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1 Original Article pissn / eissn J Korean Soc Radiol 2014;70(3): Effectiveness of Percutaneous Biliary Stone Removal as Primary Treatment in Cases with Difficulties in the Use of an Endoscopy 1 내시경적제거가어려운담관결석환자에서일차적인경피적간경유담석제거술의유용성 1 Sin Ae Choi, MD 1, Young Min Han, MD 1,2,3, Gong Yong Jin, MD 1,2, Seung Ok Lee, MD 2,4, Hee Chul Yu, MD 2,5 Department of 1 Radiology, 2 Research Institute of Clinical Medicine, 3 Institute of Cardiovascular Research, Departments of 4 Internal Medicine, 5 Surgery, Chonbuk National University Medical School and Hospital, Jeonju, Korea Purpose: To evaluate the effectiveness of percutaneous biliary stone removal as a primary treatment in cases with difficulties to use an endoscopy. Materials and Methods: From March 2004 to May 2011, 17 patients who underwent primary percutaneous biliary stone removal (Group 1) and 34 case-matched patients who underwent primary endoscopic biliary stone removal were selected (Group 2). The inclusion criteria were as follows: patients who had 1) 15 mm bile duct stones, 2) intrahepatic bile duct stones, 3) bile duct stones with a history of previous gastrointestinal bypass surgery. In the present study were analyzed the success rates, the length of postprocedural hospital stay, the change of Amylase/Lipase values and complications post procedure. Statistical analysis was performed using paired t-test and unpaired t-test. Results: The success rate was higher in Group 1 (94.1%) than in Group 2 (85.3%). Length of post procedural hospital stay and the post procedural amylase level were significantly increased in Group 2 (p = and p = 0.017, respectively). Conclusion: In cases of bile duct stones with difficulties in the use of an endoscopy a percutaneous biliary stone removal can be efficient as a primary treatment. Index terms Percutaneous Biliary Stone Removal Endoscopic Retrograde Cholangio Pancreatography 15 mm Bile Duct Stones Intrahepatic Bile Duct Stones History of Gastrointestinal Bypass Surgery Received October 28, 2013; Accepted December 20, 2013 Corresponding author: Young Min Han, MD Department of Radiology, Research Institute of Clinical Medicine, Institute of Cardiovascular Research, Chonbuk National University Medical School and Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju , Korea. Tel Fax ymhan@jbnu.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 담관결석 (biliary duct stone) 은담석 (biliary stone) 을가진환자의약 7~12% 에서보이며, 산통 (biliary colic), 담관염 (cholangitis), 폐쇄성황달및패혈증과같은다양한임상증상을일으킨다 (1, 2). 이에대한치료로내시경적역행성담췌관조영술 (endoscopic retrograde cholangio pancreatography; 이하 ERCP) 을이용한담석제거술은 1974 년처음도입된이래로담관결석의일차적인치료방법으로선호되어왔으며, 성공률이약 97% 에이르는것으로알려져있다 (3, 4). 그러나내시경적담석제거술은크기가크거나간내담관결석인경우, 큰유두부 주위게실이나원위부담관에협착이있는경우, 이전의위장관우회술을받은경우에서는도관접근이어렵고실패가능성이높고 (5-9), 이러한환자에서는경피적간경유담석제거술 (percutaneous transhepatic biliary stone removal) 을일차적으로시행하는것이안전하며효과적이라고알려져있다 (2, 8). 이전의경피적간경유담석제거술에대한연구들은내시경적담석제거술로실패한담관결석환자에한하여경피적치료술을시행하였거나, 내시경적담관결석제거가어려울것으로예상되는조건의환자에서일차적으로경피적치료술을시행한후그유용성을확인하는단일환자군연구였다. 그러나아직까지내시경적으로담관결석제거가어려운조건즉, 돌의직경이 15 Copyrights 2014 The Korean Society of Radiology 225

