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1 대한내과학회지 : 제 85 권제 3 호 유문부피막형금속스텐트의원위부이탈에의해발생한급성췌장염 1예 인하대학교의학전문대학원내과학교실 신천호 정석 이돈행 김성현 김경은 박성욱 방병욱 A Case of Acute Pancreatitis Caused by Distal Migration of a Pyloric Covered Self-Expandable Metal Stent Chun Ho Shin, Seok Jeong, Don Haeng Lee, Seong Hyun Kim, Kyung Eun Kim, Sung Wook Park, and Byung Wook Bang Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea Endoscopic metal stent insertion has been widely performed to palliatively treat gastrointestinal (GI) tract obstruction in patients with cancer. The use of metal stents for benign strictures of the GI tract is increasing due to the low risk of major complications other than stent migration. The incidence of acute pancreatitis after placing a GI tract metal stent is rare. Herein, we report a case of acute pancreatitis caused by a covered metal stent that was initially inserted for a benign stricture of a gastroduodenal anastomosis that developed after the operation, then distally migrated, bent into a U-shape, and impacted into the second portion of the duodenum in a 56-year-old female who underwent a Billroth- I gastrectomy due to gastric cancer. (Korean J Med 2013;85: ) Keywords: Pancreatitis; Gastric outlet obstruction 서론상부위장관의금속스텐트삽입술은주로근치적수술이불가능한위, 식도, 담도및췌장의악성종양에의한위장관협착환자에서위장관폐쇄증상완화를위한보존적치료목적으로사용되어왔다 [1]. 최근에는합병증이적을뿐아니라반복적시술없이협착부위의지속적인확장을기대할수있는장점이있어서소화성궤양협착이나수술후문합 부협착등유문부나십이지장구부의양성협착에도금속스텐트의사용이증가하고있다 [2]. 금속스텐트삽입으로인한합병증은장천공, 장출혈, 스텐트의이탈이나폐쇄등이있으며스텐트의이탈은후기합병증중흔히예견되어온것이지만소화관에삽입된스텐트가십이지장으로이동하여췌장염이발생한경우는흔하지않다 [3]. 스텐트삽입후의합병증으로췌장염이생기는경우는대부분담관금속스텐트에의한것으로, 악성폐 Received: Revised: Accepted: Correspondence to Seok Jeong, M.D. Department of Internal Medicine, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon , Korea Tel: , Fax: , inos@inha.ac.kr Copyright c 2013 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.

- The Korean Journal of Medicine: Vol. 85, No. 3, 2013 - 쇄성황달의치료로담관배액을위한내시경스텐트삽입술후급성췌장염이발생한예들이있으며 [4], 악성위출구협착환자에서자가팽창성금속스텐트삽입후스텐트의이탈없이스텐트벽이췌관입구를기계적으로막아발생한췌장염이보고되었다 [3].

과거력 : 환자는입원 3개월전다른병원에서조기위암진단하에 Billroth I 위아전절제술을시행받았고입원 1개월전지속적인오심, 구토증상이있어다른병원에서내시경을시행하였고상부위장관내시경검사에서문합부의양성협착이관찰되어피막형자가팽창성금속스텐트삽입술을 시행받았다. 가족력과사회력 : 특이사항없음.

2 - The Korean Journal of Medicine: Vol. 85, No. 3, 쇄성황달의치료로담관배액을위한내시경스텐트삽입술후급성췌장염이발생한예들이있으며 [4], 악성위출구협착환자에서자가팽창성금속스텐트삽입후스텐트의이탈없이스텐트벽이췌관입구를기계적으로막아발생한췌장염이보고되었다 [3]. 저자들은조기위암환자에서 Billroth I 위아전절제술후발생한문합부양성협착치료를위하여회수가능한피막형자가팽창성금속스텐트를삽입한후이의이탈로인해급성췌장염이발생하여내시경으로이탈된스텐트를제거하고보존적인치료를시행하여회복된 1예를경험하였기에보고한다. 증례환자 : 56세, 여자주소 : 전반적인복부통증현병력 : 입원당일오전부터지속된복부통증이갑자기발생하여입원하였다. 과거력 : 환자는입원 3개월전다른병원에서조기위암진단하에 Billroth I 위아전절제술을시행받았고입원 1개월전지속적인오심, 구토증상이있어다른병원에서내시경을시행하였고상부위장관내시경검사에서문합부의양성협착이관찰되어피막형자가팽창성금속스텐트삽입술을 시행받았다. 가족력과사회력 : 특이사항없음. 신체검사소견 : 입원당시활력징후는혈압 100/60 mmhg, 맥박수 90회 / 분, 호흡수 20회 / 분, 체온 37.5 였다. 의식은명료하였고공막에황달은보이지않았다. 호흡음은깨끗하였고심음은규칙적이었으며심잡음은들리지않았다. 복부는편평하였고장음은약간감소되었으며복부전반에걸쳐압통과반발통이있었다. 검사실소견 : 말초혈액검사에서백혈구 12,690/mm 3 ( 중성구 79.7%), 혈색소 11.9 g/dl, 혈소판 287,000/mm 3 였다. 혈청생화학검사에서총빌리루빈 0.4 mg/dl, 아스파르테이트아미노전달효소 49 IU/L, 알라닌아미노전달효소 19 IU/L, 알칼라인인산분해효소 189 IU/L, 아밀라아제 5,684 ( 정상치 : ) IU/L, 리파아제 3,000 ( 정상치 : 7-60) U/L, 중성지방 84 mg/dl였다. 방사선학적소견 : 복부전산화단층촬영에서소화관금속스텐트가십이지장제2부에서이동하여 U자형태로접혀져매복된소견이관찰되었으며췌장실질의종대와췌장주변부의체액고임, 지방조직침윤이관찰되어급성췌장염에합당하였다 (Fig. 1). 복부초음파검사에서담낭에담석이나담즙찌꺼기는관찰되지않았다. Figure 1. Pancreatic computed tomography scan shows collection of peripancreatic fluid. The metallic stent had folded and migrated into the second portion of the duodenum. Figure 2. Duodenoscopic finding shows folded covered metal stent that was impacted into the second portion of the duodenum

