대한내과학회지 : 제 89 권제 5 호 2015 http://dx.doi.org/10.3904/kjm.2015.89.5.487 특집 (Special Review) - 췌담도질환의최신지견 총담관결석의내시경치료 부산대학교의학전문대학원내과학교실 김동욱 The Endoscopic Management of Common Bile Duct Stones Dong Uk Kim Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea Gallbladder stone, or gallstone, is an endemic condition that affects up to 20% of the general population. Of patients with gallstones, 11-21% also have concomitant common bile duct (CBD) stones. Moreover, in East Asia-including Korea, Taiwan, and Japan-the prevalence of primary CBD stones without gallbladder stones is higher than that in Western countries. CBD stones may be associated with various symptoms and conditions. Therefore, CBD stones must be managed for the prevention of potentially life-threatening complications, such as ascending cholangitis, liver abscess, and acute pancreatitis. During the past 40 years, endoscopic retrograde cholangiopancreatography has become a widely available and routine procedure for the management of CBD stones. Other interventions include intraoperative bile duct exploration and percutaneous transhepatic stone removal. As a consequence, clinicians are now faced with a number of potentially valid options for managing patients with suspected CBD stones. (Korean J Med 2015;89:487-493) Keywords: Choledocholithiasis; Endoscopic management 서론담낭결석을가지는환자의 11-21% 는동시에총담관결석을가진다고알려져있다 [1-3]. 총담관결석은간외담관내에결석이존재하는상태로, 급성담도염, 담도성패혈증, 급성췌장염등의합병증이발생할수있어제거가필요하다 [4]. 1990년대복강경수술이널리확산되면서복강경담낭절제술을시행하면서총담관을조영하여총담관결석이발견되는경우제거를위하여총담관탐색술을많이시행하였다. 하지 만우리나라의경우담낭담석에동반한이차성총담관결석뿐만아니라원발성총담관결석의비율도높게보고되고있어담관결석의제거에서내시경치료가더욱중요하다 [5]. 최근수년사이에총담관결석을제거하는기술과기구가발달함에따라대부분의총담관결석은내시경으로제거할수있게되었고, 내시경유두괄약근절개술이나풍선확장술은담석제거를위한일차적인시술로자리잡았다. 약 85-90% 이상의총담관결석을통상적인내시경치료로제거가가능하지만, 일부에서는거대결석, 담관협착, 위장관계수술로인한 Correspondence to Dong Uk Kim, M.D. Division of Gastroenterology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea Tel: +82-51-240-7869, Fax: +82-51-244-8180, E-mail: amlm3@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 - 487 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- The Korean Journal of Medicine: Vol. 89, No. 5, 2015 - 해부학적변형등으로경피적혹은수술적방법이필요한경우도있다. 본고에서는총담관결석을제거하는내시경적인방법에대해서상세히알아보고자한다. 본론총담관결석의진단총담관결석의최적의진단을위해서는임상증상, 검사실소견, 초음파검사또는복부전산화단층촬영등을종합적으로판단하는것이비용효과적이다. 그에따라총담관결석의진단이애매할때자기공명담췌관조영술, 내시경초음파등과같은정밀검사를시행하는것이이상적이다. 대한췌담도학회에서는미국내시경학회의가이드라인을바탕으로총담관결석이있을가능성이높은군, 중간군, 낮은군으로구별하여추가검사및치료방침을결정할것을권고하였다 (Fig. 1) [6,7]. 저위험군 (low risk) 의경우는총담관결석이있을확률이 10% 미만으로진단을위하여추가적인검사가더이상필요없다. 중등도위험군 (intermediate risk) 은초기검사에서총담관결석이있을확률이 10-50% 인군이며, 총담관결석의제거를위한내시경역행담췌관조영술이필요한지를알아보기위하여자기공명담췌관조영술이나내시경초음파검사의추가검사가필요하다. 고위험군 (high risk) 은총담관결석이있을 확률이 50% 이상인군으로환자상태에따라서는다른추가검사없이담석제거등의치료를할수있는내시경역행담췌관조영술을바로시행할수있다. 