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1 Korean J Gastroenterol Vol. 71 No. 5, pissn eissn REVIEW ARTICLE 간내담석의치료 차상우 순천향대학교의과대학순천향대학교부속서울병원소화기내과 Management of Intrahepatic Duct Stone Sang-Woo Cha Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Seoul Hospital, Soon Chun Hyang University College of Medicine, Seoul, Korea Intrahepatic duct (IHD) stone is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. This stone is characterized by its intractable nature and frequent recurrence, requiring multiple therapeutic interventions. Without proper treatment, biliary strictures and retained stones can lead to repeated episodes of cholangitis, liver abscesses, secondary biliary cirrhosis, portal hypertension, and death from sepsis or hepatic failure. The ultimate treatment goals for IHD stones are complete removal of the stone, the correction of the associated strictures, and the prevention of recurrent cholangitis. A surgical resection can satisfy the goal of treatment for hepatolithiasis, i.e., complete removal of the IHD stones, stricture, and the risk of cholangiocarcinogenesis. On the other hand, in some cases, such as bilateral IHD stones, surgery alone cannot achieve these goals. Therefore, the optimal treatments require a multidisciplinary approach, including endoscopic and radiologic interventional procedures before and/or after surgery. Percutaneous transhepatic cholangioscopic lithotomy (PTCS-L) is particularly suited for patients at poor surgical risk or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. PTCS-L is relatively safe and effective for the treatment of IHD stones, and complete stone clearance is mandatory to reduce the sequelae of IHD stones. An IHD stricture is the main factor contributing to incomplete clearance and stone recurrence. Long-term follow-up is required because of the overall high recurrence rate of IHD stones and the association with cholangiocarcinoma. (Korean J Gastroenterol 2018;71: ) Key Words: Intrahepatic duct stone; Hepatolithiasis; Hepatectomy; Percutaneous transhepatic cholangioscopy; Post-operative cholangioscoopy 서론 간내담석증은담낭및간외담관담석의병발과관계없이좌우측주간관합류부상부간내담관에담석이존재하는경우로, 1 우리나라를포함하여동아시아에많이발생하는것으로알려져있다. 그러나생활환경, 위생의개선, 식습관변화등의이유로점차발생이줄고있지만여전히우리나라담석환자중상당한비율을차지하고있다. 2-4 간내담석은무증상 에서부터복통, 황달등의증상과반복적인담도염과담관협착, 화농성담관염, 간농양, 패혈증등이발생할수있고, 장기이환시속발성간경변증, 간실질위축, 심지어간내담도암이동반되기도한다. 