽입 ; 최근원위부식도나위식도접합부암의증가로스텐트삽입이필요한경우또한증가되고있는데, 이때는다른부위에비해서증상호전율이낮거나합병증의빈도가높을수있다. 1,14 특히스텐트가위분문부에걸쳐있을경우분문부의해부학적구조상스텐트가휘어지므로증상호전이안될수있고스텐트원위부가위저부에서지지되지않아스텐트이동이나일탈이흔하게발생되며또한스텐트의원위부말단이위벽을손상시켜출혈, 궤양등을유발할수있다. 그러나가장흔하고또임상적으로문제가되는것은위식도역류에의한삶의질저하이다. 14 과거에는스텐트삽입후에 PPI와같은강력한항분비억제제를사용하였으나최근에는위식도역류를방지할수있는항역류스텐트가개발되어임상에이용되고있다. 예로써기존스텐트에 windsock-type valve, Dua-valve 혹은 triscupid valve를장착하여사용하였을때일반스텐트에비해산노출시간이나역류증상이더호전되었다는보고가있다. 15,16 그러나시술의어려움, 항역류밸브의뒤집힘혹은깨짐등의단점또한있어서국내에서는이를예방하기위하여긴 S형의항역류밸브를 62 The Korean Journal of Gastrointestinal Endoscopy

3 스텐트몸통부에고정한 Shim s Hanarostent 가개발되었는데이 S형항역류스텐트는기존스텐트나 Do stent에비하여보 다효과적임이보고된바있다. 17 추후항역류효과나비용측면에서 PPI와전향적으로비교한연구가필요하다. Table 2. Nitinol Enteral Stents for Gastric Outlet Obstruction and Duodenum Company Covered Uncovered Stent. Stent, Deliv. Deliv. Stent Stent Deliv. Deliv. diameter length diameter length diameter length diameter length Boston 18, 20, 22 60, F 13,50/2,300 18, 20, 22 60, F 1,350/2,300 M.I tech 18 60, 90, F 1,200 Radio 18 80, 110, 10.5 F 1,200 Radio 1,800 Endo 140, 170 1,800 Endo Standard 20 60, F 1,200, 1,800, 20 60, 80, 10 F 1,200, 1,800, Sci tech 100 2, ,300 TaeWoong 18 60, 80, F 1,200, 1, , 80, 10 F 1,200, 1,800 2, ,300 Unit, mm. Table 3. Clinical Results of Enteral Stents in Malignant Gastric Outlet Obstruction and Duodenum No. of TSR CSR Reference Method Stent Company Complications patients (%) (%) Jeong et al 18 Fluoroscopic Niti-S stents, TaeWoong Medical & Stent migration (n=3), (2002) Song stents Doosung Medi-tech stent collapse (n=2) Adler et al 36 Endoscopic Enteral Wallstent, Boston Scientific/ Tumor overgrowth (n=3), (2002) plus Esophageal Microvasive ingrowth (n=1) fluoroscopic Ultraflex stents Stent migration (n=1), (2 cases) angulation (n=1) Biliary obstruction (n=3) Jung et al 39 Fluoroscopic Niti-S stent TaeWoong Medical Tumor overgrowth (n=6), (2002) (uncovered/covered) ingrowth (n=3) Stent migration (n=3), prolapse (n=1) Holt et al 28 Endoscopic Enteral Wallstent, Boston Scientific/ Tumor ingrowth (n=3) (2004) plus Esophageal Wallstent; Microvasive fluoroscopic Flamingo Telford et al 176 Endoscopic Enteral Wallstent Boston Scientific/ Stent migration (n=9), (2004) plus Microvasive perforation (n=2) fluoroscopic Kim et al 213 Fluoroscopic Dual expandable S&G Biotech Tumor overgrowth (n=7), (2007) nitionol stent collapse (n=4) Stent migration (n=4) Song et al 20 Endoscopic Niti-S Pyloric enteral TaeWoong Medical (2007)* plus stent (covered/ fluoroscopic uncovered) Maetani et al 37 4 Endoscopic Niti-S Enteral colonic TaeWoong Medical Primary stent dysfunction (2007) plus stent (uncovered) (n=2) Tumor ingrowth fluoroscopic (n=1), biliary stent dysfunction (n=1) Van Hooft 62 5 TTS plus Wallflex enteral stent Boston Scientific/ 85 Perforation (n=2), et al (2007) fluoroscopic (uncovered) Microvasive tumor ingrowth (n=1) Migration (n=1) *Double stent (covered and uncovered) in patients with recurrent malignant obstruction after gastric surgery. Vol. 38, No. 2 February, 2009 (61-67) 63

4 3. 유문부혹은십이지장스텐트삽입술 1) 악성종양에의한위배출구폐쇄 : 위전정부나유문부악성종양, 담도및췌장의악성종양에의한위배출구폐쇄시근치적절제가불가능한경우폐쇄증상의소실을위하여스텐트삽입술이필요하다. 현재다양한스텐트가개발되어임상적으로적용되고있는데대부분의스텐트는니켈과티타늄의합금인 nitinol 을재질로만들어시판되고있다. 국내에는 Tawoong Medical 사에서처음개발한이래 M.I tech, S&G Biotech 및 Standard Sci-Tech 사에서도개발하여사용하고있다 (Table 2). 이러한 nitinol 스텐트는재질이부드럽고선단부가유연하여장관점막의손상을예방하여합병증이적고, 고유의형상을기억하는기능이있다. 국외제품으로는 Boston Scientific 사의스테인레스스틸 (stainless-steel) 재질의 Wallstent Enteral TTS 스텐트와 nitinol 재질의 Wallflex Enteral 스텐트가있다. 이러한스텐트는크게비피막형 (uncovered) 스텐트와피막형 (covered) 스텐트로구분된다. 비피막형스텐트는부착성이우수하고조작이쉬운장점이있으나종양의스텐트내로의발육으로인한재협착이문제가된다. 이를보완하기위해개발된피막성스텐트는종양의스텐트내로의발육은억제가되나병변으로부터의스텐트일탈이문제가된다. 또한피막형스텐트의막은주로 polyurethane 또는 silicone 재질로이루어져있으나담즙및위산에안전하지않다는문제점이있다. 비피막성스텐트와동축의피막성스텐트의재삽입은재협착과일탈의빈도를줄일수있지만 18 고가의비용및두번시술을해야하는번거로움이있어최근에는한번에시술할수있도록 dual 스텐트 Table 4. Summary of the Main Study Outcomes of Stent Placement and Gastrojejunostomy in Patients with Malignant Gastric Outlet Obstruction Stent Gastrojejunostomy Technical success (%) 972/1,012 (96) 203/204 (99) Clinical success (%) 890/1,000 (89) 79/110 (72) Complications (%) Early major 43/609 (7) 6/159 (4) complications Late major 171/950 (18) 34/201 (17) complications Minor complications 66/732 (9) 66/201 (33) Persistent obstructive 43/535 (8) 10/106 (9) symptoms Reintervention 147/814 (18) 1/138 (1) Mean hospital stay 7 (2 18) 13 (7 30) (days, [range]) Mean survival 105 (23 210) 164 (64 348) (days, [range]) 가고안되었다. 현재사용되고있는주요스텐트의특성및최근에보고된임상결과는다음과같다 (Table 3). 최근까지위배출구폐쇄의고식적치료로위공장문합등의우회술과스텐트삽입술중어떤치료가우선적인치료법인가에대해의문이있어왔다. 고식적우회술과스텐트삽입술의비교연구는단지 2개의무작위연구와 6개의비교연구가있으며대부분후향적, 소규모의연구로두시술간의치료성적을비교하기는쉽지않다. 전통적인개복술은대부분의환자에서증상및위장관기능호전이있으나위배출기능이호전되기까지는약 8일정도가소요되어재원기간이늘어나게된다. 최근에복강경하에이루어지는시술은개복술보다는비침습적이어서회복기간이짧으나여전히시술과관련된이환율및사망률은높다. 우회술과스텐트삽입술의 10년간연구결과를분석한보고가있어이보고를중심으로두시술간의임상결과를비교해보면다음과같다 (Table 4). 19 즉기술적성공율은두시술간에차이는없으나임상적인성공률은우회술에서 72% (79/110), 스텐트삽입술에서 89% (890/1,000) 로폐쇄증상의완화에는스텐트삽입술이다소효과적이었다. 