2 내시경적제거가어려운담관결석환자에서일차적인경피적간경유담석제거술의유용성 mm 이상이거나, 간내담관 (intrahepatic bile duct) 에있거나, 이전에위장관우회술의과거력이있는담관결석환자들에서경피적간경유담석제거술을일차적으로시행한경우와내시경적담석제거술을일차적으로시행한환자군에대한비교는없었다 (2, 8, 10). 이에저자들은상기에서언급한내시경적경로에의한담관결석제거가쉽지않은환자를대상으로일차적으로경피적간경유담석제거술또는 ERCP 를시행받은경우에대하여비교분석하였으며, 이를통해서일차적인경피적치료술의유용성에대하여알아보고자한다. 대상과방법 이번연구는환자의의무기록검토에의한후향적분석으로, 동의서면제를신청하여임상시험심사위원회승인을받아연구를진행하였다 년 3월부터 2011 년 5월까지담관결석증을진단받고경피적간경유담석제거술 (percutaneous transhepatic biliary stone removal) 또는내시경적담석제거술을받은환자를후향적으로분석하였고, 총 1147 명의환자가이에해당하였다. 담관결석증을진단받은모든환자는발열, 황달, 우상복부통증, 황달, 소화불량등의증상으로내원하였고혈액검사와복부전산화단층촬영 (computed tomography) 을시행한후담관결석을진단받았다. 이중에서내시경적경로에의해담관결석제거가쉽지않은경우로알려져있는, 즉돌의직경이 15 mm 이상이거나, 간내담관에있거나, 이전에위장관우회술의과거력이있는담관결석환자를선별하였으며각시술별환자수는 17 명과 421 명이었다. 최종적으로일차적경피적간경유담석제거술을받은 17 명 (1군; 남자 14명, 여자 3명, 평균연령 72.1 세, 범위 : 46~88 세 ) 과조건이일치하는 34명 (2군; 남자 26명, 여자 8명, 평균연령 72.1세, 범위 : 46~88 세 ) 의내시경적담석제거술시행환자를선정하여두환자군에대하여분석하였다. 환자들이이전에시행받은위장관우회술의종류는위아전절제술과동반된위십이지장문합술또는위공장문합술 (subtotal gastrectomy with Billoth I or II operation), 위전절제술과동반된식도공장문합술 (total gastrectomy with esophagojejunostomy), 담관공장문합술 (choledochojejunostomy), 유문부보존췌십이지장절제술 (pylorus preserving pancreaticoduodenostomy) 이있었다. 1군의모든환자들은담관염증상경감및시술접근경로형성을위하여경피적담도배액술 (percutaneous transhepatic biliary drainage; 이하 PTBD) 을먼저시행하고평균 6.6일 ( 간격 일수 : 0~13 일 ) 후담관결석제거술을시행하였다. PTBD 는 2% Lidocain HCI ( 제일약품, 서울, 한국 ) 국소마취제 5~10 cc를피부에주사한후초음파와투시하에 21-G 시바 (Chiba needle; M.I.Tech, 서울, 한국 ) 로천자한후시행하였다. 1군에서시행한 PTBD 의경로로우측담관을선택한경우가 13예 (76%), 좌측담관을선택한경우가 2예 (12%), 좌우측을동시에시행한경우가 2예 (12%) 였다. PTBD 후담관조영술 (cholangiography) 을시행하여담관구조와결석의위치, 크기, 개수등을미리확인하였다. 결석의크기는담관조영술상에서가장큰결석의장경으로측정하여표기하였다. 시술시기존의 PTBD 를통하여 inch 유도철사 (stiff guidewire; Radifocus R Guide Wire M; Terumo, Tokyo, Japan) 를간외담관을거쳐십이지장유두부까지지나가게한다음 8 Fr 유도관 (Arrow introducer sheath; Super Arrow-Flex R Sheath Set with Integral Hemostasis Valve/Side Port, Arrow international, INC., Reading, PA, USA) 으로교체하였다. 먼저 10 mm 4 cm 또는 12 mm 4 cm 혈관성형용풍선카테터 (Cordis R, Johnson & Johnson Company, Roden, The Netherlands) 를가이드와이어 (guide-wire) 를통해십이지장유두부를통과시킨후풍선확장 (balloon dilatation) 을 10기압으로 30초간 2회씩시행하였다. 이렇게유두부를확장시킨후결석을확장된유두부를통해십이지장안으로밀어내어제거하였다. 크기가 15 mm를넘거나유두부풍선확장술을통해결석이제거되지않는경우, 즉간내담관에있어유두부배출이어려운경우에는배액용카테터내로기계적쇄석술 (mechanical lithotripsy) 을위한바스켓카테터를통과시켜부분쇄석술을시행하여배출시키거나 7 Fr(21.5 cm sheath, 45 mm diameter, 6 cm length) 담석바구니 (Stone basket, MTW Endoskopie, Wesel, Germany) 를사용하여결석을직접포획한다음경피적으로꺼내거나유두부로밀어내어제거하였다. 시술후에는다시원래의 PTBD 카테터로교체하고 1~7일 ( 평균 3일 ) 후추적담관조영술을시행하여잔류결석유무를확인하였으며, 관찰되는모든담관결석이제거되어조영제가소장으로원활하게통과하면성공으로간주하여배액카테터를제거하였다. 잔류결석이남아있는경우에는위의시술을다시한번반복하여결석을완전히제거하고, 2~4일 ( 평균 3 일 ) 후에담관조영술을재시행하여잔류결석유무를확인후 PTBD 를완전히제거하였다. 한번의시술로잔류결석을모두제거하지못한경우에추가적인같은시술로남은결석을제거한경우도성공한것으로간주하였다. 내시경적담석제거술은환자및보호자의동의후시행되었으며, 시술 1주일전항혈소판제및항응고제의복용을중단하 226 대한영상의학회지 2014;70(3): jksronline.org