또한간내담석은잦은재발과치료실패로반복적처치가요구될수있는난치성질환이다. 간내담석증의치료목표는완전한담석의제거와반복적인담관염의발생및담석재발을예방하고속발성간경변증이나담도암과같은질환으로진행하지않게하는것이다. 간내담석증의치료법 Received April 20, Revised May 8, Accepted May 11, CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright Korean Society of Gastroenterology. 교신저자 : 차상우, 04401, 서울시용산구대사관로 59, 순천향대학교부속서울병원소화기내과 Correspondence to: Sang-Woo Cha, Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea. Tel: , Fax: , swcha@schmc.ac.kr Financial support: None. Conflict of interest: None. Korean J Gastroenterol, Vol. 71 No. 5, May

2 248 차상우. 간내담석의치료 은내시경적치료법, 중재적방사선학적시술등비수술적치료와간절제술등수술적치료가있으며, 치료법의선택은간내담석, 담관, 간실질및환자의상태등에따라최선의치료법을선택하고병행하며최적의치료가이루어지도록하여야한다. 본론 1. 일차적치료법의선택간내담석증치료는간내담석을완전히혹은최대한제거하고, 담즙정체의원인인담관협착과확장을동시에제거하여재발을방지하는것이다. 이를위한일차적치료법의선택은명확하게결정짓기어려우나환자의상태, 간내담석의위치, 담관협착의유무및위치, 간실질위축의동반, 과거담도계수술유무, 악성질환의동반가능성등을고려하여결정해야한다. 일반적으로간내담석이있으며간실질의위축이동반되지않은경우, 이전에담도계수술을받은경우, 수술적치료를받기에환자의전신상태가적합하지않는경우는내시경적시술을이용한치료법이우선고려되어야한다. 담석이간한쪽엽또는구역에국한되어있으며담관협착이나간실질위축이동반된경우, 악성질환의동반이의심되는경우는간절제술을우선적으로고려하여야한다. 이에간내담석증의적합한일차적치료법의선택을위하여여러간내담석증분류법이소개적용되고있다. Tsunoda 분류 (Fig. 1) 5 는간내담석의위치, 담관확장혹은협착의동반여부에따른구분으로, I형은간내담석이담관의확장이나협착의동반없이존재하는경우, II형은간내담석이담관의확장에존재하 나협착이없는경우, III형은간내담석이간한쪽엽에만존재하며담관의확장과협착이동반된경우, IV형은양측엽모두에간내담석이존재하며담관의확장과협착이존재하는경우이다. 담관협착이없는 I형과 II형환자에서는담석제거를위하여내시경적치료를권고하고, 간내담석과담관협착이동반된 III형과 IV형환자에서는치료후재발률이높은것으로보고되고있어수술적치료를권고하였다. 6 Dong 등의분류 7 는간내담석의분포형태, 담관협착, 간실질위축, 간경변증이나문맥항진증동반여부, 간외담관담석의존재를더해서구분하여적절한수술적치료법의선택을권고하고있다. 담석이국한되어존재하는 I형과담석이산재되어위치하며간실질의위축, 담관협착이동반된 IIb형에서는간절제술이가장적합하고, 속발성간경변증이나문맥압항진증이동반된 IIc형은간이식을고려하고, 간외담관석이있으며간외담관의협착을동반시에는담도공장문합술의추가적시행을권고하였다. 7 실제간내담석치료에있어시행된치료법에대한조사는일본간내담석연구그룹이 1975년이후 7차례의전국적설문조사를통해수술적치료가 1998년 5차의조사까지일차치료로가장많이시행되었으나점차감소하였고 (1998년 76.6%, 2006년 52.4%, 2011년 33.3%, 수술적및비수술적병합치료포함 ), 마지막 2011년조사에서일차적치료로 66.7% 의환자에서비수술적치료가시행되었다. 8 본교실에서간내담석위치, 담관협착, 간실질위축의동반여부, 환자의전신상태등에따라일반적으로시행하고있는치료법의선택은아래그림과같다 (Fig. 2). 2. 내시경적치료법간내담석의내시경적치료법은접근경로에따라경유두적 Fig. 1. Tsunoda classification. 