시술후 7일이내의초기중증합병증으로스텐트삽입술의경우스텐트일탈, 기능부전이 7% 에서, 우회술은출혈및황달이 4% 에서발생되어두시술간의차이는없었다. 후기중증합병증으로스텐트삽입술의경우스텐트일탈, 종양발육에의한폐쇄등이 17% 에서, 우회술은문합부누출, 발열및기능부전등이 18% 에서발생하여두군간의차이는없었다. 하지만스텐트삽입술후경한합병증으로통증, 구토및경한출혈등이 9% 에서, 우회술에서는위배출지연, 창상감염등의경한합병증이 33% 에서발생하여발생빈도에있어서차이가있었다. 한후향적연구에서폐쇄증상은스텐트삽입술군에서조기에재발하였고 (median 147 days vs. 388 days, p=0.002), 시술후재시술을요하는기간도스텐트삽입술군에서우회술을시행한군에비해유의하게짧았다 (median 110 days vs. 513 days, p=0.004). 폐쇄증상이지속되어스텐트삽입술후 18% 에서, 우회술후 1% 에서재시술이시행되어스텐트삽입술군에서폐쇄증상의호전기간이짧고, 재시술을요하는경우가많았다. 시술후평균재원기간은우회술을시행하는경우 13 일 (n=385), 스텐트삽입술후는 7일 (n=324) 로차이가있고, 평균생존기간은우회술은 164일 (n=246), 스텐트삽입술 105일 (n=923) 로차이는없었다. 비용은스텐트삽입술시시술비, 입원비그리고재시술비용등을포함하더라우회술시보다저렴하였다. 20 이상으로악성위배출구협착환자에서고식적우회술과스텐트삽입술모두효과적이고비교적안전한방법이지만스텐트삽입술은특히생존기간이짧을것으로예상되는환자에서짧은시술시간, 비침습성및신속한임상증상의호전, 그리고높은비용효과면에서고식적우회술보다우월하므로우선적으로고려해야할것으로생각된다. 하지만생존기간이 64 The Korean Journal of Gastrointestinal Endoscopy

5 6개월이상비교적긴경우에는향후체계적인전향적인연구가필요하다. 2) 양성유문부협착 : 소화성궤양이나부식성위염의합병증으로유문부나십이지장구부의양성협착에의한폐쇄증상의해소를위하여과거에는풍선확장술을시도하였으나그효과는크게만족하지못한실정으로시술이후 50% 에서수술적재치료가필요하고위출구폐색증상의지속적소실은 16 70%, 천공합병증에의한응급수술이 %, 그리고반복적인시술이 22 32% 로보고되고있다. 21,22 그러나제한된경우에일시적피막형스텐트삽입술이유용할수있는데이는합병증으로스텐트일탈외에는상대적으로중증의합병증이적을뿐아니라반복적시술없이협착부위의지속적인확장을기대할수있는장점이있어서풍선확장술의단점인반복적인시술, 천공등의합병증을극복할수있는비수술적치료법의하나로고려될수있다. 본교실의보고에의하면양성유문부협착에일시적으로스텐트삽입술을한 8명의환자중 4명에서스텐트일탈이발생하였으나 5명 (71%) 에서증상의개선을보였다. 23 또다른최근의한연구에의하면소화관양성협착환자 11명에서 3주간의스텐트삽입후 27% 의스텐트일탈이발생하였고약 13개월간의추적관찰기간중약 36% 의재협착율을보고하면서소화관양성협착환자에서스텐트삽입술은비교적효과적이고안전한시술임을보고한바있다. 5 하지만보다효과적인시술이되기위해선일탈을줄일수있는스텐트의개발이요구된다. 4. 향후임상적응용이기대되는스텐트분야 식도스텐트삽입술은전술한식도의양성협착의치료이외에도 Boerhaave 증후군에의한식도천공이나식도수술후문합부누출등에서 4 6주간피막형스텐트를유치하면자연봉합 (spontaneous closure) 을유도할수있다. 24,25 최근에는자가팽창형플라스틱식도스텐트 (Polyflex, Roesch, Kernen, Germany) 가개발되어양성질환치료에사용되고있는데이는폴리에스터망으로이루어져있고실리콘막이씌워져있어기존의금속스텐트에비하여주위조직의염증변화가적어스텐트제거가용이하고 60% 까지풀리기전까지는재유치가가능한장점이있다. 2,3 최근의보고에의하면식도수술후의문합부누출환자에서 Polyflex를삽입후 70% 정도에서스텐트제거가가능하였고 78 92% 의누출소실율을보였다. 26,27 그러나아직까지양성식도질환에서식도스텐트삽입술이널리이용되기위해서는일정기간유치후완벽하게스텐트제거가가능할뿐만아니라유치시스텐트말단부의점막손상을최소화해서제거후에도새로운협착부위가발생하지않아야한다. 이상적인생체흡수 (biodegradable) 스텐트의개발이한방법이될수있고새로운구조나재질을이용한스텐트개발이그해결책일수있겠다. 한편아칼라시아환자에서일시적 스텐트삽입술로풍선확장술이나영구적인항역류스텐트삽입술보다우수한치료유지효과가있었다는연구결과도있으나 28 기존의풍선확장술이나 Heller 근절개술등과비교하여치료효과나증상감소의지속성에대한장기간의고찰이필요할것으로생각된다. 양성유문부협착은최근내시경적점막하박리술 (endoscopic submucosal dissection, ESD) 이널리시행되면서드물지만 ESD 후의합병증으로도발생될수있다. 이러한 ESD 후협착은주로내경이좁은식도병변, 위식도접합부, 그리고유문부등의생리적인협착부위에서발생될수있는데특히유문부는두꺼운근육층이발달되어있고전정부의넓은내경에비해내경이갑자기좁아져전체적으로깔때기모양의형태를보이기때문에이부위의병변에대한 ESD 시술시에는궤양이치유되는단계에서섬유화로인한협착때문에생리적으로존재하는협착이악화되어위배출구폐색이발생될수있으며특히병변의크기가커서전유문륜주위를완전절개를하는경우에는협착의가능성이높아진다. 