3 최신애외 도록하였다. 환자는복와위또는좌측와위자세에서내시경적담석제거술이시행되었다. 통상적인방법으로담도삽관에실패한경우에는내시경유두괄약근절개술 (endoscopic sphincterotomy; 이하 EST) 을시행하였고 EST 가어렵거나 EST 만으로충분한치료효과를얻기어려운상황에서는, 내시경유두풍선확장술 (endoscopic papillary balloon dilatation) 을시행하였다. 담도결석의제거는바스켓이나담석제거용풍선을사용하였다 (11). 각환자군에대하여시술성공률, 시술후입원기간, 시술후합병증을분석하였으며, 경피적간경유담석제거술또는내시경적담석제거술후에발생할수있는췌장염여부를확인하기위하여담관결석제거시술전가장마지막으로측정한 Amylase/Lipase 수치와시술후입원기간동안가장높게측정된 Amylase/Lipase 수치를비교하여의미있는상승을보이는지확인하였다. 시술후입원기간은경피적간경유담석제거술혹은내시경적역행성담췌관조영술을처음시술받은시점부터퇴원시점까지로하였다. 통계방법으로, 각환자군내에서시술전과후의 Amylase/ Lipase 수치의비교는 paired t-test 를이용하였으며, 성별, 15 mm 이상의담관결석의평균크기, 간내담관결석유무, 위장관우회술의과거력, 각환자군간시술후입원기간분석에는 unpaired t-test 를이용하였다. 모든결과는 p < 0.05 일때유의한것으로간주하였다. 통계분석프로그램은 GraphPad Prism (version 5.0, GraphPad Software Inc., San Diego, CA, USA) 을이용하였다. 결과 두군의평균연령 (72.1 세 ) 및범위 (46~88 세 ) 는동일하였고, 성별 (1군; 남자 14 명, 여자 3명, 2군 ; 남자 26 명, 여자 8명, p = 0.638), 15 mm 이상의담관결석의평균크기 (1군; 11/17, 평균 22.6 ± 3.75 mm, 2군 ; 22/34, 평균 21.4 ± 1.54 mm, p = 0.731), 간내담석비율 (1군; 5/17, 29.4%, 2군 ; 16/34, 47%) 에유의한차이는없었다 (p = 0.236). 위장관우회술의과거력은 1군 (10/17, 58.8%) 에서 2군 (7/34, 20.6%) 에비하여유의하게많았다 (p = 0.006)(Table 1). 시술성공률은 1군에서 94.1%(16/17) 로 2군 (29/34, 85.3%) 보다높았으며, 시술후입원기간은 2군 ( 평균 17.7 ± 1.40 일 ) 에서 1군 ( 평균 13.0 ± 1.20 일 ) 에비하여통계적으로유의한연장을보였다 (p = 0.036). 또한일차적으로내시경적담석제거술을시행한군에서시술전과후의 Amylase 수치가유의한상승을보였으며 (p = 0.017), 일차적으로경피적치료술을시행한경우의 Amylase 수치와두시술모두에서 Lipase 수치의유의한변화는없었다 (Table 2). 1군에서일차적으로경피적담관결석제거술은 1회에서최대 5회 ( 평균 1.5회 ) 까지시행하였으며, 2군에서내시경적역행성담췌관조영술은 1회에서최대 4회 ( 평균 1.9회 ) 까지시행하였다. 2군에서총 34 명중 8명은내시경적담석제거술에서담관결석을완전히제거하는데실패한후경피적간경유담석제거술을시행받아잔여담관결석을완전히제거하였다 (Figs. 1, 2). 시술후합병증으로는혈담즙증이 1명 (2군) 의환자에서발 Table 1. Patient and Disease Characteristics Group 1 (n = 17) Group 2 (n = 34) p Value Patient age (y) 72.1 ± ± Sex M F 3 8 Bile duct stone size (mm) 22.6 ± 3.75 (11/17) 21.4 ± 1.54 (22/34) IHBD stone 5/17 16/ Hx of GI bypass surgery 10/17 7/ Note.-Hx of GI bypass surgery = history of gastrointestinal bypass surgery, IHBD = intrahepatic bile duct Table 2. Amylase and Lipase Level at Pre- and Post-Procedure Group Amylase Lipase Pre* Post p Value Pre* Post p Value 1 (n = 17) ± ± ± ± (n = 34) ± ± ± ± Note.-*Latest level before first biliary stone removal procedure. Highest level after last biliary stone removal procedure. Group 1 = Group who underwent primary percutaneous biliary stone removal, Group 2 = Group who underwent primary endoscopic retrograde cholangiopancreatography jksronline.org 대한영상의학회지 2014;70(3):