총담관결석의내시경치료 합병증예방을위한치료전주의사항내시경역행담췌관조영술과관련된합병증은췌장염, 출혈, Figure 1. The pathway of the diagnosis of CBD stones. CBD, common bile duct; CT, computed tomography; MRCP, magnetic resonance cholangiopancreatography; EUS, endoscopic ultrasonography; ERCP, endoscopic retrograde cholangiopancreatography; PTBD, percutaneous transhepatic biliary drainage; US, ultrasonography. Table 1. The incidence and risk factors of ERCP-related complications Post-ERCP pancreatitis Hemorrhage Perforation Biliary tract infection Incidence, 3.5 (1.6-15.7) 1.3 (1.2-1.5) 0.2 (0.1-0.6) Less than 1 % (range) Risk factors Definite Suspected SOD Young age Normal bilirubin History of post-ercp pancreatitis Pancreatic duct injection Pancreatic sphincterotomy Precut sphincterotomy Balloon dilation of biliary sphincter Maybe Female gender Acinarization Absence of CBD stone Lower ERCP case volume Definite Coagulapathy Hemodialysis Anticoagulation < 3 day after sphincterotomy Visible bleeding during the procedure Higher bilirubin Cholangitis before ERCP Lower ERCP case volume Maybe Cirrhosis Dilated CBD CBD stone Periampullary diverticulum Precut sphincterotomy Definite Malignancy Precut sphincterotomy Maybe The performance of a sphincterotomy Billroth II anatomy The intramural injection of contrast Prolonged duration of procedure Biliary stricture dilation SOD Cholangitis Use of combined percutaneous-endoscopic procedures Stent placement in malignant strictures Presence of jaundice Incomplete or failed biliary drainage. Low case volume Cholecystitis Presence of stones in the GB Possibly filling of the GB with contrast during the procedure. Placement of SEMSs ERCP, endoscopic retrograde cholangiopancreatography; SOD, sphincter of Oddi; GB, gallbladder; CBD, common bile duct; SEMS, self-expandable metal stents. - 488 -
- Dong Uk Kim. The endoscopic management of CBD stones - 천공, 담도계감염으로그발생률과위험요인이비교적잘알려져있다 (Table 1) [7-10]. 젊은여성, 정상빌리루빈, 정상담도직경, 오디괄약근기능이상등의요인이있으면시술후췌장염이증가하는것으로알려져있다. 따라서시술후췌장염의위험요인이있는환자에서는합병증의발생가능성에대해서충분히설명하여야하며, 시술시에불필요한기구의조작은피하도록특히주의해야한다. 출혈은혈액응고장애, 혈소판감소증, 항응고제의사용, 만성신부전, 간경화를가진환자에서잘발생한다. 따라서출혈위험성을줄이기위해서는환자및가족의출혈과거력, 약물복용력등을반드시확인해야하며, 혈소판수치가 50,000-80,000/mm 3 미만이거나프로트롬빈시간이 2초이상연장되어있는경우적절히교정한후시술을시행해야한다. 담도계감염을줄이기위하여예방적항생제를사용하는것은균혈증을줄이기는하지만실제패혈증이나담관염을줄이지는못하였다 [11]. 하지만담관폐쇄가있다거나패혈증의양상을보였던환자혹은면역억제환자에서는임상적으로심한패혈증의발생을줄여주는것으로나타나권장된다 [12,13]. 무엇보다도내시경역행담췌관조영술이꼭필요한환자만 을선별적으로시행하는것이불필요한시술을줄이고그에따른합병증을예방하는데중요하다. 총담관결석의통상적인제거방법내시경유두괄약근절개술을시행하고풍선도관이나바스켓을사용하여총담관결석을제거하는것이표준내시경치료방법이다. 내시경유두괄약근절개술은출혈과천공등의합병증을예방하기위하여혼합파 (blended current) 를사용하여유두부의구측융기의상단을넘지않도록 11시-12시방향으로시행한다 [14-16]. 최근에는 endocut 이개발되어조직에주어지는파장을자동으로조절하여, 췌방염의발생을증가시키지않으면서출혈의발생률을낮추었다는보고가있다 [17]. 담석의제거는풍선도관이나바스켓을사용하게되는데, 사용이간편하고담관내에감돈될위험성이없는풍선도관을우선적으로사용되는경향이있다. 담석의제거를원활히하기위해서는담석과관련된양성담관협착을미리조사하여적절한담석제거방법을선택해야하고, 다발성담석은말단부에서부터하나하나씩제거해야한다 (Fig. 2) [18,19]. 만일, 총담관결석이완전히제거되지않아추가적인내시경역행담췌관조영술이필요한경우담관염의위험성을감소시키기위하여플라스틱담관스텐트혹은비담관배액관을사용하 Figure 2. Conventional method for the removal of multiple CBD stones. CBD, common bile duct. - 489 -