5 Type I, no marked dilatation or strictures of intrahepatic bile ducts. Type II, diffuse dilatation of the intrahepatic biliary tree without intrahepatic duct strictures and frequently a stricture of the distal common bile duct. Type III, unilateral solitary or multiple cystic intrahepatic dilatation, frequently accompanied by stenosis of the left or right intrahepatic bile ducts. Type IV, the same attributes as type III but with bilateral involvement of hepatic lobes. Fig. 2. Proposed therapeutic algorithm for the management of IHD stones. IHD, intrahepatic duct; EST-L, endoscopic sphincterotomylithotomy; PTCS-L, percutaneous transhepatic cholangioscopy-lithotomy; POC-L, postoperative cholangioscopy-lithotomy. The Korean Journal of Gastroenterology

3 Cha SW. Management of Intrahepatic Duct Stone 249 경로 (peroral transpapillary route) 로 endoscopic retrograde cholangiopancreatograpy (ERCP) 를이용한유두괄약근절개술후쇄석법 (endoscopic sphincterotomy-lithotomy, EST-L), 경구담도경을이용한경구담도경하쇄석법 (peroral cholangioscopy-lithotomy, POCS-L) 이있고, 경피경간적경로 (percutaneous transhepatic route) 로경피경간담도경하쇄석법 (percutaneous transhepatic cholangioscopy-lithotomy, PTCS-L), 경피경복적경로 (percutaneous transabdominal route) 로수술중 (intraoperative cholangioscopy-lithotomy, IOC-L) 혹은수술후담도경하쇄석법 (postoperative cholangioscopy-lithotomy, POC-L) 이있다. 9 1) 경유두부간내담석제거술 ERCP를이용한간내담석치료는제한적이다. 간내담석과동반된담관의협착이나굴곡이심한경우, 간내담석이말초분지에위치한경우는 ERCP를통한접근이어렵기때문이다. 간내담석이일차분지에위치하며동반된담관의협착이없거나심하지않은경우라면경험있는내시경에서 ERCP를이용한경유두부적간내담석제거를시도할수는있으나, 완전제거실패의가능성이높아일반적으로는권고되지는않는다. 10 모자내시경 (mother and baby scope) 시스템, SpyGlass 시스템 (SpyGlass ; Boston Scientific, Natick, MA, USA) 혹은 ultraslim upper endoscope를이용한경구적담도내시경 (peroral cholangioscopy, POCS) 역시간내담석치료로시행되고있다. 하지만담관협착이없는첫번째, 두번째분지의간내담관에위치한간내담석수술후, 간공장문합술을시행한환자군에서일부선택적인시행이보고되고있어폭넓은활용에는한계가있다 ) 경피경간간내담석제거술경피경간담도경하쇄석술 (PTCS-L) 은담도경의간내담관진입을위해서경피경간담도배액술 (percutaneous transhepatic biliary drainage, PTBD) 을통한누공의형성, 확장이필요하다. 누공을만들기위한 PTBD를시행할담관의선택은간내담석의위치와구역의수에따라결정이필요하다. 간의한쪽엽, 한구역에국한된간내담석은담석이있는담관으로직접 PTBD 누공을만들어도담석의제거가가능하지만, 간내담석이같은엽의 2개이상의구역에위치하는경우는담석이존재하는반대편옆에 PTBD 누공을만드는것이추후담도경을이용한담석의제거에유리하다. 이는같은엽에누공을만들경우에담도경이삽입된담관과간내담석이위치한담관사이의급격한굴곡으로담도경의접근이어려울가능성이크기때문이다. 간양측엽에담석이존재하는경우는좌측담관을통한우측으로의담도경의접근이더용이하 여좌측옆에 PTBD 누공을형성하는것을권장하고있다. 14 PTBD를시행후누공의확장은 PTCS가가능한한최소 16 Fr까지이루어져야하는데 PTBD 후바로시행하는경우도있지만, 일반적으로 PTBD 형성 2-3일후누공을 Fr 까지확장시킨다. 확장시킨누공에배액관을삽입하여 10-12일이상유지하면담관, 간, 복벽간의결합조직이형성되어누공이견고해지고안정적으로형성되어간내담석제거를위하여담도경을이용한시술이가능해진다. 누공을통하여처음으로담도경을삽입할때는배액관내로유도철사를삽입하여간내담관안에위치시킨후, 배액관을제거하고유도선을따라담도경간내담관으로삽입하여야한다. 이는누공이견고하지못한상태에서담도경이삽입되어누공이파괴되는경우먼저삽입된유도철사를통하여배액관을간내담도로재삽입하여위치시켜 PTBD를다시해야하는상황을피할수있기때문이다. PTCS-L 시에는담도경겸자구를통하여생리식염수를지속적으로주입하며선명한내시경시야를확보하며시술을진행한다. 