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1 대한내과학회지 : 제 93 권제 2 호 Interpretation of diagnostic test 최신담도내시경검사기법 순천향대학교의과대학내과학교실 문종호ㆍ최현종ㆍ이윤나 Recent Advances of Peroral Cholangioscopy Jong Ho Moon, Hyun Jong Choi, and Yun Nah Lee Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea 서 론 사방법들에대하여알아보고자한다. 담도내시경검사 (cholangioscopy) 는담관내부의내시경적검사를통해치료가어려운담관결석의안전한쇄석술, 일반적인영상검사나내시경역행담췌관조영술 (endoscopic retrograde cholangiopancreatography, ERCP) 을통해정확한진단이어려운담관협착이나담관내미세한병변에대한내시경적검사, 또는특정담관질환에대하여병변의경계확인등의보다정밀한검사등을시행할수있는유용한검사방법이다. 하지만담관의해부학적구조등근본적으로담관내부로의내시경적접근에제한이있어일부제한된기관에서, 선택적으로시행되어왔다. 담도내시경검사는경피적 (percutaneous) 또는경구적 (peroral) 접근이가능하고, 경피적담도내시경검사는경피경간 (percutaneous transhepatic) 경로를형성하는데 2-3주정도기간이필요하고검사를모두마칠때까지경피적배액관을유지해야하는불편함이있다. 최근 10여년간담도내시경분야, 특히경구적담도내시경검사 (peroral cholangioscopy, POC) 의방법에서획기적인발전이있어왔으며, 그임상적유용성이확대되고있다. 본고에서는경구적담도내시경검사에있어서최근까지진보된검 본론경구적담도내시경 (POC) 의세가지검사방법현재시행되고있는경구적담도내시경검사방법은크게세가지로나누어볼수있다. 1975년 [1] 경구적담도내시경검사가처음소개된이후현재까지이어져온 1) 모자내시경시스템 (mother-baby endoscope system), 2) 2007년처음소개된 SpyGlass 시스템 (SpyGlass Direct Visualization System, Boston Scientific Corp., Marlborough, MA, USA) [2,3] 3) 2006 년부터시작된극세경내시경 (ultra-slim endoscope) 을이용한직접경구적담도내시경 (direct POC) 방법이있다 [4-7]. 담관내로내시경을삽입하는방법에따라나누면모자내시경시스템과 SpyGlass 시스템은 ERCP를시행하는십이지장경 (duodenoscope) 의부속기구채널을통해십이지장경의지지하에작은직경의담관내시경 (choledochoscope) 을 ERCP 의기구와같이담관내로삽입하는방법이고, 직접경구적담도내시경검사는십이지장경과같은다른내시경의도움없이작은직경의내시경을구강, 식도및위를지나십이지장 Correspondence to Jong Ho Moon, M.D. Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, 170 Jomaru-ro, Bucheon 14584, Korea Tel: , Fax: , jhmoon@schmc.ac.kr Copyright c 2018 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.

2 - Jong Ho Moon, et al. Recent advances of peroral cholangioscopy - 유두부입구를통하여담관내로직접삽입하는방법이다. 시술에필요한내시경의사에따라나누면, 모자내시경시스템은모내시경과자내시경을두명의내시경의사가각각조작하여서로긴밀한협력이필요하며, 최근도입된 SpyGlass 시스템과직접경구적담도내시경방법은한명의내시경의사가시술을시행할수있다 (single-operator cholangioscopy). 모자내시경시스템 (mother-baby endoscope system) 모자내시경시스템은십이지장경이 모내시경 이되고십이지장경의부속기구채널을통해삽입되는담관내시경이 자내시경 이되어경구적담도내시경검사를시행하여 모자내시경 이라이름하게되었다 [8]. 경구적담도내시경검사 Figure 1. Mother-baby endoscope system. Two endoscopists who are experts for ERCP is handling each other endoscopes in close cooperation. ERCP, endoscopic retrograde cholangiopancreatography. 를시행하기에앞서일반적으로내시경유두괄약근절개술 (endoscopic sphincterotomy, EST) 이시행되어십이지장유두부입구가확장된상태에서검사를시행하게되며, 자내시경인담관내시경을십이지장경의부속기구채널을통해삽입하고십이지장경을조작하는내시경의사와담관내시경을조작하는내시경의사간에긴밀한협조하에담관내시경을유두부입구를통하여담관내로삽입하게된다 (Fig. 1) [8,9]. 담관내시경의외경은 mm 정도이고, 담관내시경의부속기구채널의직경은 mm이다 (Table 1). 내시경의기술적인발전이계속되면서담관내시경영상의해상도가매우향상되었고, 이전에광섬유방식에서최근에는디지털영상장치를도입함으로써더욱향상된해상도의영상을얻을수있으며, 협대역영상 (narrow band imaging, NBI) 과같은영상증강내시경검사 (image enhanced endoscopy) 를통한담관내병변의내시경적검사가가능하다 [10-12]. 최근도입된 SpyGlass 시스템이나직접경구적담도내시경검사가소개되기전까지모자내시경시스템이경구적담도내시경검사의주요한방법이었지만여러가지제한점으로인해널리시행되지못하였다. 먼저두개의별개내시경시스템이사용되고각각의내시경을 ERCP 에익숙한두명의전문내시경의사가협력하면서시술을시행해야하고실제로검사를시행하면서내시경조작에어려움이있다. 또한자내시경인담관내시경은미세한장비들과기술들이집약된기기로서비교적고가이면서또한내구성이약한단점이있어조작에매우주의가필요하다. 그리고담관내시경의부속기구채널의직경이작아여러가지부속기구사용에제한이있고내시경적관찰후확진을위해조직생검을시행할수있지만충분한양의검체를획득하기어려운단점이있다 [4,13]. Table 1. Brief specifications of choledochoscopes in Mother-baby endoscope system for peroral cholangioscopy Olympus Pentax CHF-B20 CHF-BP30 CHF-B260 FCP-9P Image Fiberoptic Fiberoptic Digital Fiberoptic Image enhancement NBI Distal end diameter (mm) Accessory channel diameter (mm) Angulation 160 up 100 down 160 up 130 down 70 up 70 down 90 up NBI, narrow band imaging