$(A) Fluoroscopic finding reveals that the fractured and folded metal stent was impacted into the duodenum.$ (B) It was removed from the duodenum through the overtube using an alligator forcep and a polypectomy snare.

(B) It was removed from the duodenum through the overtube using an alligator forcep and a polypectomy snare.

치료및경과 : 임상적으로스텐트가이탈하면서주췌관입구를막아췌장염이생겼을가능성이높아, 입원 2병일째상부위장관내시경 (GIF-H260; Olympus Corp.

3 - Chun Ho Shin, et al. Pancreatitis caused by stent migration - A B Figure 3. (A) Fluoroscopic finding reveals that the fractured and folded metal stent was impacted into the duodenum. (B) It was removed from the duodenum through the overtube using an alligator forcep and a polypectomy snare. 내시경소견 : 2병일째시행한상부위장관내시경검사에서위와십이지장구부내강의확장이관찰되었으나위-십이지장문합부협착은더이상관찰되지않았으며십이지장제2부에중간부가항문측을향해꺾이면서전체가 U자형태로접혀서십이지장내강내에박혀있는피막형금속스텐트가관찰되었다 (Fig. 2). 치료및경과 : 임상적으로스텐트가이탈하면서주췌관입구를막아췌장염이생겼을가능성이높아, 입원 2병일째상부위장관내시경 (GIF-H260; Olympus Corp., Tokyo, Japan) 을십이지장제2부에접근시켜악어입집게 (alligator forcep) 로스텐트한쪽말단의 wire를잡아위내로끌어올린후 overtube를식도내에삽입하고폴립절제용올가미로스텐트한쪽끝전체를포획하여체외로회수하였다 (Fig. 3). 회수된금속스텐트는중간부위의 wire들이절반이상절단되어있었다 (Fig. 4). 3병일째환자는상복부통증이다소완화된상태였으며혈액검사에서아밀라아제 700 IU/L, 리파아제 243 U/L로감소된소견을보였다. 4병일째췌장염을일으킬수있는다른원인을배제하기위하여내시경초음파검사와내시경역행담췌관조영검사를시행하였으나특이소견은보이지않았다. 환자는적절한수액공급과항생제정주등 Figure 4. A nearly complete cut of the stent wall with wire breakage was observed at the mid portion of the retrieved stent. 보존적인치료를시행하며복통이소실되고정상적인식사가가능하여 8병일째퇴원하였고위암수술후의정기적인검진을위해위암수술을시행하였던병원으로전원되었다