대략 6 mm 미만인간내담석은바스켓카테터를이용하여누공을통해바로제거가가능하다. 많은담석이존재할경우에는누공의입구에서가장근접한담석부터제거해야하며, 너무크거나많은담석을한번에포획하면바스켓카테터의감돈이발생할수있고, 무리하게제거를시도하면누공및담관, 간실질의열상, 천공및출혈등의합병증이발생할수있다. 이에 6 mm 이상의담석은담도경하전기수압쇄석술 (electrohydraulic lithotripsy, EHL) 또는레이저쇄석술등을시행하여직접담석을분쇄하여담석조각을바스켓으로포획하여경피적으로제거한다. 10 간내담관협착으로담도경이담석으로의접근이불가능한경우에는담도경직시하유도선을협착부위를통과하여위치시킨후 8-10 mm 풍선도관을이용하여풍선확장술을시행하거나, Fr 배액관을협착부위를통과하여위치하게하고며칠간유지하여담관을확장시킨후, 담도경의접근을이루어담석을제거할수있다. 심한협착의경우재협착을예방하기위하여담석을제거한후에도 3-6개월간배액관을협착부위에유치시키기도한다. 특히수술문합부협착 ( 담관공장문합술등 ) 이동반된간내담석의경우담석만을제거하고협착이해결되지않으면간내담석이재발할수있어풍선확장술후담즙배액관 (16-18 Fr) 을협착부위에통과시켜장기간유치하여문합부협착의확장효과를기대하는방법을사용하기도한다. 15 PTCS-L을시행하는과정에서작은간내담석들은간외담도로모이게될수있다. 특히쇄석술을시행하게되면작은담석이많이생기며간외담도에모인담석을바스켓을이용해반복적으로경피적제거하는경우, 시술시간이상당히길어지고많은노력이요구되는단점이있다. 이러한경우직경 8 mm 풍선도관을사용하여경피적유두부풍선확장술 (percutaneous transhepatic Vol. 71 No. 5, May 2018

4 250 차상우. 간내담석의치료 papillary balloon dilatation, PTPBD) 을시행한후에내시경의선단부로담석을십이지장으로밀어내는방법을시행하면담석제거를위한시술시간을단축시킬수있다. 16 또한많은간내담석환자에서간외담관담석이동반되는데간외담관담석이크거나, 개수가많은환자에서는먼저 ERCP를통하여유두부괄약근절개술을시행하여간외담관담석의제거를시행하면간내담석이유두부를통한자연배출이이루어질수있고, 간내담석에대한 PTCS-L시크기가작은담석을담도경을이용하여십이지장내로밀어내기가용이하다. PTCS-L의합병증은 PTBD, 누공의확장및형성과정, PTCS-L 시술과정등에서혈담즙증, 혈복강, 간열상, 배액관의일탈및막힘, 담도염, 담즙누출및복막염등이발생할수있다. 9 이러한합병증의발생률과이로인한사망률은 6-17%, 0-2% 로보고되고있으며담도염에의한패혈증, 혈담즙증, 혈복강이사망원인의대다수를차지한다. 6,14,17 PTCS-L 중생검이나쇄석술등에의해담관손상으로발생되는출혈은대부분시술중자연적으로멈추고지혈의촉진을위하여 epinephrine 희석액을담도경을통하여주입할수도있다. 혈담즙증은많은경우에서저절로지혈되고, 출혈부위를압박할수있는적절한크기의배액관을위치하는정도로지혈이이루어지지만, 출혈이지속되고혈압이떨어지는경우는혈관조영술을통한색전술이필요하다. 9 드물게담도배액관을제거하자마자누공을만드는과정에서생긴담도문맥혹은담도동맥사이의누공에의한심한출혈이생길수있는데이러한출혈은동맥색전술을통한지혈이필요하다. 9 다발성담석, 협착에의한담도배액이불충분한경우담도염발생빈도가높아지고드물게간농양이합병될수도있다. 그러므로시술과연관된담도염의발생을낮추기위한예방적항생제의투여가필요하다 수술적치료법주요수술적치료법으로는담도절개를통하여간내결석을제거하는방법, 담도배액술, 부분간절제술등세가지형태가있다. 1) 간절제술간내담석의수술적치료원칙은간내담석의완전제거와함께담즙정체의원인인담관협착과확장을제거함으로써재발을방지하고전암병소의가능성이있는위축된간실질을제거하는것이다. 이에간절제술은간내담석의제거와동반된염증, 농양, 협착, 암성담도병변, 위축된간실질등도함께제거할수있고, 간내담석재발의위험도줄일수있는가장효과적인치료법이라할수있다. 일반적으로간절제술은간내담석이한쪽엽에국한되어있고간내담관의협착이심한경우, 간농양이나간실질의위축이동반된경우, 담관확장증 같은선천성기형과동반된경우, 담도암이의심되는경우시행할수있으며, 수술후담도경을통한잔류담석의제거를위하여간내통로를만들어두는일이중요하다. 10,18,19 일반적으로수술후 T-tube를 6-8주동안유치시키면새로운경피경복간누공이안정적으로성숙되어, T-tube 제거후형성된누공을통한방사선학적중재술로담석을제거하거나담도경을이용한수술후담도경하쇄석법 (POC-L) 시행이가능하다. POC-L의시술방법은 PTCS-L과크게다르지않다. 간내담석이편측성으로분포하는경우병변쪽의간을절제하는것이근치적방법이될수있다. 간내담석은좌엽특히좌외구역에발생빈도가높고우엽에국한된간내담석은좌엽에비하여드문편이다. 과거간내담석증에서우간엽절제술은간좌엽절제술에비하여합병증의발생위험이높아기피하는경향이있었으나, 점차지식과경험이축적되고광범위한간절제술이안전된술식으로정착됨에따라보다적극적인우간절제술이시행되고있다. 