- 대한내과학회지 : 제 93 권제 2 호통권제 681 호 2018 - SpyGlass 시스템 (spyglass direct visualization system) SpyGlass 시스템은한명의내시경의사가시행할수있는경구적담도내시경검사로서 2007년처음소개되었는데,

) 을 10 Fr 직경의카테터 (SpyScope, Boston scientific Corp.) 에장착하여다른 ERCP 부속기구와같이담관내로삽입하며, SpyScope의조작부를십이지장경조작부아래에장착함으로한명의 ERCP 내시경의사가담도내시경검사를시행할수있도록하였다.

이러한 SpyGlass 시스템이소개되면서그동안제한된기관에서제한적으로시행되어오던경구적담도내시경분야에새로운장이마련되게되었다 [14,15].

) 이최근개발되었는데, SpyGlass 광학탐침과 SpyScope을일체화시켜사용이편리하고초기모 A B A B Figure 3. Images of the normal bile duct by SpyGlass systems (SpyGlass Direct Visualization System, Boston Scientific Corp.

3 - 대한내과학회지 : 제 93 권제 2 호통권제 681 호 SpyGlass 시스템 (spyglass direct visualization system) SpyGlass 시스템은한명의내시경의사가시행할수있는경구적담도내시경검사로서 2007년처음소개되었는데, 올림푸스사의모자내시경시스템과유사한방식이지만그단점들을극복할수있는새로운담도내시경시스템으로서미국보스턴사에서개발되었다 [2,3]. 모자내시경시스템의자내시경, 즉담관내시경역할을하는 0.9 mm 직경의광학탐침 (SpyGlass, Boston scientific Corp.) 을 10 Fr 직경의카테터 (SpyScope, Boston scientific Corp.) 에장착하여다른 ERCP 부속기구와같이담관내로삽입하며, SpyScope의조작부를십이지장경조작부아래에장착함으로한명의 ERCP 내시경의사가담도내시경검사를시행할수있도록하였다. 이 SpyScope은선단부가상, 하, 좌, 우의네방향으로굴곡이가능하고 SpyGlass 광학탐침이통과되는채널외에조직검사를위한조직생검겸자 (SpyBite, Boston scientific Corp.) 나쇄석술을위한레이저또는전기수압탐침을삽입할수있는 1.2 mm의부속기구채널과물을주입할수있는채널이독립적으로존재한다. 이러한 SpyGlass 시스템이소개되면서그동안제한된기관에서제한적으로시행되어오던경구적담도내시경분야에새로운장이마련되게되었다 [14,15]. 초기모델의만족스럽지못한영상해상도 (6,000 픽셀 ) 나조작의불편함등을향상시킨새로운모델의 SpyGlass 시스템 (SpyGlass DS Direct Visualization System [DS: digital and simple ], Boston scientific Corp.) 이최근개발되었는데, SpyGlass 광학탐침과 SpyScope을일체화시켜사용이편리하고초기모 A B A B Figure 3. Images of the normal bile duct by SpyGlass systems (SpyGlass Direct Visualization System, Boston Scientific Corp., Marlborough, MA, USA). (A) SpyGlass legacy. (B) SpyGlass DS. Figure 2. Peroral cholangioscopy by using SpyGlass DS system (Boston Scientific Corp., Marlborough, MA, USA). (A) A SpyScope attached to a duodenoscope. (B) A fluoroscopic image of the SpyScope in the bile duct. 델보다 4배향상된해상도의디지털영상을제공하며내시경시야각도약 60% 정도향상되었다 (Figs. 2 and 3) [16,17]. 이러한 SpyGlass 시스템의개발은여러가지담췌관질환의진단및치료에있어서담도내시경검사의접근성을보다쉽게하였고, 어려운담석의쇄석술이나진단이어려운담관협착에대한내시경적검사및조직생검등다양한담췌관질환에대하여임상적으로사용되고있다 [18-20]. 하지만비교적고가의 SpyScope 은일회용내시경기기이며, 아직까지

