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1 대한소화기내시경학회지 2007;35: Billroth II 위절제술을시행한환자들에서회전절개도 (Rotatable papillotome, Autotome R ) 를이용한내시경역행성담췌관조영술및내시경유두괄약근절개술 2 예 포천중문의과대학교내과학교실 김용훈ㆍ권창일ㆍ김대영ㆍ손명수ㆍ고광현ㆍ홍성표ㆍ황성규ㆍ박필원ㆍ임규성 Case Series of ERCP and EST with Rotatable Papillotome (Autotome R ) in Patients with Billoth II Gastrectomy Yong Hun Kim,.D., Chang-Il Kwon,.D., Dae Young Kim,.D., yung Su Son,.D., Kwang Hyun Ko,.D., Sung Pyo Hong,.D., Seong Gyu Hwang,.D., Pil Won Park,.D. and Kyu Sung Rim,.D. Department of Internal edicine, Bundang CHA General Hospital, College of edicine, Pochon CHA University, Seongnam, Korea 내시경역행성담췌관조영술 (endoscopic retrograde cholangipancreatography, ERCP) 과내시경유두괄약근절개술 (endoscopic sphincterotomy, EST) 은여러담췌관질환의표준치료로널리사용되고있다. 위아전절제술과위공장문합술 (radical subtotal gastrectomy with gastrojejunostomy, Billroth II gastrectomy) 을시행한환자들에서 ERCP 및 EST 는수술후변형된해부학적이유로시술의성공률이정상해부학적구조에서시행하는경우보다낮은것으로알려져있다. 이런환자들에서 EST 시행시해부학적으로절개해야할유두부의방향이정상구조와비교하여반대로위치하기때문에, 표준형절개도를사용하지않고침형괄약근절개도, 유도철선을이용한 B-II 유두괄약근절개도등을사용해왔다. 저자들은최근에소개된회전형절개도 (rotatable papillotome, Autotome R ) 를이용하여 ERCP 및 EST 를성공적으로시행하고있기에증례를모아문헌고찰과함께보고하는바이다. 색인단어 : Billroth II 위절제술, 위공장문합술, 회전절개도, 내시경역행성담췌관조영술, 내시경유두괄약근절개술 서 내시경역행성담췌관조영술 (endoscopic retrograde cholangiopancreatography, ERCP) 과내시경유두괄약근절개술 (endoscopic sphincterotomy, EST) 은담관내결석제거나내시경적담즙배액을위한치료술기로그유 접수 :2007 년 8 월 6 일, 승인 :2007 년 10 월 1 일연락처 : 권창일, 경기도성남시분당구야탑동 351 번지우편번호 : , 포천중문의대분당차병원소화기내과 Tel: , Fax: mdkwon71@freechal.com 론 용성과안정성이인정된후, 1 현재여러담췌관질환의표준치료로널리사용되고있다. ERCP에서원하고자하는담관이나주췌관혹은부췌관으로의선택적인삽관의성공은담도질환, 췌장질환의진단과치료에필수적이다. 하지만위아전제술과위공장문합술 (radical subtotal gastrectomy with gastrojejunostomy, Billroth II gastrectomy, Billroth II 위절제술 ) 을비롯한위장관수술을시행받은환자에서는수술후변형된해부학적이유로수입관 (afferent loop) 을통한유두부접근이어려우며따라서진단과치료를위한적절한술기의실행이어렵다. 2 특히이로인해담관내결석을제거하기위해시행되는 EST는보편적으로시행하기어렵고위 445

446 대한소화기내시경학회지 2007;35:445-450 험성이따른다. 3 그이유는절개해야할유두부의방향이정상구조와비교하여반대로위치하기때문이며, 통상많이사용하는당김형 (pull type) 괄약근절개기로는원하는절개가어려워여러가지새로운괄약근절개법이시도되었다.