87-year-old woman with distal common bile duct stones. A.

On endoscopic examination, one stone was broken using by mechanical lithotripsy.

The ampullary sphincter was dilated using a 10 mm-sized balloon catheter. E.

stone basket. The fragmented stones were completely extracted. F.

고찰 PTBD 경로를통한경피적간경유담석제거술은 1962 년에 Mondet (12) 에의해처음으로보고되었고, Burhenne (13, 14) 가바스켓카테터등을사용하면서실용화되었다.

4 내시경적제거가어려운담관결석환자에서일차적인경피적간경유담석제거술의유용성 A B C D E F Fig. 1. A 87-year-old woman with distal common bile duct stones. A. Cholangiogram shows a large impacted stones (55, 18 mm in each diameter) in the distal common bile duct. B, C. On endoscopic examination, one stone was broken using by mechanical lithotripsy. But lithotripsy for large proximal stone was failed. D. The ampullary sphincter was dilated using a 10 mm-sized balloon catheter. E. The stone was captured and fragmented using 7 Fr stone basket. The fragmented stones were completely extracted. F. Follow-up cholangiogram shows no demonstrable residual stone in the distal common bile duct. 생하였으며, 시술로인한사망이나치명적합병증은없었다. 고찰 PTBD 경로를통한경피적간경유담석제거술은 1962 년에 Mondet (12) 에의해처음으로보고되었고, Burhenne (13, 14) 가바스켓카테터등을사용하면서실용화되었다. 최근에는경피경간경로를통해접근해서십이지장으로결석을밀어내어제거하는방법이주로사용되고있으며, 여기에는오디괄약근에대한풍선확장술과혈관삽입기 (vascular introducer) 가적용되어사용된다 (15). 이러한방법또는기구들을이용한경피적간경유담석제거술은내시경적담석제거술을이용하여담관결석을제거할때와달리, 결석이배출되는방향과힘을가하는방향을보다쉽게유지할수있으며제거하는힘의세기를높일수있어결석의크기가확장용풍선의지름또는폐쇄 풍선카테터의지름과비교하여상대적으로직경이크더라도쉽게제거할수있다. 그리고타원형의결석들은유두부를지나갈때종축으로지나가기때문에 15 mm 정도의크기이더라도횡축의크기가작기때문에쉽게밀어낼수있다. 또한국내에서고령에발생하는담관결석은주로갈색색소성결석이기에결석의크기가풍선카테터의지름보다매우크더라도기계적쇄석술용바스켓카테터를이용하거나확장용풍선카테터를이용한부분쇄석술로크기를작게할수있으며, 해부학적변이가있는경우에는유두부에대한내시경적접근이어려워경피적접근으로담관결석을제거하는것이유용하다 (2, 8). 또한간내담석을제거할때에는 PTBD 의경로를이용하여내시경적접근방법에비하여접근경로가짧고결석제거시힘의방향조절에용이한장점이있다. 한편 ERCP 를이용한 EST 는 1974 년 Kawai 등 (3) 에의해도입된이후로현재담관결석환자에게서가장널리이용되는치 228 대한영상의학회지 2014;70(3): jksronline.org

최신애외 A B C D E Fig. 2. A 77-year-old woman with distal common bile duct stone.