29 문헌상보고는아주드물고최근의한보고에의하면유문부협착 5예모두전정부의 2/5 이상차지한크기가큰병변에서발생되었고발생시기는시술후 6주이내였다. 30 ESD 후에발생한협착의치료는현재까지의보고에의하면일반적인양성협착의통상적인치료법인풍선확장술이이용되어왔지만 ESD 후의유문부협착환자 4예중 2예에서만풍선확장술이성공적이었고 2예에서는천공이합병되어응급수술을요하여풍선확장술의안정성및효율에대해의문을제기한바있다. 30 또다른치료로다른양성유문부협착에서와같이스텐트삽입술이대안이될수있는데저자는유문환을포함하는조기위암병변에대하여내시경적점막하박리술을시행한이후발생한양성유문부협착의치료로스텐트를삽입하였고시행 8주후에제거함으로서성공적으로협착이호전된예를보고한바있다. 31 하지만아직까지이러한치료예의보고가적기때문에보다많은예를통한평가가요구된다. 향후 ESD 적응증확대및적응외시술이증가추세에있으므로합병증으로협착이동반되는예도점차증가될것이며따라서이에관한체계적인연구가가능할것으로생각한다. 끝으로악성위배출구폐쇄에서의스텐트삽입술은미래에도널리각광받을수있는비수술적고식적치료법임은자명하지만보다유용하고효과적인치료법이되기위해서는이론적으로완벽한스텐트즉스텐트일탈이없고위산및담즙에내구성이있는피막성스텐트의개발이절실하다고하겠다. 결론최근스텐트재질이나제작기술의진보, 내시경적시술경험의증가로스텐트삽입술은상부위장관악성종양에의한 Vol. 38, No. 2 February, 2009 (61-67) 65

6 위장관폐쇄증상의효과적이고안전하며또효과적인치료법으로서확고하게자리잡았다. 그러나스텐트일탈이나스텐트폐쇄에의한증상재발과같은합병증이발생할수있으므로시술후관리또한중요하며이러한합병증들을극복할수있는새로운기구나기술의개발이요구된다. 또한양성협착이나천공, 누출과같은증례에서도스텐트를이용한치료를기대할수있으나좀더많은임상적경험이축적되고기존치료법과의전향적인비교를통하여치료효과를입증할수있어야하겠다. 요약 상부위장관의스텐트삽입술은근치적수술이불가능한상부악성종양에의한협착환자의폐쇄증상완화를위한보존적치료로서확립되었다. 내시경개발기술이발달하고임상경험이축적됨에따라이제는여러상부위장관질환에서스텐트삽입술을보다편리하고안전하게시행할수있게되었다. 또한, 악성병변의보존적치료뿐아니라소화성궤양에의한양성협착, 식도천공혹은수술후문합부누출등의질환에서도일시적인스텐트삽입술로치료효과를거둘수있을것으로기대된다. 본종설에서는최근상부위장관스텐트삽입술의현황, 그리고앞으로기대되는임상적응용분야에대하여기술하였다. 색인단어 : 상부위장관, 스텐트삽입술, 적응증, 임상적응용 참고문헌 1.Spinelli P, Cerrai FG, Ciuffi M, Ignomirelli O, Meroni E, Pizzetti P. Endoscopic stent placement for cancer of the lower esophagus and gastric cardia. Gastrointest Endosc 1994;40: Lee YC. Esophagus. Korean J Gastrointest Endosc 2007; 35(suppl):314S-318S. 3. Moon JS. Upper gastrointestinal stenting: detailed techniques in esophageal and pyloric stenting. Korean J Gastrointest Endosc 2006;32(suppl):158S-162S. 4. Lee BJ, Park JJ. Pylorus and duodenum. Korean J Gastrointest Endosc 2007;35(suppl):319S-323S. 5. Han HW, Lee IS, Park JM, et al. Self-expandable metallic stent therapy for a gastrointestinal benign stricture. Korean J Gastrointest Endosc 2008;37: Ekberg O, Borgstro m A, Fork FT, Lo vdahl E. Endoscopic balloon dilatation of benign esophageal stricture-a nonhazardous procedure? Diagn Ther Endosc 1994;1: Zhou JH, Jiang YG, Wang RW, et al. Management of corrosive esophageal burns in 149 cases. J Thorac Cardiovasc Surg 2005;130: Siersema PD. Treatment options for esophageal strictures. Nat Clin Pract Gastroenterol Hepatol 2008;5: Inoue H. Treatment of esophageal and gastric tumors. Endoscopy 2001;33: Shim CS. Treatment for upper gastrointestinal stricture. Korean J Gastrointest Endosc 2001;21(suppl):61S-68S. 11. Raijman I, Siddique I, Ajani J, Lynch P. Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients. Gastrointest Endosc 1998;48: Shim CS, Cho YD, Moon JH, et al. Fixation of a modified covered esophageal stent: its clinical usefulness for preventing stent migration. Endoscopy 2001;33: Shields SJ. Esophageal self-expandable metallic stents. Gastrointest Endosc 1997;45: Siersema PD, Marcon N, Vakil N. Metal stents for tumors of the distal esophagus and gastric cardia. Endoscopy 2003;35: Dua KS, Kozarek R, Kim J, et al. Self-expanding metal esophageal stent with anti-reflux mechanism. Gastrointest Endosc 2001;53: Power C, Byrne PJ, Lim K, et al. Superiority of anti-reflux stent compared with conventional stents in the palliative management of patients with cancer of the lower esophagus and esophago-gastric junction: results of a randomized clinical trial. Dis Esophagus 2007;20: Shim CS, Jung IS, Cheon YK, et al. Management of malignant stricture of the esophagogastric junction with a newly designed self-expanding metal stent with an antireflux mechanism. Endoscopy 2005;37: Song GA, Kang DH, Kim TO, et al. Endoscopic stenting in patients with recurrent malignant obstruction after gastric surgery: uncovered versus simultaneously deployed uncovered and covered (double) self-expandable metal stents. Gastrointest Endosc 2007;65: Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol 2007;7: Jeurnink SM, Steyerberg EW, Hof G, et al. Gastrojejunostomy versus stent placement in patients with malignant gastric outlet obstruction: a comparison in 95 patients. J Surg Oncol 2007;96: Yusuf TE, Brugge WR. Endoscopic therapy of benign pyloric stenosis and gastric outlet obstruction. Curr Opin Gastroenterol 2006;22: Lau JY, Chung SC, Sung JJ, et al. Through-the-scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc 1996;43: Kim HJ, Park JJ, Kang CD, et al. Effect of the temporary placement of stent in benign pyloric stenosis. Gastroint Endosc 2004;59(abstr):153A. 24. Chung MG, Kang DH, Park DK, Park JJ, Park HC, Kim JH. Successful treatment of Boerhaave's syndrome with endoscopic insertion of a self-expandable metallic stent: report of three cases and a review of the literature. Endoscopy 2001;33: Kauer WK, Stein HJ, Dittler HJ, Siewert JR. Stent implantation as a treatment option in patients with thoracic anastomotic 66 The Korean Journal of Gastrointestinal Endoscopy

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