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CASE REPORT THE KOREAN JOURNAL OF PANCREAS AND BILIARY TRACT 스파이글래스담도내시경을이용한내시경적경비담낭배액술 신재욱ㆍ이종균ㆍ김광민ㆍ이광혁ㆍ이규택 성균관대학교의학전문대학원삼성서울병원내과 Endoscopic Naso-Gallbladder Drainage with the Spyglass Cholangioscopy System Jae-uk Shin, Jong Kyun Lee, Kwang Min Kim, Kwang Hyuck Lee, Kyu Taek Lee Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Cholecystectomy is the treatment of choice for acute cholecystitis. However, decompression of the gallbladder by percutaneous transhepatic gallbladder drainage or endoscopic transpapillary gallbladder drainage can be performed as an alternative treatment method in surgically high risk patients. Endoscopic transpapillary gallbladder drainage has been used in patients in whom the percutaneous approach is contraindicated because of severe coagulopathy, thrombocytoscopic gallbladder drainage has failed in some patients because of nonvisualization of cystic duct on the cholangiogram or failure of guidewire passage through the cystic duct into the gallbladder. The authors report the successful endoscopic naso-gallbladder drainage tube insertion by using direct cholangioscopic visualization of the cystic duct with the SpyGlass cholangiopancreatography system in a patient with acute calculous cholecystitis and cholangitis. Key words: Acute cholecystitis, Gallstone, Endoscopic gallbladder drainage, SpyGlass 서론 급성당남염은대부분이담석에의한담낭관이나담낭경부의폐쇄에의해발생하며수술적치료가원칙이다. 하지만심한기저질환으로인해전신마취하에수술을받을수없는환자에서는보존적인치료방법을이용하게된다. 보존적치료방법으로는경피적또는내시경적방법을이용한비수술적담낭배액술을사용할수있으나내시경을이용한담낭배액술은성공률이높지않아대부분경피적담낭루를이용한담낭배액술이사용되어져왔다. 하지만심한응고장애나혈소판감소증또는담낭의구조적변형으로인해경피적접근이불가능한경우 Corresponding author. 이종균서울시강남구일원동 50 번지 (135-710) 성균관대학교의학전문대학원삼성서울병원내과 Tel: 02-3410-3409, Fax: 02-3410-6983 E-mail: jongk.lee@samsung.com 경피적담낭루를통한담낭배액술이불가능할때가있다. 최근에내시경을이용한담낭배액술에대한많은연구가이루어지고있으며특히스파이글래스 (SpyGlass) 담도내시경을이용할경우좀더쉽게담낭관으로접근이가능하여성공률이높을것으로생각되나아직외국에서도증례보고정도만되어있는실정이다. 저자들은국내에서최초로담석을동반한급성담낭염환자에게스파이글래스담도내시경을이용하여경비담낭관배액에성공한증례를보고한다. 증례 30세여자가복통을주소로소화기내과로의뢰되었다. 11개월전급성림프모구성백혈병진단하에항암치료를시행하였으나재발하여 3개월전에재항암치료를시행받고백혈구감소증과패혈증으로입원치료중인환자였다. 환자는전날저녁부터명치부위의답답한양상의통증이발생하여지속되었고모르핀 2회와바리움 2회정주후에통증은호전되었다가악화되기를반복하는양상이었다. 환자는당뇨나고혈압의병력은 139