2 446 대한소화기내시경학회지 2007;35: 험성이따른다. 3 그이유는절개해야할유두부의방향이정상구조와비교하여반대로위치하기때문이며, 통상많이사용하는당김형 (pull type) 괄약근절개기로는원하는절개가어려워여러가지새로운괄약근절개법이시도되었다. 2,4-6 저자들은 Billroth II 위절제술을시행받은환자에서최근에소개된회전절개도 (rotatable papillotome, Autotome R, Boston Scientific Corp, Natik, A, USA) 를이용한 ERCP 및 EST를성공적으로시행하고있기에증례를모아문헌고찰과함께보고하는바이다. 1. 증례 1 증 례 Figure 1. Abdominal CT scan findings in case 1. It demonstrates a distal CBD stone with biliary obstruction and cholangitis. 78세여자환자가 15일전부터발생한우상복부통과식욕감소를주소로내원하였다. 40년전위궤양천공으로타병원에서 Billroth-II 위절제술을시행받았으며이후비교적건강히지내왔다. 일년전부터소화불량, 속쓰림등의증상으로타병원에서간헐적으로약물치료받던중우상복부통증과식욕감퇴증상이악화되어입원하였다. 전신상태는급성병색을보였으나의식은명료하였다. 활력징후는혈압 130/80 mmhg, 맥박수 70 회 / 분, 호흡수 20 회 / 분, 체온 36.7 C 소견을보였다. 공막은황달소견을보이지않았으나다소창백하였다. 복부는수술반흔이있었으며장음은청진되었고심와부압통이있었으나반발통이나 urphy 징후는저명하지않았다. 혈액검사에서백혈구 8,230/mm 3 ( 호중구 76%, 림프구 16%), 혈색소 11.3 g/dl, 혈구용적 33.2%, 혈소판은 200,000/mm 3 이었다. 공복혈당은 166 mg/dl였고혈청생화학검사상 BUN/Cr 21.6/0.9 mg/dl, 총단백 6.5 g/dl, 알부민 3.5 g/dl, Na/K/Cl 133/3.2/97 mg/dl, AST/ ALT 27/59 mg/dl, 총빌리루빈 4.10 mg/dl, ALP 996 IU/L, r-gtp 216 IU/L, Ca 8.7 mg/dl였다. 소변검사에서 SG 1.010, bilirubin (-), urobilinogen (-), RBC (-), protein (-), WBC 1/HPF, RBC <1/HPF였다. 입원후시행한복부전산화단층촬영에서총담관원위부의담석과담도폐쇄가동반된담관염소견이관찰되어 (Fig. 1), 내원 2일째 ERCP를시행하였다. 내시경은전방형위내시경 (GIF-XQ260, Olympus, Tokyo, Japan) 을사용하였고, 내시경으로유두의접근은어렵지않았으며 (Fig. 2A), 회전절개도 (Autotome R, Boston Scientific Corp, Natik, A, USA) 를이용하여담도삽관에성공하였고 (Fig. 2B), 이어서회전절개도의첨단부 분을 5시방향으로회전시킨뒤절개파를통전하여 EST를시행하였다 (Fig. 2C, 2D). 진흙양갈색담석과침전물을바스켓으로제거하였다. 보존적치료후내원 8일째환자의총빌리루빈은 1.14 mg/dl로감소하였으며퇴원후현재외래에서추적관찰중이다. 2. 증례 2 75세남자환자가내원 10일전부터발생한발열과황달을주소로내원하였다. 4년전타병원에서진행형위암으로진단받고 Billroth-II 위절제술을시행받았으며, 이후비교적건강히지내오던중내원 7개월전고열과황달을주소로본원에입원하여담도염의심하에경피적담도배액술및경피적담관내스텐트삽입술을시행받았다. 입원당시담즙에대한세포진검사에서담도암으로진단되어방사선치료 (6주간 3,000 cgy) 를받았다. 전신상태는급성병색을보였으나의식은명료하였다. 활력징후는내원당시혈압 90/50 mmhg, 맥박수 105회 / 분, 호흡수 22회 / 분, 체온 38.0 C 였다. 공막은황달소견을보였으며복부는수술반흔이있었다. 장음은청진되었고심와부압통이있었으나반발통이나 urphy 징후는없었다. 혈액검사에서백혈구 10,000/mm 3 ( 호중구 98%, 림프구 1%), 혈색소 10.8 g/dl, 혈구용적 32.2%, 혈소판은 249,000/mm 3 였다. 공복혈당은 124 mg/dl였고혈청생화학검사에서 BUN 13.5 mg/dl, creatinine 0.7 mg/dl, 총단백 4.7 g/dl, 알부민 1.9 g/dl, Na/K/Cl 141/3.9/103 mg/dl, AST/ALT 91/57 mg/dl, 총빌리루빈 9.1 mg/dl, ALP 1,417 IU/L, r-gtp 256 IU/L, Ca/g 7.9 /2.9 mg/dl, LDH (lactic acid dehydrogenase) 260 U/L, ESR 89 mm/hr, CRP mg/dl 소견과, 소변검사에서 SG

김용훈외 : Billroth II 수술환자에서회전절개도를이용한 ERCP 및 EST 447 Figure 2.