Cholangiogram shows an impacted stones in the distal common bile duct (white arrow). B.

The ampullary sphincter was dilated using a 10 mm-sized balloon catheter (stone diameter: 13 mm, black arrow). D.

Follow-up cholangiogram shows no demonstrable residual stone in the distal common bile duct. 료방법이며이시술의효과는 76~92% 로보고되고있다 (4, 16-18).

따라서내시경적담석제거술로치료하기가어려운경우에는경피적간경유접근 (percutaneous transhepatic approach) 을통한결석제거술이대체방법으로서시행된다.

5 최신애외 A B C D E Fig. 2. A 77-year-old woman with distal common bile duct stone. She underwent total gastrectomy with esophago-jejunostomy due to gastric cancer. A. Cholangiogram shows an impacted stones in the distal common bile duct (white arrow). B. On endoscopic examination, the ampullary orifice could not be found due to previous operation. C. The ampullary sphincter was dilated using a 10 mm-sized balloon catheter (stone diameter: 13 mm, black arrow). D. The stone was captured and pulled using 7 Fr stone basket. The fragmented stone was completely extracted. E. Follow-up cholangiogram shows no demonstrable residual stone in the distal common bile duct. 료방법이며이시술의효과는 76~92% 로보고되고있다 (4, 16-18). 이시술은유두부게실, 십이지장협착, 십이지장팽대부협착, 이전에시행한위절제술과같은담관구조를변화시킬수있는수술, 크기가 15 mm 넘는큰결석을가진환자등에서는실패할수있으며, 전신상태가불량한고령의환자에서는금기에해당된다 (16, 19-21). 따라서내시경적담석제거술로치료하기가어려운경우에는경피적간경유접근 (percutaneous transhepatic approach) 을통한결석제거술이대체방법으로서시행된다. 그러나최근까지도실패할가능성이높은환자군에서여전히내시경적담석제거술이일차적으로시행되고있으며, 본연구에서는해당조건의환자에서일차적으로경피적간경유담석제거술을시행하였을때 (1군) 에비하여내시경적담석제거술을시행하였을때 (2군) 에성공률이더낮고입원기간의유의한연장을보였으며, Amylase 의유의한상승을보 였다. 경피적담석제거술의합병증으로는괄약근확장술을이용하였을때췌장염발생이 5~14% 의빈도를보이는것으로보고되고있고그외에담관염, 담즙흉막삼출, 혈액담즙증등이드물게보고되고있으며, 본연구에서 2군에해당하는 1예에서내시경적담석제거술로인한담관결석의완전제거에실패하여이차적으로경피적간경유담석제거술을시행한이후혈담즙증이발생하였다. 그러나시술로인한치명적인합병증이나사망은보고되지않았다. 반면내시경역행췌담관조영술을이용한담관결석제거시술로인한합병증은 5~19%, 사망률이 1~3% 에이르는것으로알려져있으며, 유두괄약근절개술은괄약근확장술에비하여괄약근손상에의한출혈및십이지장-담관역류에의한염증재발의빈도가높고젊은환자에게는특히시술하지않는것이좋다. 그외에도단기적으로는췌 jksronline.org 대한영상의학회지 2014;70(3):