4 - 문종호외 2 인. 최신담도내시경검사기법 - 국내에서상용화하기위해서는경구적담도내시경검사에대한급여정책등의문제가해결되어야한다. 직접경구적담도내시경검사 (direct peroral cholangioscopy) 1977년 Urakami 등 [21] 은모자내시경방식에서와같은십이지장경의도움없이일반상부위장관내시경을십이지장유두부입구를통하여직접담관내로삽입하여담도내시경검사를시행하여보고하였고, 1978년 Rösch 와 Koch [22] 는담관-십이지장문합술 (choledochoduodenostomy) 이시행된환자에서소아용상부위장관내시경을이용하여직접경구적담도내시경검사를시행하여보고하였다 [21,22]. 이와같이모자내시경방식과달리하나의내시경을담관내로직접삽입하여담도내시경검사를시행하는것을직접경구적담도내시경검사라고한다. 하지만이러한검사방법은 1977년처음소개된이후더이상의연구나보고가없다가 2006년, 2009년에미국과국내에서내시경을직접담관내로삽입하기위해보조기구의도움을사용하는연구들이보고되면서발전하게되었다 [5-7]. 담관이매우확장되어있고, 십이지장유두부입구가넓게확장되어있는경우에는일반상부위장관내시경을이용한직접경구적담도내시경검사가가능할수있지만, 일반적인담관질환에서담관직경및유두부입구의확장정도를고려하여소아상부위장관내시경검사나경비내시경검사에사용되는극세경내시경 (ultra-slim endoscope) 이사용된다 (Table 2). 십이지장과담관이일반적으로급격한각도로서로만나기때문에내시경의담관내삽입을돕기위한보조기구를사용하게된다. Larghi와 Waxman [5] 은 ERCP 를통해 유두철선을미리담관내에삽입한후, 십이지장경을제거하고삽입되어있는유도철선을극세경내시경의부속기구채널을통해역으로삽입하면서유두철선을따라내시경을담관내로삽입하는방법을보고하였지만시술도중유도철선이쉽게담관에서이탈하여담도내시경의성공률이높지못하였다. 이후여러가지보조기구를사용한직접경구적담도내시경방법이보고되었지만, 국내에서연구하여보고된풍선도관을이용한방법이높은성공률을보였고현재까지가장널리이용되고있다 [5,7]. 먼저 ERCP 를시행하여유도철선을간내담관이나협착상부의담관에삽입한후, 십이지장경을제거하고유도철선을따라극세경내시경을십이지장유두부입구까지삽입한다. 이때극세경내시경의부속기구채널에 5 Fr 두께의풍선도관 (ERCP 를통한담석제거술에사용되는풍선도관 ) 을삽입하고풍선도관을통하여유도철선을따라내시경을삽입하게된다. 십이지장유두부입구에서유도철선을따라풍선도관을상부담관으로삽입하고풍선을통해고정한후, 고정된풍선도관을지지대로삼아내시경이담관내로삽입될수있다. 환자에따라서는 ERCP 를통해유도철선을삽입하는과정없이극세경내시경을직접십이지장유두부입구까지삽입하고, 직접유도철선과풍선도관을담관내로삽입한후담도내시경검사를시행할수있다 [23]. 극세경상부위장관내시경을이용한직접경구적담도내시경검사는일반적인상부위장관내시경영상과같은매우우수한내시경영상을얻을수있고내시경의종류에따라 NBI, i-scan 등과같은영상증강내시경검사또한가능하다 (Fig. 4) [4,24,25]. 또한 2.0 mm 크기의부속기구채널을통해 Table 2. Brief specifications of ultra-slim upper endoscopes Olympus Pentax Fujifilm GIF-N230 GIF-N260 GIF-XP260N GIF-XP290N EG16-K10 EG-530N Image enhancement NBI NBI i-scan FICE Distal end diameter (mm) Accessory channel diameter (mm) Angulation 180 up 180 down 180 left 180 right 120 down 100 left 100 right 100 left 100 right 120 down 120 left 120 right 100 left 100 right NBI, narrow band imaging; FICE, flexible spectral imaging color enhancement

- The Korean Journal of Medicine: Vol. 93, No. 2, 2018 - 충분한양의조직검체획득이가능하고조직검사외에 5 Fr 두께의다양한부속기구들을사용한담관내내시경시술이가능하다.

