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1 대한내과학회지 : 제 89 권제 4 호 개의내시경을이용한금속스텐트삽입술을통해치료한들창자증후군 건국대학교의학전문대학원내과학교실 김준재 천영국 이태윤 심찬섭 A Case of Afferent Loop Syndrome Treated by Endoscopic Metal Stent Insertion Using Two Endoscopes Jun Jae Kim, Young Koog Cheon, Tae Yoon Lee, and Chan Sup Shim Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea Afferent loop syndrome is a rare complication of pancreaticoduodenectomy, and the endoscopic approach is difficult due to the surgically altered anatomy. Herein, we report a case of afferent loop obstruction treated by endoscopic metal stent insertion using two endoscopes. A 57-year-old male who had undergone the Whipple operation 7 months prior for pancreatic head cancer presented with abdominal pain and jaundice. Abdominal computed tomography showed afferent loop obstruction due to recurrent metastatic pancreatic cancer. First, we attempted to insert the stent using percutaneous transhepatic approaches following percutaneous transhepatic biliary drainage, but these failed. We therefore accessed the obstruction site using a relatively thin endoscope and then exchanged this endoscope for another with a large working channel, through which the self-expandable metal stent was passed. The stent was inserted successfully. This method will increase the success rate of endoscopic treatment. (Korean J Med 2015;89: ) Keywords: Afferent loop syndrome; Pancreaticoduodenectomy; Pancreatic neoplasm; Endoscopy 서론들창자증후군 (afferent loop syndrome) 은위아전절제술및 Billroth II 위-공장문합술이후에약 0.5-2% 에서발생하는매우드문합병증이다. 췌- 십이지장절제술 (pancreaticoduodenectomy) 이후에도역시발생할수있다 [1,2]. 원인은내부탈장, 장유착, 장꼬임및비틀림, 수술부위협착, 췌장염과같은양성요인에서부터악성종양의재발및전이에이르기까지다양하다 [3]. 들창자 (afferent loop) 의완전혹은부분폐쇄가발생한다면담즙과췌액의정체로담관염, 췌장염이발생할수 Received: Revised: Accepted: Correspondence to Young Koog Cheon, M.D., Ph.D. Digestive Disease Center, Department of Internal Medicine, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Korea Tel: , Fax: , yksky001@hanmail.net Copyright c 2015 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

- Jun Jae Kim, et al. Treatment of afferent loop syndrome - 있으며내강의압력이높아지게되어장의괴사와천공이발생할수있다 [4]. 양성요인에의한들창자증후군의근본적인해결방안은수술적치료이나악성요인인경우에는비수술적방법들이시행될수있다.

9 cm low-density mass (arrow) within the head-and-neck portion of the pancreas with involvement of the medial aspect of the duodenum. 증례 57세남자가소화불량과속쓰림을주소로외래를방문하였다.

5 cm 크기의십이지장과총담관을침범하는췌관선암종및췌장주변림프절전이가관찰되었다 (stage IIB, Ameriacn Joint Committee on Cancer, 2010) [5]. 수술후보조화학요법을고려하였으나환자의개인사정으로시행하지못하였다. 7개월뒤환자는복통과발열, 황달그리고반복되는구토증상을주소로응급실을방문하였다.

6 g/dl, 혈소판 90,000/uL이었으며아스파르테이트아미노전달효소 443 IU/L, 알라닌아미노전달효소 130 IU/L, 총빌리루빈 6.5 mg/dl, 알칼리인산분해효소 898 IU/L, 고감도 C-반응성단백 (high-sensitive C-reactive protein) 15.57 mg/dl 로관찰되었다.