4 - 대한내과학회지 : 제 85 권제 3 호통권제 637 호 고찰상부위장관에서금속스텐트삽입술의적응증은주로위전정부, 십이지장및췌담도의악성종양에의한소화관의협착및폐쇄로증상이발생한경우이며 [5,6], 일반적으로양성병변에의한협착의경우장기간의스텐트유치는적응증이되지않으나일시적으로스텐트를삽입하여폐쇄병변의확장효과가기대되는경우는제한적으로시술할수있다 [6]. 유문양성협착은조기위암치료를위한내시경점막하박리술 (endoscopic submucosal dissection, ESD) 후의합병증으로도발생할수있는데, ESD 적응증의확대로시술이증가하면서합병증으로협착이동반되는경우도점차늘어날가능성이있다 [7]. 과거에는이러한양성유문협착의경우비수술적치료법으로내시경풍선확장술을시행하였으나이는천공과같은중증의합병증의발생위험이높고반복적인시술을요한다는단점이있어최근에는금속스텐트삽입이증가하고있다. 상부위장관에서의금속스텐트삽입후합병증으로발생할수있는급성췌장염은매우드물다. 진행성위암에의한위출구협착으로유문스텐트삽입술후합병증으로급성췌장염이보고된예가있으나 [3] 이는암의진행에의해서췌관을직접압박했거나십이지장제2부에위치한스텐트의원위부가췌관개구부를막아췌장염이발생했을것으로추측된다. 이번증례처럼위-십이지장문합부의양성협착환자에게삽입된스텐트가항문측으로이탈되고이것이십이지장제2부에서직접췌관개구부를막아급성췌장염이발생한예는아직보고된바없다. 양성협착병변에서의스텐트삽입은이론적으로스텐트일탈, 스텐트제거시의출혈및천공가능성이있다. 한연구에의하면소화관양성협착환자 11명에서 3주간의스텐트삽입후 27% 의스텐트일탈이보고된바있다 [6]. 통상적으로담관이나유문혹은위-십이지장문합부에삽입된금속스텐트가원위부로이탈되는경우, 특별한문제없이십이지장을지나쳐대변을통해체외로빠져나가지만이탈된스텐트가회장에걸리는경우소장의폐색을일으키기도한다 [8]. 이번증례의경우이탈된스텐트가십이지장제2부를지나치지않고내강내에매복된이유는금속스텐트중간부의철사들이절단되면서중간부가꺾이고이를중심으로스텐트가 U자형으로접힘으로써십이지장내강내에박혔을 것으로생각된다. 또한매복된스텐트의벽을싸고있는실리콘피막이십이지장점막에밀착되면서췌관개구부의폐쇄를유발하여결국급성췌장염을유발하였을것으로추정된다. 한편스텐트의철사가절단되는경우는악성종양환자에서스텐트삽입후종양의증식으로인해발생하는비교적흔한합병증이만, 양성질환의경우는몇몇증례보고가있을정도로드물며원인은명확하지않다 [9]. 이번증례에서스텐트의철사가자발적으로절단된원인으로는스텐트가양성협착을가진문합부에유치된상태에서호흡에따른반복적인장기의움직임으로좁아진문합부의조직과금속스텐트중간부의철사사이, 그리고스텐트벽에서교차되어서로접촉해있는철사들간에마찰이반복적으로발생하고여기에위산에의한직접적인부식성손상이더해져절단되었을것으로추측할수있다. 임상의들은상부위장관의양성협착환자에서피막형금속스텐트의사용을고려할때, 스텐트의이탈과더불어이번증례와같이급성췌장염이라는심각한합병증이동반될수있음을염두에두어야할것이다. 요 저자들은조기위암수술후발생한문합부양성협착환자에서금속스텐트삽입술후스텐트의원위부이탈로인해급성췌장염이발생한증례를경험하였기에보고한다. 중심단어 : 췌장염 ; 위출구폐쇄 약 REFERENCES 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: Park JJ, Yang CH. The current status and the future of upper GI stenting. Korean J Gastrointest Endosc 2009;38: Kim JH, Park JJ, Lee BJ, et al. Two cases of acute pancreatitis complicating insertion of self-expandable metallic stent for malignant gastric outlet obstruction. Korean J Med 2006;71(1 Suppl):S Kim SG, Park JJ, Chung MG, et al. Three cases of acute pancreatitis complicating endoscopic insertion of the biliary

5 - 신천호외 6 인. 스텐트이탈로인한췌장염 - stent. Korean J Gastrointest Endosc 2001;22: Moon JS. Upper gastrointestinal stenting: detailed techniques in esophageal and pyloric stenting. Korean J Gastrointest Endosc 2006;32(Suppl):158S-162S. 6. Han HW, Lee IS, Park JM, et al. Self-expandable metallic stent therapy for a gastrointestinal benign stricture. Korean J Gastrointest Endosc 2008;37: Lee WW, Park JJ, Oh CR, et al. A case of endoscopic temporary stent insertion to treat a pyloric stenosis caused by endoscopic submucosal dissection for early gastric cancer. Korean J Gastrointest Endosc 2008;37: Kim JH, Song HY, Shin JH, et al. Metallic stent placement in the palliative treatment of malignant gastroduodenal obstructions: prospective evaluation of results and factors influencing outcome in 213 patients. Gastrointest Endosc 2007;66: Stern N, Smart H. Repeated enteral stent fracture in patient with benign duodenal stricture. Gastrointest Endosc 2010; 72:

8 월대한소화기내시경학회교육자료 - 위이소성췌장에서발생한췌장염과가성낭종 이소성췌장은선천성기형의하나로, 주로위와십이지장에위치하며대부분증상없이우연히발견된다. 1,2 이소성췌장은정상췌장에서나타나는췌장염, 가성낭종, 농양, 출혈, 괴사등의병적인변화를겪을수있으며, 병변의위치와크

8 월대한소화기내시경학회교육자료 - 위이소성췌장에서발생한췌장염과가성낭종 이소성췌장은선천성기형의하나로, 주로위와십이지장에위치하며대부분증상없이우연히발견된다. 1,2 이소성췌장은정상췌장에서나타나는췌장염, 가성낭종, 농양, 출혈, 괴사등의병적인변화를겪을수있으며, 병변의위치와크기에따라위장관폐쇄, 협착, 장중첩증등을동반하기도한다. 3-5 증상이없는경우이소성췌장에대한특별한치료가필요하지않지만증상이나합병증을동반하는경우치료가필요하며,