6 내시경적제거가어려운담관결석환자에서일차적인경피적간경유담석제거술의유용성 장염, 십이지장천공, 담관패혈증, 장기적으로는상행성담관염, 십이지장유두부협착, 재발성결석의합병증을유발하는것으로알려져있다 (16, 17, 22-25). 이연구의한계점으로는모든분석이후향적으로단일기관에서만이루어졌고, 일차적으로내시경적담석제거술을시행한 2군의환자를 1군과같은조건으로선정하였음에도불구하고선택편향이발생하였을가능성이있다는점이다. 1군과연령, 성별, 15 mm 이상의담관결석, 간내담관결석또는위장관우회술의기왕력의포함기준이일치하는 2군을선정하였으나, 일차적내시경적담석제거술을시행받은담관결석증환자 421 명중에서위장관우회술의기왕력을가진환자는총 7명만존재하였기때문에앞서일치시킨 5가지조건중에서위장관우회술의과거력은두군간에유의한차이가있었다. 또한 2군의환자중일차적인내시경적담석제거술을통하여담관결석의완전제거에실패한 8명이포함되었으며, 이환자들은이차적으로경피적간경유담석제거술을시행하여결석을완전제거하였다. 따라서이 8명의환자에서는두가지시술모두가입원기간과 Amylase/Lipase 수치에영향을주었을가능성이있다. 다만 1군은일차적으로경피적담석제거술을시행한환자군이므로, 2군과중복되는환자는존재하지않았다. 마지막으로세가지의포함기준각각에따른구체적인결과분석이미흡하다는점이다. 각기준의환자에서내시경적담석제거술에비하여경피적담석제거술은상기언급된바와같은장점을가지고있으나, 본연구에서각기준에대한개별적인치료성적에대한분석은이루어지지않았다. 따라서향후에는선택편향을배제할수있는대규모및다기관연구를통해경피적간경유담석제거술의효과및유용성과합병증및제한점등에대한더구체적이고많은연구가이루어져야할것이다. 결론적으로, PTBD 를이용한경피적담석제거술은적절한배액으로담관염을치료하는동시에돌의직경이 15 mm 이상이거나, 간내담관에있거나, 이전에위장관우회술의과거력이있는환자와같이내시경적담석제거술에실패할가능성이높은환자들에서담관결석제거에좋은치료성적을보여안전하고효과적인일차적접근방법이라고판단할수있다. 참고문헌 1. Lim JH. Oriental cholangiohepatitis: pathologic, clinical, and radiologic features. AJR Am J Roentgenol 1991;157: Kim SH, Sohn CH, Kim YH. Percutaneous lithotripsy for removing difficult bile duct stones using endoscopy. J Korean Radiol Soc 2008;58: Kawai K, Akasaka Y, Murakami K, Tada M, Koli Y. Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974;20: Vaira D, D Anna L, Ainley C, Dowsett J, Williams S, Baillie J, et al. Endoscopic sphincterotomy in 1000 consecutive patients. Lancet 1989;2: Clouse ME, Stokes KR, Lee RG, Falchuk KR. Bile duct stones: percutaneous transhepatic removal. Radiology 1986;160: Neuhaus H. Intrahepatic stones: the percutaneous approach. Can J Gastroenterol 1999;13: Park YS, Kim JH, Choi YW, Lee TH, Hwang CM, Cho YJ, et al. Percutaneous treatment of extrahepatic bile duct stones assisted by balloon sphincteroplasty and occlusion balloon. Korean J Radiol 2005;6: Seon HG, Kwon CI, Yoon SP, Yoo KH, Ok CS, Kim WH, et al. PTPBD for managing extrahepatic bile duct stones in patients with failed or contraindicated ERCP. Korean J Med 2012;83: Ozcan N, Kahriman G, Mavili E. Percutaneous transhepatic removal of bile duct stones: results of 261 patients. Cardiovasc Intervent Radiol 2012;35: van der Velden JJ, Berger MY, Bonjer HJ, Brakel K, Laméris JS. Percutaneous treatment of bile duct stones in patients treated unsuccessfully with endoscopic retrograde procedures. Gastrointest Endosc 2000;51(4 Pt 1): Cho DH, Park GT, Oh JE, Chung CW, Yoo GJ, Kim SR, et al. [A single institution s experience of endoscopic retrograde cholangiopancreaticography in the eldery patients: outcomes, safety and complications]. Korean J Gastroenterol 2011;58: Mondet AF. [Technic of blood extraction of calculi in residual lithasis of the choledochus]. Bol Trab Soc Cir B Aires 1962;46: Burhenne HJ. Garland lecture. Percutaneous extraction of retained biliary tract stones: 661 patients. AJR Am J Roentgenol 1980;134: Burhenne HJ. Nonoperative retained biliary tract stone extraction. A new roentgenologic technique. Am J Roentgenol Radium Ther Nucl Med 1973;117: Gil S, de la Iglesia P, Verdú JF, de España F, Arenas J, Irurzun J. Effectiveness and safety of balloon dilation of the 230 대한영상의학회지 2014;70(3): jksronline.org