- 대한내과학회지 : 제 89 권제 5 호통권제 663 호 2015 - 여일시적인담관배액술을시행하는것이안전하다 [20-22]. 췌장염의위험성이높은경우췌관스텐트를삽입하는것이시술후췌장염의예방효과를나타낼수있다 [23]. 특히어려운삽관등으로예비절개술을시행한경우에는합병증의비율이증가함으로시술의합병증을예방하기위하여추가적인조치들을시행하는것이바람직하다. 거대총담관결석의제거방법바스켓을이용하여포획된결석을유두부로부터제거할수없는거대결석의경우통상적으로기계적쇄석기를이용한쇄석술이사용된다. 기계적쇄석술은기본적인내시경적결석제거술과같은기본적인기술을필요로하며같은시술의일부로시행될수있기때문에거대결석의치료에효과적인방법으로사용될수있다 [24]. 통상적인방법으로제거되지못한결석에서기계적쇄석술의성공률은 79-92% 로보고되고있으며, 흔한실패의원인은결석이담관내에감돈되거나결석이 3 cm보다큰경우이다 [25,26]. 결석을포획한바스켓이감돈되는경우바스켓의손잡이부분을제거하고바스켓을그대로유치해놓은상태로내시경을빼낸후방사선투시하에시행하는응급기계적쇄석술이유용하게사용될수있다 (Fig. 3) [19]. 내시경유두괄약근풍선확장술은출혈의위험이적고, 오 디괄약근의기능을파괴하지않으며, 기술적으로비교적쉽게시행할수있다는장점때문에유두괄약근절개술의대안적방법으로제시되었으나, 시술후췌장염의발생이증가하고이로인한사망사례까지보고되면서거의사용하지않게되었다 [27-31]. 하지만최근에는통상적인방법으로제거가어려운거대총담관결석환자에서내시경유두괄약근절개술후 12-20 mm의풍선도관을사용하는내시경유두괄약근큰풍선확장술 (endoscopic papillary large balloon dilatation) 이안전하고효과적인치료방법으로여러연구에서보고되었다 [32-35]. 거대총담관결석환자에서내시경유두괄약근큰풍선확장술후담관결석의완전제거율은 95-100% 로높게보고되어있으며, 출혈, 천공, 췌장염등의합병증은 0-16% 로통상적인경우와비슷하다. 다만, 원위부담관협착이있는환자에서천공등의심한합병증으로사망한경우가있어시술을피해야한다. 담관내충격파쇄석술은대체로담도내시경하에전기수압쇄석술 (electrohydraulic lithotripsy) 또는레이저쇄석술 (laser lithotripsy) 의탐침을결석에직접접촉시켜쇄석술을시행하여분쇄된결석조각을바스켓으로포획하여제거하는방법으로거대감돈결석에서가장유용하게사용될수있다. 통상적인방법으로내시경적제거가어려운담관결석 Figure 3. Mechanical and emergency lithotripsy for the removal of large CBD stones. CBD, common bile duct. - 490 -
김동욱. 총담관결석의 내시경 치료 치료에서 대개의 경우 1회의 치료로 74-97%의 높은 성공률 생률이 5-17%로 정상 해부학적 구조를 지닌 환자와 비교하 이 보고되며, 합병증은 담관염과 출혈 등으로 3-19% 정도로 여 더 높다[46,47]. 만일 내시경으로 역행성 접근이 어려운 경 보고된다[36-39]. 그 동안 담관 내 충격파 쇄석술은 모자내시 우, 총담관결석 환자에서는 담관협착이나 담관의 급격한 굴 경(mother-baby scope system)을 사용하여 두 명의 숙련된 시 곡이 없는 경우가 많기 때문에 경피적 경간 담도내시경을 통 술자를 필요하였으나, 최근에 그 단점을 극복하기 위하여 한 쇄석술(PTCSL)이 비교적 어렵지 않게 시행할 수 있다[48,49]. SpyGlass Direct Visualization System (Boston Scientific Corp., 결론적으로, Billroth II 수술, Roux-en-Y 문합술로 해부학적인 Natick, MA, USA)이나 극세경내시경을 이용한 직접 경구적 변화가 발생한 총담관결석 환자는 경험있는 숙련가나 상급 담관내시경검사(direct peroral cholangioscopy)을 사용할 수 있 병원에 의뢰하는 것이 바람직하다. 다[40,41]. 결 내시경 역행담췌관조영술을 통한 결석 제거에 실패하는 경 론 우 경피적 경간 담도내시경을 통한 쇄석술(Percutaneous transhepatic cholangioscopic lithotomy, PTCSL)을 사용할 수 있다. 총담관결석은 내시경 유두괄약근절개술을 시행한 후 다양 접근 경로가 되는 누공의 확장 및 완성에 시간을 요하지만 결 한 바스켓과 풍선도관을 통하여 제거하는 것이 표준술식으로 석의 제거에 있어 높은 성공률이 보고되고 있으며 경구경유 인정받고 있다. 내시경의사는 내시경역행담췌관조영술 전에 두로의 접근이 어려운 경우에 유용하게 사용될 수 있다[42,43]. 미리 시술과 관련된 합병증의 위험인자를 파악하고, 시술 중 에 합병증을 최소화할 수 있는 노력을 기울이는 것이 무엇보 수술로 변형된 해부학적 구조에서의 제거방법 Billroth II 수술, Roux-en-Y 문합술 등으로 해부학적인 변 화가 발생한 환자의 경우 구심성 고리가 너무 길거나 문합 부위의 심한 예각으로 인하여 내시경 진입이 어렵고, 담관 삽 관이 통상적인 방향과 반대이기 때문에 삽관 성공률이 낮고, 다도 중요하다. 지역과 인종에 따라 총담관결석의 자연경과 및 시술에 따른 합병증의 발생빈도가 다르기 때문에, 환자 개 개인의 특성을 고려하여 적절한 시술방법을 권유할 수 있도 록 해야 한다. 내시경 유두부절개술 등을 시행하는데 어려움이 있다(Fig. 4) [44-47]. 또한 시술과 관련하여 출혈, 천공 등의 합병증의 발 중심 단어: 총담관결석, 내시경 치료 Figure 4. Endoscopic CBD stone removal by using a forward-view scope in a Billroth II gastrectomy patient. CBD, common bile duct. - 491 -