하지만총담관이 8-10 mm 이상으로확장된환자에서시행되고, 풍선도관의지지를통해내시경이담관내에삽입되었다가 A 담관내시술을위해서풍선도관을제거하게될때내시경이담관에서이탈되는내시경위치의불안정성이환자에따라나타날수있다.

5 - The Korean Journal of Medicine: Vol. 93, No. 2, 충분한양의조직검체획득이가능하고조직검사외에 5 Fr 두께의다양한부속기구들을사용한담관내내시경시술이가능하다. 또한담도내시경검사를위한추가적인장비가필요하지않고일반적으로사용되고있는내시경시스템과극세경내시경을사용하여검사를시행하기때문에현재로서가장경제적인경구적담도내시경검사방법이다 [26]. 하지만총담관이 8-10 mm 이상으로확장된환자에서시행되고, 풍선도관의지지를통해내시경이담관내에삽입되었다가 A 담관내시술을위해서풍선도관을제거하게될때내시경이담관에서이탈되는내시경위치의불안정성이환자에따라나타날수있다. 최근에는풍선도관의조작부를잘라도풍선이유지되는풍선도관이개발되어 ERCP를통해풍선도관을간내담관이나협착상부에위치시켜고정한후, 풍선도관조작부를절단하고십이지장경을제거한다음, 고정된풍선도관을따라극세경내시경을삽입하여담도내시경검사를시행할수있다. 극세경내시경을삽입하는도중지지하는풍선도관이담관에서이탈될위험이적어쉽고안전하게담도내시경검사를시행할수있다 [27]. 또한풍선도관과같은보조기구의도움없이직접내시경을담관내로삽입하기위해내시경선단에이중굴곡기능을갖는극세경내시경이직접경구적담도내시경검사를위해개발되고있다 [28,29]. 결론 B 상부위장관조영술과대장조영술대신위내시경검사와대장내시경검사가보편화되면서위장관질환의진단및치료에있어서많은진보가있었던것과같이, 담도내시경검사는 ERCP의한계를넘어서는진단및치료적발전을가져올수있다. 현재까지도 ERCP 가담도질환에대한진단및치료적내시경검사의기본적이고주요한방법이지만, 경구적담도내시경검사는진단이어려운담관협착의진단과치료가어려운담관결석의치료에매우유용한방법으로자리잡고있으며, 일반적인영상검사와 ERCP를통해진단이어려운미세한담관병변이나조기담관암등이담도내시경검사를통해진단될수있다. 과거일부기관에서제한적으로시행되어오던경구적담도내시경검사는최근까지의발전을통해그접근성이매우확대되어왔으며, 향후그추이를주목할만하다. 중심단어 : 담도내시경 ; 경구적담도내시경 ; 모자내시경 ; SpyGlass; 극세경내시경 REFERENCES Figure 4. Direct peroral cholangioscopy by using an ultra-slim endoscope. (A) An ultra-slim upper endoscope was advanced into the bile duct. (B) Endoscopic image of bile duct mass on direct peroral cholangioscopy. 1. Takekoshi T, Takagi K. Retrograde pancreatocholangioscopy. Gastroenterol Endosc 1975;17: Chen YK. Preclinical characterization of the Spyglass pero

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Dae Won Park, et al.. 1,2 POC (electrohydraulic lithotripsy, EHL) 1. 증례 , 64, 18, 140/80 mmhg... 4,400/mm³, 10.8 g/dl, 232,000/mm³. 131

Dae Won Park, et al.. 1,2 POC (electrohydraulic lithotripsy, EHL) 1. 증례 , 64, 18, 140/80 mmhg... 4,400/mm³, 10.8 g/dl, 232,000/mm³. 131 Case Report The Korean Journal of Pancreas and Biliary Tract 2015;20:146-150 http://dx.doi.org/10.15279/kpba.2015.20.3.146 pissn 1976-3573 eissn 2288-0941 경구담도내시경후발생한간내담도천공의증 1 예 광주기독병원소화기내과 박대원 박상욱 김두진