(A) Reversely positioned papilla is easily reached by forwardviewing endoscope.

(C, D) By slightly pulling and rotating the papillotome toward 5 o'clock, EST was successfully performed without

It demonstrates extension of tumor growth to the proximal portion of the stent with stent obstruction and biliary

025, bilirubin (++), urobilinogen (+), RBC (-), protein (+/-), WBC <1/HPF, RBC <1/HPF 소견을보였다.

3 김용훈외 : Billroth II 수술환자에서회전절개도를이용한 ERCP 및 EST 447 Figure 2. Use of a rotatable papillotome to cannulate the bile duct in case 1. (A) Reversely positioned papilla is easily reached by forwardviewing endoscope. (B) Radiograph showing the success of cannulation into the CBD by rotatable papillotme and round filling defect in the CBD. (C, D) By slightly pulling and rotating the papillotome toward 5 o'clock, EST was successfully performed without complications. Figure 3. Abdominal CT scan findings in case 2. It demonstrates extension of tumor growth to the proximal portion of the stent with stent obstruction and biliary obstruction and dilatation of the right IHD , bilirubin (++), urobilinogen (+), RBC (-), protein (+/-), WBC <1/HPF, RBC <1/HPF 소견을보였다. 패혈성쇼크상태에서응급으로시행한복부전산화단층촬영에서이전경피적으로삽입된금속스텐트의막힘으로인한담도폐쇄가동반된담관염소견이관찰이되어 (Fig. 3), 응급으로경피경간담도배액술 (percuatneous transhepatic biliary drainage, PTBD) 을시행하였고항생제투여를시작하였다. 환자전신상태와수치의호전소견을보여내원 4일째 ERCP를시행하였다. 내시경은전방형위내시경 (GIF-XQ260, Olympus, Tokyo, Japan) 을사용하였다. 내시경으로유두부의접근은어렵지않았으며 (Fig. 4A), 회전절개도 (Autotome R ; Boston Scientific Corp, Natik, A, USA) 를이용하여담도조영에성공하였고이전경피적으로삽입되어있던담관내스텐트는막혀있었다. 회전절개도의첨단부분을 5시방향으로회전시킨뒤절개파를통전하여괄약근절개를시행하였다 (Fig. 4B, 4C). 출혈없이괄약근이절개된후다량의갈색이물들이분출되었다. 유

448 대한소화기내시경학회지 2007;35:445-450 Figure 4. Use of a rotatable papillotome to cannulate the bile duct in case 2.

(B, C) By slightly pulling and rotating the papillotome toward 5 o'clock, EST was successfully performed without complications.

도철사 (J-WIRE, TW Endoscopie, Germany) 를막혀있는스텐트내로어렵게통과시킬수있었고내시경경비담도배액술 (endoscopic nasobiliary drainage, ENBD) 로배액관 (Cook Endoscopy, USA) 을삽입한뒤시술을마쳤다.

74 mg/dl로감소하고임상증상이호전되어내원 8일째 ENBD 배액관을제거후유두부를통하여이전경피적으로삽입되어있던금속스텐트내로 ERBD (endoscopic retrograde biliary drainage) 배액관 (plastic, 7 Fr, 10 cm; Cook Endoscopy, USA)