2 - Jun Jae Kim, et al. Treatment of afferent loop syndrome - 있으며내강의압력이높아지게되어장의괴사와천공이발생할수있다 [4]. 양성요인에의한들창자증후군의근본적인해결방안은수술적치료이나악성요인인경우에는비수술적방법들이시행될수있다. 저자들은췌장암환자에서 Whipple 수술후재발성종양으로인해발생한들창자증후군을 2개의내시경을이용한금속스텐트삽입을통하여성공적으로치료한예를경험하였기에보고하고자한다. Figure 1. Computed tomography scan showing about a 2.9 cm low-density mass (arrow) within the head-and-neck portion of the pancreas with involvement of the medial aspect of the duodenum. 증례 57세남자가소화불량과속쓰림을주소로외래를방문하였다. 환자는 10년전부터당뇨병으로약물치료하던중이었으며술과담배는하지않았다. 시행한복부전산화단층촬영에서췌장두부암이관찰되었으며십이지장으로의침윤이의심되었다 (Fig. 1). 타장기로의전이소견은관찰되지않았다. Whipple 수술을시행하였으며조직검사결과 3.5 cm 크기의십이지장과총담관을침범하는췌관선암종및췌장주변림프절전이가관찰되었다 (stage IIB, Ameriacn Joint Committee on Cancer, 2010) [5]. 수술후보조화학요법을고려하였으나환자의개인사정으로시행하지못하였다. 7개월뒤환자는복통과발열, 황달그리고반복되는구토증상을주소로응급실을방문하였다. 내원당시혈압 135/92 mmhg, 맥박수분당 116회, 호흡수분당 20회, 체온 39.9 C 였으며시행한신체검사에서우상복부의압통및가스팽만소견이관찰되었다. 말초혈액검사에서백혈구 24,730/uL, 혈색소 9.6 g/dl, 혈소판 90,000/uL이었으며아스파르테이트아미노전달효소 443 IU/L, 알라닌아미노전달효소 130 IU/L, 총빌리루빈 6.5 mg/dl, 알칼리인산분해효소 898 IU/L, 고감도 C-반응성단백 (high-sensitive C-reactive protein) mg/dl 로관찰되었다. 폐쇄성황달및담관염의심하에복부전산화단층촬영을시행하였다. 촬영결과간-공장문합부에약 3.6 cm 크기의종괴가관찰되었으며이보다근위부공장에도약 3.6 cm 크기의종괴가관찰되었다. 근위부공장의종괴로인해장폐쇄가발생하여원위부공장의확장과간내담관의확장이관찰되었다. 간에는다발성전이와더불어간 Figure 2. (A) Computed tomography transverse image showing dilated afferent loop and a 3.9 cm liver abscess in segment 6. Coronal scan showing 3.6 cm metastatic masses (arrow) at the hepaticojejunostomy site (B) and proximal jejunum (C), with obstruction of the jejunum

- 대한내과학회지 : 제 89 권제 4 호통권제 662 호 2015 - 농양이관찰되고있었다 (Fig. 2). 재발한전이성췌장암에의한들창자폐쇄로판단되었다.

하지만장의예각화와폐쇄정도가심하여유도철사의진입에실패하였다. 4일뒤환자는내시경적접근을시도하였다.

을이용하여진입을시도하였으며장의루프가생기는것을최대한방지하기위하여위내의공기를최대한흡인하고장을단축화하여최단거리로접근하였다.

종괴로인한장폐쇄가심하여어려움이있었으나결국유도철사와카테터의삽 입에성공할수있었다 (Fig. 3).

이후자가팽창성금속스텐트 (Bonastent, Standard Sci Tech, 직경 18 mm 길이 12 cm; Seoul, Korea) 를삽입하였다 (Fig. 4).

폐쇄성황달은호전되어 2주뒤혈액검사에서총빌리루빈은 2.2 mg/dl 로감소하였다. 하지만환자는스텐트삽입한달후간농양및이로인한패혈증으로사망하였다. Figure 3. Endoscopy.