양측성으로분포하는담석의경우치료후잔류담석및재발의빈도가높고적절한치료를선택하는것이어려워다양한방법의병합적치료가필요하다. 양측성으로분포하는간내담석증에대한간절제술의유용성에대해서는이견이있지만최근양측간엽중주병소가있는편측엽혹은제한된분절에대한부분간절제술과함께수술후담도내시경을이용한담석제거술을병행한치료가많이시행되고있다. 간내담석증의경우염증으로인한주변장기와의유착, 간실질의위축, 간심부의담도및혈관의변형이동반되는경우가많고, 경우에따라담관장문합술의필요성이있어복강경을이용한수술의어려움과한계가있다. 하지만성공적인치료결과들이보고되고있으며우간절제술에대한경험도보고되고있다. 20 따라서향후간내담석의치료에복강경을이용한간절제술의적용이늘어날것으로예상된다. 2) 담도절개를통한담석제거술담도절개를통한간내외담석제거술은간실질위축, 재발성담관염, 간내담관암의발생위험등을생각하면일차적치료로는부적합하다. 그러나담관협착이나간실질의위축이없으면담석의완전한제거가가능한경우와간내담관암을의심할소견이없는경우라면시행할수있다. 총담관의주행방향으로절개를시행한뒤절개창을통해담석을제거하고절개창에 T-tube를삽입하여담즙의배액과수술후검사를통해잔류담석이존재하는경우담석을제거하는통로로사용한다. 이때 T-tube는담도경의사용가능성을고려하여 16 Fr 이상충분한굵기의관을사용해야하며가능한복벽과의거리가가까워지도록직선의경로를취하도록한다. The Korean Journal of Gastroenterology

5 Cha SW. Management of Intrahepatic Duct Stone 251 3) 담관장문합술간내담석증의치료에서재발혹은잔류담석은중요한문제이다. 이러한경우담즙정체의예방및잔류담석의자연배출을목적으로과거부터담관장문합술을시행하였는데, 공장이나십이지장을간관혹은총담관과문합하는수술로단독또는간절제술후보조적으로사용되고있다. 최근담관장문합술은총담관혹은총간관공장문합술이주로시행되고있다. 담관장문합술은일차치료로써적합하지않으며양측간엽에분포하는간내담석, 간외담관의협착이동반된경우, 담관확장증과같은선천성담관기형이동반된경우, 원위부총담관, 십이지장팽대부와같은팽대부주위의협착이동반된경우에고려할수있겠다. 4. 간내담석증치료성과및추적간내담석증의치료성과에대한여러연구들에서간절제술및수술후담도경시술 (POC-L) 을포함한경우에서완전한담석의제거는 % 로, 완전제거치료후 개월의추적기간동안간내담석재발률은 % 로보고하였다. 18,19,21 PTCS-L를이용한치료결과는 80-90% 의완전담석제거율과평균추적관찰기간 42개월-13.9년동안간내담석의재발률을 % 로보고하였다. 6,14,21 다른보고에서도마찬가지로일차치료로간절제술및수술후담도경시술을시행한경우에서 PTCS-L를이용한경우보다담석의잔류및재발이낮았고, ERCP를이용한치료군 (EST-L) 에서가장낮았다. 8 본교실에서간내담석환자 311명을대상으로후향적으로시행한연구 22 에서도부분간절제술, PTCS-L, EST-L을시행한환자들군에서완전한간내담석제거는각각 83.3%, 63.9%, 57.1% 였다. 중앙추적관찰기간 8년동안전체환자군에서간내담석및담관염재발률은 30.9% 였으며, 간내담석의제거가모두이루어졌던환자들중에서는 20% 에서재발하였다. 각치료법에따른재발률은부분간절제술, PTCS-L, EST-L을시행한환자군들에서 18%, 21%, 25% 로 ERCP를이용한치료에서가장높았으나통계학적유의한차이는나타나지는않았다. 치료후불완전담석제거의위험인자는담관협착, 간양측엽에담석, 비수술적치료법시행이었고, 담석이나담관염재발의위험인자는비수술적치료, 간경변증, 잔류담석, 담도협착이었다. 그외속발성경변증은 8.5%, 담도암은 4.8% 에서병발하였다. 다른연구들에서도담도협착이동반되어있는경우치료후간내담석잔류가많이발생하였고, 간내담석재발역시담관협착이동반된경우, 간내담석의완전제거가이루어지지못한경우에서더많이, 더일찍발생하였다. 6,14,18,19,21,22 간내담석과연관된담관암과의발생은대략 % 로보고하고있으나, 8,23 본교실의연구에서는간내담석이완전제거된환자들에서 4%, 완전제거가이루어지 지못한환자들의 8% 에서발생하여잔류담석이있는경우높게발생하였다 (p=0.06). 22 다른연구에서도잔류담석이있는경우담도암이의미있게높게발생하였다 (6.6% vs. 0.7%, p=0.026). 14 일본이 2010년이후시행한코호트연구 8 에서는담도암의발생에의미있는위험인자는 65세이상의고령과치료로담석제거만시행한경우였다. 위의결과들로보아간내담석의완전한제거는합병증발생및담석재발의위험을낮추는데중요하고, 담관협착이있는경우완전한담석의제거에방해가되고재발의위험도증가함으로, 간내담석의치료는완전한간내담석의제거와담관협착, 간실질변화의해소에집중되어야한다고하겠다. 또한간내담석을완전히제거한후에도간내담석이재발하는경우가많고, 속발성간경변증으로진행하여합병증이발생할수있으며담도암의동반및발생가능성을항상염두에두어야한다. 5. 