4 448 대한소화기내시경학회지 2007;35: Figure 4. Use of a rotatable papillotome to cannulate the bile duct in case 2. (A) Reversely positioned papilla was easily reached by forward-viewing endoscope. (B, C) By slightly pulling and rotating the papillotome toward 5 o'clock, EST was successfully performed without complications. (D) ERBD was inserted into the CBD through the clogged metal stent. 도철사 (J-WIRE, TW Endoscopie, Germany) 를막혀있는스텐트내로어렵게통과시킬수있었고내시경경비담도배액술 (endoscopic nasobiliary drainage, ENBD) 로배액관 (Cook Endoscopy, USA) 을삽입한뒤시술을마쳤다. 이후배액관으로답즙이잘유출되었고총빌리루빈이 4.74 mg/dl로감소하고임상증상이호전되어내원 8일째 ENBD 배액관을제거후유두부를통하여이전경피적으로삽입되어있던금속스텐트내로 ERBD (endoscopic retrograde biliary drainage) 배액관 (plastic, 7 Fr, 10 cm; Cook Endoscopy, USA) 을성공적으로삽입하였다 (Fig. 4D). 환자는 PTBD 제거후재원 14일째퇴원하였고현재외래에서추적관찰중이다. 고찰 Billroth II 위절제술을시행받은환자에서 ERCP 시행은해부학적인변형으로인해삽관및 EST 시행이어려워이전보고에의하면내시경삽관의성공은 67 95%, ERCP의성공은 46 92% 로알려져있으며, 이 로인한수입관천공을포함한합병증의발생률은 6 8% 로다소높은것으로보고되고있다. 7-8 ERCP 시행을위해측방형내시경과전방형내시경이모두사용될수있으며, 삽관용도관과유두괄약근절개도를제외하고는표준 ERCP 검사와동일한기구를사용해왔다. 9 측방형내시경과전방형내시경중어느방법이좋은지는논란의여지가있지만, 전방형내시경의경우는위-공장문합부와십이지장-공장접합부의급격한예각통과가가능하여천공등의합병증발생이적으며, 수입관을확인하고삽입하는것이가능하여유두로의접근이상대적으로용이하게되어보다안전한것으로보고되고있다. 9,10 그러나전방형내시경을사용할때에는측방형내시경에서와달리유두가비스듬하게관찰되므로삽관에실패하거나, 절개범위나방향을결정할수있는시야확보가곤란하여 EST가제대로이루어지지않거나합병증을초래할수도있다. 이러한이유로절개도의선단이십이지장내강을향하도록굽은것을선택하는것이담관삽관에유리한것으로알려

5 김용훈외 : Billroth II 수술환자에서회전절개도를이용한 ERCP 및 EST 449 Table 1. Clinical Characteristics of Patients with Previous Billoth II Gastrectomy, Treated by ERCP and EST with Rotatable Papillotome No. Sex Age Reason for Billoth II Reason for ERCP Technical success of ERCP & EST Additional treatment F Ulcer perforation Stomach cancer Gastric adenomatous polyposis Stomach cancer Ulcer perforation Acute cholangitis with CBD stone Acute cholangitis d/t clogged metal stent, cholangiocarcinoma Acute cholangitis with liver abscess and CBD stone, acute cholecystitis Acute cholangitis with CBD stone Acute cholangitis with CBD stone, acute cholecystitis No CBD stone removal ERBD after ENBD CBD stone removal, Laparoscopic cholecystectomy CBD stone removal, ENBD Explo-laparotomy CBD, common bile duct. 져있다. 10 EST는독일의 Classen과 Demling, 일본의 Kawai가동시에독자적으로개발되어, 최근에수기의확립, 처치기구의개량, 담석제거방법의다양한개발로담도질환의치료에널리이용되고있다. EST의약 10% 는해부학적변이, 유두협착등의이유로당김형괄약근절개기로시술이불가능하다. 이러한경우침형괄약근절개기 (needle type papillotome) 가이용되었으나심각한합병증의가능성을가지고있고시술에많은경험을요한다. 특히 Billroth II 위절제술을시행받은환자에서는특별히고안된역방향절개도 (reverse papillotome) 나 S자형절개도 (sigmoid papillotome), 또는침형절개도 (precut biliary needle-knife papillotome) 를이용하여 5 시 6시방향을절개해왔으며, 최근유도철선을이용한유두부절개도 (wire-guided billroth II papillotome) 는도관삽입의성공률을높이는것으로보고되었다. 10,11 이후 athuna 등 12 이유두괄약근절개술이기술적으로어려운경우유두부풍선확장술이담관내결석제거를위한한방법으로제시하였으며, Zanon 등 13 은경피경간유두절개술의효용성을제한된증례에서입증하였으나경구경유두경로를통한제거가불가능하고수술에따른위험도가높은환자들에게서제한적으로사용될것으로보고하였다. Shah 등 14 과 Freeman 등 15,16 은해부학적변형이동반된환자에서 ERCP를위해유도선과결합된회전절개도를이용한방법을새로소개하였다. 회전절개도의장점은절개도의선단을원하는대로여러각도로회전할수있으며, 당김형절개도의장점인굴곡을조절할수있어선단이십이지장내강을향하도록굽게조작할수있게되어, 5 6시방향뿐아니라원하는방향으로의삽관과유두절개를합병증을최소화하면서안 전하게시행할수있다. 저자들은위에소개한두증례이후에 3명의환자에대하여회전절개도를이용하여 ERCP와 EST를시행하였다. 이들중 2예는합병증없이시술에성공하였으나 1예에서삽관에실패하였다 (Table 1). Billroth II 위절제술을시행받은환자에서는 EST와관련된천공을비롯한합병증이통상적인경우보다매우높게보고되고있어, 17,18 향후다른유두절개방법과비교하여성공률, 합병증에대한대규모연구가필요할것으로생각한다. 본증례들에서는 Billroth II 위절제술을시행받은환자에서 ERCP 및 EST는회전절개도를이용하여성공적으로시행할수있었으며추후많은경험축적및비교연구가필요하다. ABSTRACT Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are the mainstays of the diagnosis and treatment of variable hepatobiliary and pancreatic diseases. The success rate of ERCP and EST in patients who have undergone a Billroth II gastrectomy is lower than in patients with a normal anatomy. Because the view of the ampulla is rotated 180 o in patients with Billroth II, several methods (ex, precut biliary needle-knife papillotome or wire-guided billroth II papillotome) have been used for endoscopic sphincterotomy instead of a pull-type papillotome. Using the recently devised pull-type and rotatable papillotome (Autotome R ), we performed successful ERCP and EST in 2 patients with a Billroth II gastrectomy without complications. (Korean J Gastrointest Endosc 2007;35: ) Key Words: Gastrectomy, Gastroenterostomy, Endos-