3 - 대한내과학회지 : 제 89 권제 4 호통권제 662 호 농양이관찰되고있었다 (Fig. 2). 재발한전이성췌장암에의한들창자폐쇄로판단되었다. 일단담도의감압을위해경피적담관배액술을시행하였으며추가로간농양에대해경피적도관배액술을시행하였다. 이후담즙배액로를통하여막힌소장의스텐트삽입을시도하였다. 하지만장의예각화와폐쇄정도가심하여유도철사의진입에실패하였다. 4일뒤환자는내시경적접근을시도하였다. 먼저비교적가늘어좁은길을통과하는데유용한내시경 (GIF-H260, Olympus, Tokyo, Japan) 을이용하여진입을시도하였으며장의루프가생기는것을최대한방지하기위하여위내의공기를최대한흡인하고장을단축화하여최단거리로접근하였다. Whipple 수술및공장- 공장문합을시행하여세갈래의진입로가관찰되었으며적절한방향으로진입하여폐쇄부위에도달할수있었다. 종괴로인한장폐쇄가심하여어려움이있었으나결국유도철사와카테터의삽 입에성공할수있었다 (Fig. 3). 이후유도철사를남겨둔채내시경을제거한후스텐트삽입이가능한내시경 (GIF-2T240, Olympus) 을유도철사를따라폐쇄부위까지위치시켰다. 이후자가팽창성금속스텐트 (Bonastent, Standard Sci Tech, 직경 18 mm 길이 12 cm; Seoul, Korea) 를삽입하였다 (Fig. 4). 이후시행된담관조영술에서확장된스텐트와조영제가근위부공장으로원활히배출되는것을관찰할수있었다. 또한반복적인구토증상은호전되었으며촬영한복부 X-선검사에서들창자의가스팽만소견은관찰되지않았다. 폐쇄성황달은호전되어 2주뒤혈액검사에서총빌리루빈은 2.2 mg/dl 로감소하였다. 하지만환자는스텐트삽입한달후간농양및이로인한패혈증으로사망하였다. Figure 3. Endoscopy. (A) The lumen was compressed by an extrinsic mass. Fluoroscopy. (B, C) A dilated afferent loop was observed, and the contrast agent could not pass though the obstructed lumen. A guidewire was inserted into the dilated afferent loop. Figure 4. Fluoroscopy. (A, B) An uncovered self-expandable metal stent was inserted at the obstruction site after exchanging the endoscope for another with a larger working channel. Endoscopy. (C) The metal stent was inserted successfully

4 - 김준재외 3 인. 들창자증후군의내시경적치료 - 고찰들창자증후군의치료는크게수술적방법과비수술적방법으로나뉘어지게된다. 수술적치료방법으로는공장간연결술 (jejunojejunostomy) 이나 Roux-en-Y 우회술이주로시행되어지게되며근치적절제술이나공장조루술 (jejunostomy) 역시고려해볼수있다. 수술적치료는근본적으로문제를해결할수있는유일한방법이다 [1,2]. 하지만본증례와같이악성종양의재발및전이에의해발생한경우환자의전신상태나상황이수술을시행하기어려운경우가대부분이다. 따라서임시적방편으로경간적혹은직접적인경피적경로를통한스텐트의삽입이나내시경적치료를고려하기도한다 [6-8]. 경간적경로를통한스텐트의삽입은폐쇄성황달이발생한경우에유용한방법이라할수있다. 확장되어있는담도를통하여경피경간담도배액술을시행한뒤이후이경로를통하여스텐트를이동시키는방법이다. 하지만이방법은폐쇄부위가담도-장문합부위와의거리가먼경우에접근이쉽지않으며간내담도의확장이없는들창자증후군환자의경우적용에어려움이있다 [7]. 또다른방법은직접적으로들창자를천자하여경피적배액을시행하는방법이다. 그러나들창자가복벽에고정되어있지않은경우시술이어려울수있고또한팽창되어있던들창자가줄어들면서담즙의누출및이로인한복막염이발생할수있다. Laasch [6] 는이를극복하기위하여 T자형조임쇄를이용한복벽고정술을제안하기도하였지만추가적인연구가필요해보인다. 본증례의경우먼저경피경간담도배액술을시행한뒤경간적경로를통한스텐트의삽입을시행하려하였으나장의예각화가심하고들창자의완전폐쇄로인해스텐트삽입에실패하여결국내시경적접근을시도하였다. 들창자증후군의내시경적치료의장점은비침습적이며직접육안으로폐쇄부위를확인할수있으므로진단및치료가용이하다는것이다. 하지만대부분수술로인한해부학적변형으로폐쇄부위까지내시경의접근이쉽지않다. Burdick 등 [3] 은들창자협착환자에서소아용대장내시경을이용해폐쇄부위에접근한뒤 endoscopic retrograde cholangiopancreatography (ERCP) 용스텐트로배액을성공적으로시행한예를보고하였다. 또한 Kim 등 [8] 은재발성췌장암으로인해발생한들창자증후군을성인용대장내시경을이용하여폐쇄부위에접근후자가팽창성금속스텐트를삽입하여치료한사례를 보고하였다. 그러나소아용대장내시경은 working channel의크기가작아금속스텐트의삽입이불가능하다. 또한성인용대장내시경은직경이커서폐쇄부위까지의접근이그다지용이한것은아니다. 최근오버튜브 (overtube) 와풍선을이용한소장내시경기술을통해해부학적변형이있는환자들에서 ERCP를시행한사례가보고되고있으나들창자증후군에서의적용예는드물다 [9,10]. 본증례에서는비교적직경이작은내시경을이용하여유도철사를들창자내로전진시킨뒤유도철사를남겨둔채자가팽창성금속스텐트의삽입이가능한내시경으로교체하여성공적으로스텐트를삽입할수있었다. 이시술의장점은직경이작은내시경을사용함으로써좀더쉽고빠르게병변부위에접근할수있으며환자의불편감역시감소할것으로예상된다. 또한들창자증후군의원인또는진단이불분명한경우일차적으로시도해볼수있겠으며소장내시경술과같은특수한장비나기술이없는기관에서도일차적접근방법이실패하였을경우차선책으로시행해볼수있겠다. 본증례에서는일반적진단용내시경 (GIF-H260, Olympus) 을사용하였지만상황에따라경비내시경또는소아용대장내시경을이용한접근도가능할것이다. 하지만주의할것은내시경을교체할때발생할수있는유도철사의소실이다. 이를방지할수있는방법으로충분한길이의유도철사를들창자내로전진시켜놓아야하며내시경교체시가능한위내의공기를최대한흡인하여유도철사가당겨지는것을막아야하겠다. 수술로인한해부학적변형이있을때들창자내의폐쇄병변으로의내시경삽입방법은아직까지표준화되어있지않다. 저자들이제시한접근법역시아직까지다른방법들과의비교연구는알려져있지않다. 하지만이러한시도가내시경삽입및치료실패율을낮추는또하나의대안이될수있을것으로생각된다. 요약들창자증후군의비수술적치료방법은다양하지만언제나모든방법이다적용가능한것은아니다. 특히내시경적치료방법은해부학적변형으로인해병변으로의접근에제한점이있다. 이에저자들은악성종양으로인한들창자증후군환자에서 2개의내시경을이용하여성공적으로금속스텐트를삽입한사례를문헌고찰과함께보고하는바이다