무증상간내담석증의임상경과무증상간내담석증의치료는아직명확하지는않다. 간내담석진단시증상이없었던환자들 122명을대상으로 15년이상관찰한연구 24 에서관찰기간중 14명, 11.5% 에서간내담석과연관된증상으로복통, 간농양, 담관염, 담관암등이발생하였고, 증상이발현되기까지의기간은 9개월에서 7.3년 ( 평균 3.4년 ) 이었다. 이들중 9명에서증상발현시간외담관으로담석의이탈이동반되어있었다. 또한증상이발생한환자들에서간실질위축이의미있게많았다 (92.9% vs. 13%). 이들중 3명이사망에이르렀는데 2명은담도암, 1명은간부전이원인이었다. 이상의결과들로이들은간실질위축과간외담도로의담석이탈이증상발현및담도암발생에중요한위험인자임을주장하였고, 간외담석이동반되어있지않거나간실질위축이없는무증상간내담석환자들에게는주의깊은경과관찰도하나의대체적치료로가능하다고주장하였다. 그러나이미다른보고들에서완전한간내담석의제거가이루어지지못한환자들에서담도염및담석의재발이나혹은담도암발생이의미있게높아무증상간내담석의장기간의경과관찰은모험일수있을것이다. 결론 간내담석증은흔히발견되는담도계의양성질환이나합병증의발생이많고악성종양을유발할수있으며치료후에도재발이많아주의가필요한난치성질환이다. 간담도계의복잡한구조로인해환자마다다양한임상증상을유발하고다양한임상적형태로발현되어치료선택이어렵고힘든경우가많다. 간내담석의치료는담석의위치, 담관협착유무, 간실질위축동반여부등과증상및합병증유무, 환자의전신 Vol. 71 No. 5, May 2018

6 252 차상우. 간내담석의치료 상태등여러요인들을고려하여환자개개인의상황에맞게이루어져야한다. 또한수술적, 내시경적, 중재적치료의장단점을잘파악하고내과, 외과, 영상의학과와의유기적협조하에적절한치료방법을선택, 병행하는것이가장효과적인치료성과를얻을수있을것이다. 성공적인간내담석의치료후에도간내담석의재발, 간경변으로의진행, 담관암의발생이가능하므로장기적인추적관찰이필요하다. REFERENCES 1. Choi TK. Intrahepatic stones. Br J Surg 1989;76: Tazuma S. Gallstone disease: epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 2006;20: Kim MH, Lim BC, Myung SJ, et al. Epidemiological study on Korean gallstone disease: a nationwide cooperative study. Dig Dis Sci 1999;44: Park YH, Park SJ, Jang JY, et al. Changing patterns of gallstone disease in Korea. World J Surg 2004;28: Tsunoda T, Tsuchiya R, Harada N, et al. Long-term results of surgical treatment for intrahepatic stones. Jpn J Surg 1985;15: Lee SK, Seo DW, Myung SJ, et al. Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence. Gastrointest Endosc 2001;53: Feng X, Zheng S, Xia F, et al. Classification and management of hepatolithiasis: a high-volume, single-center's experience. Intractable Rare Dis Res 2012;1: Suzuki Y, Mori T, Yokoyama M, et al. Hepatolithiasis: analysis of Japanese nationwide surveys over a period of 40 years. J Hepatobiliary Pancreat Sci 2014;21: Shim CS, Neuhaus H, Tamada K. Direct cholangioscopy. Endoscopy 2003;35: Mori T, Sugiyama M, Atomi Y. Gallstone disease: management of intrahepatic stones. Best Pract Res Clin Gastroenterol 2006;20: Okugawa T, Tsuyuguchi T, K C S, et al. Peroral cholangioscopic treatment of hepatolithiasis: long-term results. Gastrointest Endosc 2002;56: Liu R, Zhang B, Liu D. Peroral cholangioscopy-guided laser lithotripsy to treat regional hepatolithiasis without stricture. Dig