6 450 대한소화기내시경학회지 2007;35: copic retrograde cholaniopancreatography, Endoscopic sphincterotomy, Papillotomy 참고문헌 1. Kawai K, Akasaka Y, urakami K, Tada, Koli Y. Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974;20: Lee DK, Lee SW, Kim SR, Bae SW, Jang WI, Kwon SO. Therapeutic endoscopic retrograde cholangiography in patients with a Billoth II gastrectomy: 2 cases of ERBD & 1 case of endoscopic stone retrievial. Korean J Gastrointest Endosc 1992;12: Faylona J, Qadir A, Chan AC, Lau JY, Chung SC. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy 1999;31: Ikeda S, Tanaka, Itoh H, Tamura R. A newly devised cutting probe for endoscopic sphincterotomy of the ampulla of vater. Endoscopy 1977;9: Burlefinger RJ, von Sanden H, Ottenjann R, Schmitt W. A new reverse cutting sphincterotome for endoscopic sphincterotomy after Billroth II gastrectomy. Endoscopy 1993;25: Hintze RE, Veltzke W, Adler A, Abou-Rebyeh H. Endoscopic sphincterotomy using an S-shaped sphincterotome in patients with a Billroth II or Roux-en-Y gastrojejunostomy. Endoscopy 1997;29: Lin LF, Siauw CP, Ho KS, Tung JC. ERCP in post-billroth II gastrectomy patients: emphasis on technique. Am J Gastroenterol 1999;94: Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut 1984;25: Kim H, Lee SK, Lee H, 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: Le DH. ERCP in patients with deformed anatomical structure following upper gastrointestinal surgery (translated from Korean). Korean J Gastrointest Endosc 2003;26(suppl):166S-174S. 11. Ahn JH, Park BS, Choi WS, et al. 123 cases of endoscopic sphincterotomy (EST). Korean J Gastrointest Endosc 1994;14: athuna P, White P, Clarke E, erriman R, Lennon JR, Crowe J. Endoscopic balloon sphincteroplasty (papillary dilation) for bile duct stones: efficacy, safety, and follow-up in 100 patients. Gastrointest Endosc 1995;42: Zanon E, Righi D, aisano U, et al. Percutaneous transhepatic sphincterotomy - a report on 3 cases. Endoscopy 1991;23: Shah RJ, Antillon R, Springer EW, Penberthy JA, Chen YK. A new rotatable papillotome (RP) in complex therapeutic ERCP: indications for use and results. Gastrointest Endosc 2003;57(abstr):AB Freeman L, Guda N. ERCP cannulation: a review of reported techniques. Gastrointest Endosc 2005;61: Law N, Freeman L. ERCP by using a prototype obliqueviewing endoscope in patients with surgically altered anatomy. Gastrointest Endosc 2004;59: Freeman L, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J ed 1996;335: Safrany L. Endoscopic treatment of biliary-tract diseases. An international study. Lancet 1978;2:

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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