5 - The Korean Journal of Medicine: Vol. 89, No. 4, 중심단어 : 들창자증후군 ; 췌십이지장절제술 ; 췌장암 ; 내시경 REFERENCES 1. Park KS. Acute and chronic gastrointestinal disorders after gastric surgery: organic vs. functional. Korean J Med 2010;78: Aimoto T, Uchida E, Nakamura Y, et al. Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases. J Nippon Med Sch 2006;73: Burdick JS, Garza AA, Magee DJ, Dykes C, Jeyarajah R. Endoscopic management of afferent loop syndrome of malignant etiology. Gastrointest Endosc 2002;55: Spiliotis J, Karnabatidis D, Vaxevanidou A, et al. Acute cholangitis due to afferent loop syndrome after a Whipple procedure: a case report. Cases J 2009;2: Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York: Springer, Laasch HU. Obstructive jaundice after bilioenteric anastomosis: transhepatic and direct percutaneous enteral stent insertion for afferent loop occlusion. Gut Liver 2010;4 Suppl 1:S Hosokawa I, Kato A, Shimizu H, Furukawa K, Miyazaki M. Percutaneous transhepatic metallic stent insertion for malignant afferent loop obstruction following pancreaticoduodenectomy: a case report. J Med Case Rep 2012;6: Kim JK, Park CH, Huh JH, et al. Endoscopic management of afferent loop syndrome after a pylorus preserving pancreatoduodenecotomy presenting with obstructive jaundice and ascending cholangitis. Clin Endosc 2011;44: Skinner M, Popa D, Neumann H, Wilcox CM, Mönkemüller K. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy 2014;46: Itokawa F, Itoi T, Ishii K, Sofuni A, Moriyasu F. Single- and double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y plus hepaticojejunostomy anastomosis and Whipple resection. Dig Endosc 2014;26 Suppl 2:

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Kjhps016( ).hwp Surgical Extent and Types in Pancreatic Cancer Song Cheol Kim, M.D. Department of Surgery, Ulsan University College of Medicine & Asan Medical Center, Seoul, Korea Pancreatic cancer continues to pose a