Endosc 2018 Mar 25. [Epub ahead of print] 13. Matsumoto K, Tsutsumi K, Kato H, et al. Effectiveness of peroral direct cholangioscopy using an ultraslim endoscope for the treatment of hepatolithiasis in patients with hepaticojejunostomy (with video). Surg Endosc 2016;30: Huang MH, Chen CH, Yang JC, et al. Long-term outcome of percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis. Am J Gastroenterol 2003;98: Kim JH, Lee SK, Kim MH, et al. Percutaneous transhepatic cholangioscopic treatment of patients with benign bilio-enteric anastomotic strictures. Gastrointest Endosc 2003;58: Moon JH, Cho YD, Ryu CB, et al. The role of percutaneous transhepatic papillary balloon dilation in percutaneous choledochoscopic lithotomy. Gastrointest Endosc 2001;54: Oh HC, Lee SK, Lee TY, et al. Analysis of percutaneous transhepatic cholangioscopy-related complications and the risk factors for those complications. Endoscopy 2007;39: Lee TY, Chen YL, Chang HC, et al. Outcomes of hepatectomy for hepatolithiasis. World J Surg 2007;31: Uenishi T, Hamba H, Takemura S, et al. Outcomes of hepatic resection for hepatolithiasis. Am J Surg 2009;198: Park JS, Han HS, Hwang DW, et al. Current status of laparoscopic liver resection in Korea. J Korean Med Sci 2012;27: Uchiyama K, Kawai M, Ueno M, Ozawa S, Tani M, Yamaue H. Reducing residual and recurrent stones by hepatectomy for hepatolithiasis. J Gastrointest Surg 2007;11: Cheon YK, Cho YD, Moon JH, Lee JS, Shim CS. Evaluation of long-term results and recurrent factors after operative and nonoperative treatment for hepatolithiasis. Surgery 2009;146: Kim HJ, Kim JS, Joo MK, et al. Hepatolithiasis and intrahepatic cholangiocarcinoma: a review. World J Gastroenterol 2015;21: Kusano T, Isa T, Ohtsubo M, Yasaka T, Furukawa M. Natural progression of untreated hepatolithiasis that shows no clinical signs at its initial presentation. J Clin Gastroenterol 2001;33: The Korean Journal of Gastroenterology

REVIEW ARTICLE THE KOREAN JOURNAL OF PANCREAS AND BILIARY TRACT 간내담석의내과적치료 황재철 아주대학교의과대학내과학교실 Medical Treatment of Intrahepatic Duct Stones Jae Chul H

REVIEW ARTICLE THE KOREAN JOURNAL OF PANCREAS AND BILIARY TRACT 아주대학교의과대학내과학교실 Medical Treatment of Intrahepatic Duct Stones Jae Chul Hwang Department of Internal Medicine, Ajou University School of Medicine,