- The Korean Journal of Medicine: Vol. 89, No. 5, 2015 - REFERENCES 1. Menezes N, Marson LP, debeaux AC, Muir IM, Auld CD. Prospective analysis of a scoring system to predict choledocholithiasis. Br J Surg 2000;87:1176-1181. 2. Videhult P, Sandblom G, Rasmussen IC. How reliable is intraoperative cholangiography as a method for detecting common bile duct stones? : a prospective population-based study on 1171 patients. Surg Endosc 2009;23:304-312. 3. Borzellino G, Rodella L, Saladino E, et al. Treatment for retained common bile duct stones during laparoscopic cholecystectomy: the rendezvous technique. Arch Surg 2010;145: 1145-1149. 4. Lee J. Clinical manifestation and diagnosis. In: Chung JB, ed. Diseases of the gallbladder and bile ducts. 1st ed. Seoul: Koonja, 2008:189-210. 5. Yasuda I. Management of the bile duct stone: current situation in Japan. Dig Endosc 2010;22 Suppl 1:S76-S78. 6. ASGE Standards of Practice Committee, Maple JT, Ben- Menachem T, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71:1-9. 7. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335:909-918. 8. Rabenstein T, Schneider HT, Bulling D, et al. Analysis of the risk factors associated with endoscopic sphincterotomy techniques: preliminary results of a prospective study, with emphasis on the reduced risk of acute pancreatitis with low-dose anticoagulation treatment. Endoscopy 2000;32: 10-19. 9. Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc 2004;60:721-731. 10. Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007;39:793-801. 11. Harris A, Chan AC, Torres-Viera C, Hammett R, Carr-Locke D. Meta-analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1999;31:718-724. 12. Thompson BF, Arguedas MR, Wilcox CM. Antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice: is it worth the cost? Aliment Pharmacol Ther 2002;16:727-734. 13. Niederau C, Pohlmann U, Lübke H, Thomas L. Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study. Gastrointest Endosc 1994;40:533-537. 14. Stefanidis G, Karamanolis G, Viazis N, et al. A comparative study of postendoscopic sphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis. Gastrointest Endosc 2003;57:192-197. 15. Gorelick A, Cannon M, Barnett J, Chey W, Scheiman J, Elta G. First cut, then blend: an electrocautery technique affecting bleeding at sphincterotomy. Endoscopy 2001;33:976-980. 16. Verma D, Kapadia A, Adler DG. Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes. Gastrointest Endosc 2007;66:283-290. 17. Perini RF, Sadurski R, Cotton PB, Patel RS, Hawes RH, Cunningham JT. Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference? Gastrointest Endosc 2005;61:53-57. 18. Stave R, Osnes M. Endoscopic gallstone extraction following hydrostatic balloon dilatation of a stricture in the common bile duct. Endoscopy 1985;17:159-160. 19. Binmoeller KF, Schafer TW. Endoscopic management of bile duct stones. J Clin Gastroenterol 2001;32:106-118. 20. Maluenda F, Csendes A, Burdiles P, Diaz J. Bacteriological study of choledochal bile in patients with common bile duct stones, with or without acute suppurative cholangitis. Hepatogastroenterology 1989;36:132-135. 21. Bergman JJ, Rauws EA, Tijssen JG, Tytgat GN, Huibregtse K. Biliary endoprostheses in elderly patients with endoscopically irretrievable common bile duct stones: report on 117 patients. Gastrointest Endosc 1995;42:195-201. 22. Sharma BC, Kumar R, Agarwal N, Sarin SK. Endoscopic biliary drainage by nasobiliary drain or by stent placement in patients with acute cholangitis. Endoscopy 2005;37:439-443. 23. Fazel A, Quadri A, Catalano MF, Meyerson SM, Geenen JE. Does a pancreatic duct stent prevent post-ercp pancreatitis? A prospective randomized study. Gastrointest Endosc 2003; 57:291-294. 24. Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut 2008; 57:1004-1021. 25. Shaw MJ, Mackie RD, Moore JP, et al. Results of a multicenter trial using a mechanical lithotripter for the treatment of large bile duct stones. Am J Gastroenterol 1993;88:730-733. 26. Garg PK, Tandon RK, Ahuja V, Makharia GK, Batra Y. Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones. Gastrointest Endosc 2004;59:601-605. 27. Bergman JJ, Rauws EA, Fockens P, et al. Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bileduct stones. Lancet 1997;349: - 492 -
- Dong Uk Kim. The endoscopic management of CBD stones - 1124-1129. 28. Yasuda I, Tomita E, Enya M, Kato T, Moriwaki H. Can endoscopic papillary balloon dilation really preserve sphincter of Oddi function? Gut 2001;49:686-691. 29. Fujita N, Maguchi H, Komatsu Y, et al. Endoscopic sphincterotomy and endoscopic papillary balloon dilatation for bile duct stones: a prospective randomized controlled multicenter trial. Gastrointest Endosc 2003;57:151-155. 30. Arnold JC, Benz C, Martin WR, Adamek HE, Riemann JF. Endoscopic papillary balloon dilation vs. sphincterotomy for removal of common bile duct stones: a prospective randomized pilot study. Endoscopy 2001;33:563-567. 31. DiSario JA, Freeman ML, Bjorkman DJ, et al. Endoscopic balloon dilatation vs. sphincterotomy (EDES) for bile duct stone removal [abstract]. Digestion 1998;59(Suppl 3):26. 32. Heo JH, Kang DH, Jung HJ, et al. Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones. Gastrointest Endosc 2007;66:720-726. 