신재욱외 4 인 140 없었으며흡연과음주는하지않았다. 진찰소견에서의식은명료하였으며, 공막황달은관찰되지않았다. 명치부위와우상복부에압통이있었고간종대나비장종대는없었다. 활력징후는혈압 116/81 mmhg, 맥박수 131/min, 호흡수 20/min, 체온 38.3 o C 였다. 일반혈액검사에서백혈구 2,790/mm 3, 혈색소 10.5 g/dl, 혈소판 44,000/mm 3, 적혈구침강속도 76 mm/hr, CRP 12.05 mg/dl였다. 일반화학검사상총단백 7.5 g/dl, 알부민 4.5g /dl, aspartate aminotransferase (AST) 571 IU/L, alanine aminotransferase (ALT) 475 IU/L, gamma-glutamyl transferase (γ-gt) 733 IU/L, alkaline phosphatase (ALP) 361 IU/L, 총빌리루빈 3.1 mg/dl, 직접빌리루빈 2.1 mg/dl, amylase 35.8 U/L, lipase 23.1 U/L, BUN 17.0 mg/dl, creatinine 0.33 mg/dl, 프로프롬빈시간은 14.7초 (INR, 1.14) 였다. Fig. 1. Abdominal ultrasonography showing a gallbladder fillded with sludge and borderine thickening of the gallbladder wall. 복부초음파검사에서간내외담관이약간확장된소견이관찰되었으며담낭벽의두께는 0.3 cm로두꺼워져있으면서담낭내부를가득채우고있는담즙찌꺼기 (sludge) 가관찰되었다 (Fig. 1). 환자는 1주일전에방광의혈뇨와통증으로복부컴퓨터단층촬영을시행하였고당시담도와담낭에이상소견은관찰되지않았었다. 담관확장과빌리루빈등간수치상승으로총담관평가가추가적으로필요하여초음파내시경검사를시행하였다. 초음파내시경검사상담낭은팽창되어있으면서내부에담즙찌꺼기가가득차있었고담낭벽의비후가관찰되었다 (Fig. 2A). 총담관내에도결석음영이관찰되었다 (Fig. 2B). 담낭결석과담낭염에동반된담도결석과담도염진단하에내시경적역행성담췌관조영술 (ERCP) 을시행하였다. ERCP 시행중담도에카테터를삽입하자약간의담즙찌꺼기가흘러나왔으며 (Fig. 3A), 담도조영술에서총담관내부에결석으로판단되는충만결손음영이관찰되었다 (Fig. 3B). 내시경적유두절개술을시행후다량의담즙찌꺼기가저절로배출되는소견이관찰되었으며 (Fig. 3D), 풍선카테터를이용하여잔여담석을제거한후담도조영술에서잔여담석이관찰되지않았지만 (Fig. 3F), 담즙찌꺼기가소량씩지속적으로배출되었다 (Fig. 3E). 담낭에서지속적으로담즙찌꺼기가총담관으로유입된다고판단되어투시촬영하에유도철선을담낭관으로삽입하기위해수차례시도하였으나실패하여스파이글래스 (SpyGlass) 담도내시경 (Bostom Scientific Corp., USA) 을이용하여담낭배액술을시행하기로하였다. 스파이글래스담도내시경을이용하여총담관에진입하였고 (Fig. 4A), 담낭관입구를찾을수있었다 (Fig. 4B). 담낭관에서담즙찌꺼기가지속적으로배출되는것을확인할수있었으며 (Fig. 4C E), 담낭관입구를관찰하면서유도선을담낭관내부로삽입할수있었다 (Fig. 4F, 5A C). Fig. 2. Endoscopic ultrasonograpy of gallbladder and common bile duct. (A) Distended gallbladder filled with sludge and thicked wall (arrow). (B) A sludge (arrow) was seen inside of common bile duct.

스파이글래스담도내시경을이용한내시경적경비담낭배액술 141 Fig. 3. Endoscopic retrograde cholangiopancreatography (ERCP) findings. (A) A few bile sludge was seen near the papilla after cannulation. (B) Cholangiogram showed filling defect (arrow) on the distal CBD. (C) Endoscopic sphicterotomy (EST) was perfomed. (D) Large amount of bile sludge came out spontaneously from the papilla after EST. (E) Bile slude continuosly came out after multiple sessions of balloon swipping. (F) Balloon cholangiogram showed no filling defect in CBD and no filling of contrast dye in gallbaldder. 이후유도선을따라서경비-담낭배액관을성공적으로삽입하고시술을종료할수있었다 (Fig. 5D F). 경비-담낭배액관을삽입한이후에복통과발열은호전되었으며총빌리루빈수치도정상으로회복되었다. 배액관삽입 1주일후담낭내부의담즙찌꺼기소실을기대하고복부초음파를촬영하였으나담낭내부를가득채우고있는담즙찌꺼기의소견은변화가없었다. 환자는배액관삽입 10일뒤에복강경담낭절제술을시행하고퇴원할수있었다. 고찰 내시경적담낭배액술은 1990년 Feretis 등 1 이보고한이후로현재까지많은연구가이루어져왔다. 내시경적담낭배액술의방법은내시경적경비-담낭배액술 (ENGBD), 내시경적경유두 담낭스텐트 (endoscopic transpapiilary gallbladder stenting), 초음파내시경유도하담낭배액술 (EUS guided transmural gallbladder drainage) 의방법이있다. 2,3 내시경적경비-담낭배액술은후향적연구들에서기술적성공률및임상적반응률은 60 100% 이며평균 80% 정도로보고되고있다. 2,3 발생가능한부작용은췌장염, 담낭관또는담낭의천공, 담도염, 패혈증등의합병증으로사망까지알려져있으며발생률은 0 14% 이다. 2,3 내시경적경비-담낭배액술은대부분수술전에일시적인임상적호전을위해시행되며대부분괄약근절개술없이도시행가능하여항응고제를복용중이거나출혈가능성이높은환자들에게유용하게시행될수있다. 또한경비-담낭배액관을통하여세척을시행함으로써혈액이나찌꺼기에의한배액관의폐쇄를예방하고배액의효과를증가시킬수있다는장점이있다. 내시경적경유두담낭스텐트는시술성공률이 96%, 임상