7 최신애외 papilla and the use of an occlusion balloon for clearance of bile duct calculi. AJR Am J Roentgenol 2000;174: Miller BM, Kozarek RA, Ryan JA Jr, Ball TJ, Traverso LW. Surgical versus endoscopic management of common bile duct stones. Ann Surg 1988;207: Neoptolemos JP, Carr-Locke DL, Fraser I, Fossard DP. The management of common bile duct calculi by endoscopic sphincterotomy in patients with gallbladders in situ. Br J Surg 1984;71: Siegel JH, Safrany L, Ben-Zvi JS, Pullano WE, Cooperman A, Stenzel M, et al. Duodenoscopic sphincterotomy in patients with gallbladders in situ: report of a series of 1272 patients. Am J Gastroenterol 1988;83: Ozcan N, Erdogan N, Baskol M. Common bile duct stones detected after cholecystectomy: advancement into the duodenum via the percutaneous route. Cardiovasc Intervent Radiol 2003;26: Meranze SG, Stein EJ, Burke DR, Hartz WH, McLean GK. Removal of retained common bile duct stones with angiographic occlusion balloons. AJR Am J Roentgenol 1986; 146: Ilgit ET, Gürel K, Onal B. Percutaneous management of bile duct stones. Eur J Radiol 2002;43: Stokes KR, Clouse ME. Biliary duct stones: percutaneous transhepatic removal. Cardiovasc Intervent Radiol 1990; 13: Maydeo A, Bhandari S. Balloon sphincteroplasty for removing difficult bile duct stones. Endoscopy 2007;39: Ersoz G, Tekesin O, Ozutemiz AO, Gunsar F. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest Endosc 2003;57: García-García L, Lanciego C. Percutaneous treatment of biliary stones: sphincteroplasty and occlusion balloon for the clearance of bile duct calculi. AJR Am J Roentgenol 2004;182: 내시경적제거가어려운담관결석환자에서일차적인경피적간경유담석제거술의유용성 1 최신애 1 한영민 1,2,3 진공용 1,2 이승옥 2,4 유희철 2,5 목적 : 내시경적제거가어려운담관결석환자에서일차적경피적간경유담석제거술의유용성에대하여알아보고자한다. 대상과방법 : 2004 년 3월부터 2011 년 5월까지담관결석증을진단받고일차적경피적간경유치료술을받은 17 명 (1군) 과조건이일치하는 34명 (2군) 의일차적내시경적치료환자를선정하였다. 환자포함기준은 15 mm 이상의담관결석, 간내담관결석또는위장관우회술의기왕력이있는환자였으며, 각군에대하여시술성공률, 시술후입원기간, 시술전과후의 Amylase/Lipase 수치, 시술후합병증을분석하였다. 통계적분석에는 paired t-test 또는 unpaired t-test 를이용하였다. 결과 : 시술성공률은 1군에서 94.1% 로 2군 (85.3%) 에서보다높았으며, 2군에서시술후입원기간 (p = 0.036) 과시술전과후의 Amylase 수치 (p = 0.017) 가유의한증가를보였다. 결론 : 내시경적제거가어려운담관결석환자에서일차적경피적간경유담석제거술은안전하고효과적인일차적접근방법이다. 전북대학교의학전문대학원전북대학교병원 1 영상의학과, 2 임상연구소, 3 심혈관연구소, 4 내과, 5 외과 jksronline.org 대한영상의학회지 2014;70(3):

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untitled 전남의대학술지제 46 권제 1 호 Chonnam Medical Journal Vol. 46, No. 1, pp. 62 66 DOI: 10.4068/cmj.2010.46.1.62 Billroth II 문합술을시행한환자에서총담관결석제거를위한누공형성술과큰풍선유두확장술병합요법 1 예 전남대학교의과대학내과학교실 기호석ㆍ박선영ㆍ윤경원ㆍ김민형ㆍ김현수ㆍ최성규ㆍ류종선 * Endoscopic