33. Maydeo A, Bhandari S. Balloon sphincteroplasty for removing difficult bile duct stones. Endoscopy 2007;39:958-961. 34. Minami A, Hirose S, Nomoto T, Hayakawa S. Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy. World J Gastroenterol 2007;13:2179-2182. 35. Attasaranya S, Cheon YK, Vittal H, et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointest Endosc 2008;67:1046-1052. 36. Arya N, Nelles SE, Haber GB, Kim YI, Kortan PK. Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones. Am J Gastroenterol 2004;99:2330-2334. 37. Swahn F, Edlund G, Enochsson L, Svensson C, Lindberg B, Arnelo U. Ten years of Swedish experience with intraductal electrohydraulic lithotripsy and laser lithotripsy for the treatment of difficult bile duct stones: an effective and safe option for octogenarians. Surg Endosc 2010;24:1011-1016. 38. Neuhaus H, Zillinger C, Born P, et al. Randomized study of intracorporeal laser lithotripsy versus extracorporeal shockwave lithotripsy for difficult bile duct stones. Gastrointest Endosc 1998;47:327-334. 39. Prat F, Fritsch J, Choury AD, Frouge C, Marteau V, Etienne JP. Laser lithotripsy of difficult biliary stones. Gastrointest Endosc 1994;40:290-295. 40. Maydeo A, Kwek BE, Bhandari S, Bapat M, Dhir V. Singleoperator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos). Gastrointest Endosc 2011;74:1308-1314. 41. Moon JH, Ko BM, Choi HJ, et al. Direct peroral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones. Am J Gastroenterol 2009;104: 2729-2733. 42. Chen MF, Jan YY. Percutaneous transhepatic cholangioscopic lithotripsy. Br J Surg 1990;77:530-532. 43. Moon JH, Cho YD, Ryu CB, et al. The role of percutaneous transhepatic papillary balloon dilation in percutaneous choledochoscopic lithotomy. Gastrointest Endosc 2001;54:232-236. 44. Hintze RE, Adler A, Veltzke W, Abou-Rebyeh H. Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with billroth II or Roux-en-Y gastrojejunostomy. Endoscopy 1997;29:69-73. 45. Wright BE, Cass OW, Freeman ML. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Gastrointest Endosc 2002;56:225-232. 46. Bergman JJ, van Berkel AM, Bruno MJ, et al. A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy. Gastrointest Endosc 2001;53: 19-26. 47. Faylona JM, Qadir A, Chan AC, Lau JY, Chung SC. Smallbowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy 1999;31:546-549. 48. Jeong EJ, Kang DH, Kim DU, et al. Percutaneous transhepatic choledochoscopic lithotomy as a rescue therapy for removal of bile duct stones in Billroth II gastrectomy patients who are difficult to perform ERCP. Eur J Gastroenterol Hepatol 2009;21:1358-1362. 49. Rimon U, Kleinmann N, Bensaid P, et al. Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones. Cardiovasc Intervent Radiol 2011;34:1262-1266. - 493 -