신재욱외 4 인 142 Fig. 4. SpyGlass cholangioscopic view. (A) A few bile sludge on the CBD. (B) The opening of cystic duct (arrow) was seen on the right side. (C E) Yellowish bile sludge continuosly came out from the cystic duct. (F) A guide wire (arrow) was inserted through the cystic duct under the visual obervation with SpyGlass cholangioscopy. 적성공률 88% 까지높게보고되나스텐트를삽입하기위해괄약근절개술이필요하며, 스텐트내부가혈액이나찌꺼기로막히는것을예방하지못한다는단점이있어주로경비-담낭배액술을먼저시행한이후에급성염증이호전되면스텐트삽입을시행하는경향이다. 2 최근에내시경초음파를이용하여담낭배액술을시도하는연구가이루어지고있다. 위체부나전정부에서담낭으로접근한후경비배액관이나플라스틱또는금속스텐트를삽입하는방법으로아직시험단계이며많은연구는되어있지않다. 2,4 급성담낭염환자의일부는담낭관이막혀서담도촬영상담낭과담낭관을확인할수없거나, 담낭관의구조적인이상으로인하여유도철선의삽입이불가능하여내시경적담낭배액술의시행이불가능하다. 최근에개발된스파이글래스담췌관내시경은담관또는췌관내부로내시경을삽입하여육안적으로병변을확인하면서진단과치료를시행할수있다. 5,6 기존의담도내시경보다직경이가늘고, 한명의검사자가전후좌우조작이 가능하며검사와시술이가능하다는장점이있어최근많은연구가이루어지고있다. 5,7-10 스파이글래스를이용한내시경적담낭배액술은 2009년급성담낭염환자에게플라스틱스텐트를담낭관에삽입한증례가보고된바있다. 11 저자들은국내에서최초로스파이글래스를이용하여담낭결석을동반한급성담낭염및담도염환자에게내시경적경비-담낭배액술을성공한증례를보고한다. 요약 급성담낭염은수술적치료가원칙이나중증의심폐질환이나혈소판감소증으로인해수술이불가능할경우보존적인치료로경피적또는내시경적담낭배액술이필요할수있다. 경피적담낭배액술이간편하여많이시행되고있으나배액관을경피적으로유지해야하므로환자에게많이불편하며, 심한응고장애나담낭의구조적변형으로인해경피적접근이힘든경

스파이글래스담도내시경을이용한내시경적경비담낭배액술 143 Fig. 5. Endoscopic naso-gallbladder drainage inserted under the visual guidance of Spyglass cholangioscopy. (A) A guide wire was inserted into the cystic duct. (B) Spyglass cholangioscope located at the opening of cystic duct. (C) The guide wire was inserted through the gallbladder. (D F) Naso-gallbladder drainage tube was inserted. 우가있어내시경적담낭배액술이유용할때가있다. 내시경적담낭배액술은경험많은기관에서평균성공율이 80% 정도로문헌에서보고되고있으나실제급성당남염환자의형광투시촬영을이용한담도조영술에서담낭관이보이지않아서접근이힘든경우가많다. 최근개발된스파이글래스담도내시경을이용하여내시경적담낭배액술을시행한외국증례는있으나아직그유용성에대해확립된바는없었다. 저자들은국내에서최초로스파이글래스담도내시경을이용하여담낭결석을동반한급성담낭염및담도염환자에게내시경적경비-담낭배액술을성공하여보고한다. 국문색인 : 급성담낭염, 담낭결석, 내시경적담낭배액술, 스파이글래스 참고문헌 1. Feretis CB, Manouras AJ, Apostolidis NS, et al. Endoscopic transpapillary drainage of gallbladder empyema. Gastrointest Endosc 1990;36:523-525. 2. Itoi T, Coelho-Prabhu N, Baron TH. Endoscopic gallbladder drainage for management of acute cholecystitis. Gastrointest Endosc 2010;71:1038-1045. 3. Mutignani M, Iacopini F, Perri V, et al. Endoscopic gallbladder drainage for acute cholecystitis: technical and clinical results. Endoscopy 2009;41:539-546. 4. Lee SS, Park DH, Hwang CY, et al. EUS-guided transmural cholecystostomy as rescue management for acute cholecystitis in elderly or high-risk patients: a prospective feasibility study. Gastrointest Endosc 2007;66:1008-1012. 5. Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007;65:832-841.

신재욱외 4 인 144 6. Chen YK. Preclinical characterization of the Spyglass peroral cholangiopancreatoscopy system for direct access, visualization, and biopsy. Gastrointest Endosc 2007;65:303-311. 7. Nguyen NQ, Shah JN, Binmoeller KF. Diagnostic cholangioscopy with SpyGlass probe through an endoscopic retrograde cholangiopancreatography cannula. Endoscopy 2010;42 Suppl 2:E288-E289. 8. Mou S, Waxman I, Chennat J. Peroral cholangioscopy in Roux-en-Y hepaticojejunostomy anatomy by using the SpyGlass Direct Visualization System (with video). Gastrointest Endosc 2010;72:458-460. 9. Bhat YM, Kochman ML. Novel management of complex hilar biliary strictures with the Spyglass Direct Visualization System (with video). Gastrointest Endosc 2009;69:1182-1184. 10. Wright H, Sharma S, Gurakar A, et al. Management of biliary stricture guided by the Spyglass Direct Visualization System in a liver transplant recipient: an innovative approach. Gastrointest Endosc 2008;67:1201-1203. 11. Barkay O, Bucksot L, Sherman S. Endoscopic transpapillary gallbladder drainage with the SpyGlass cholangiopancreatoscopy system. Gastrointest Endosc 2009;70:1039-1040.