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Review Article pissn 1976-3573 eissn 2288-0941 THE KOREAN JOURNAL OF PANCREAS AND BILIARY TRACT 총담관결석의진료가이드라인 : 난치성, 재발담관결석의내시경치료 황재철 1, 고동희 2, 최현종 3 1 아주대학교의과대학내과학교실, 2 한림대학교의과대학내과학교실, 3 순천향대학교의과대학부천병원내과 Clinical Practice Guidelines for Common Bile Duct Stones : The Endoscopic Management of Difficult and Recurrent Common Bile Duct Stones Jae Chul Hwang 1, Dong Hee Koh 2, Hyun Jong Choi 3 1 Department of Internal medicine, Ajou University School of Medicine, Suwon, Korea 2 Department of Internal medicine, Hallym University College of Medicine, Hwaseong, Korea 3 Department of Internal medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea Endoscopic retrograde cholangiopancreatography and stone extraction are well-established therapeutic procedures for the treatment of common bile duct (CBD) stones. The endoscopic stone removal procedure involves extraction using various devices after endoscopic sphincterotomy (EST). Many reports state that at least 90% of stones are extracted after conventional EST. However, some cases are still difficult to treat. Despite apparently complete clearance of bile duct stones at endoscopic retrograde cholangiography, recurrent CBD stones developed in 3% to 15% of patients. We reviewed the guidelines currently enacted in United Kingdom, Europe and United Stated of America for the management of difficult and recurrent CBD stones. This guideline review suggests the guideline of Korean Pancreatobiliary Association for the endoscopic management of difficult and recurrent CBD stones. Key words: bile duct stone, endoscopic sphincterotomy, mechanical lithotripsy, electrohydraulic lithotripsy, laser lithotripsy 서론 1) 내시경역행담췌관조영술 (endoscopic retrograde cholangiopancreatography, ERCP) 을이용한내시경치료는현재총담관결석의주요한치료법으로사용되고있으며내시경유두괄약근절개술 (endoscopic sphincterotomy, Corresponding author. 황재철아주대학교병원소화기내과 442-721, 경기도수원시영통구원천동산 5 Tel: 031-219-7825 Fax: 031-219-7820 E-mail: cath07@ajou.ac.kr EST) 시행후바스켓이나풍선카테터를이용하는전통적인내시경적방법을이용하여약 85~90% 에서결석의제거가가능하다. 1,2 그러나이러한통상적인방법으로도 10 15% 정도에서는완전한결석제거가불가능한경우가있는데성공적인결석제거를어렵게하는요인들로는결석의크기, 개수, 모양과같은결석자체의요인뿐아니라, 담관원위부의굴곡정도, 담관협착, 위장관계수술로인한해부학적변형등이있다. 3-7 제거가어려운거대결석에대한정의는아직까지명확하지않다. 대개의경우 10 mm 이하의총담관결석은 EST 후제거가가능한것으로알려져있으나결석의크기가증가함에따라결석제거성공률은감소하는것으로알려져있으며, 내시경적결석제거의기술적 21

황재철외 2 명 22 어려움과관련된요인을전향적으로분석한국내연구에서는결석의크기가 15 mm 이상인경우가결석에대한내시경적제거를어렵게하는요인들중하나로보고하였다. 8,9 이처럼난치성담관결석의내시경적치료에서결석의크기도중요하나결석에대한상대적인담관의직경및협착여부도중요하게고려되어야한다. 또한난치성담관결석의내시경치료에서내시경유두큰풍선확장술을제외한기계적쇄석술등의추가적인내시경시술전에는충분한대절개 EST가되어있어야한다. 일반적으로 ERCP 시행후 6개월을기준으로이전에발견된경우는잔류총담관결석으로분류하고그이후는재발총담관결석으로분류하는데, 10 ERCP에서담관결석이완전히제거되었음이확인되어도 5년이상장기간추적관찰연구들에서는 3~15% 정도의결석의재발을보고하고있다. 10-16 총담관결석재발의보고된위험인자로는담낭결석, 기계적쇄석술시행, 담관확장 (15 mm 이상 ), 유두부주위의게실, 총담관굴곡, 담즙정체, 담관협착, 유두부협착, 용혈성빈혈등이있다. 10,13,16-18 유럽, 영국과미국에서는통상적인방법으로제거가어려운총담관결석이나재발성총담관결석의치료에대한가이드라인이만들어져사용되고있으나, 19,20 국내에서는이러한치료지침에대한명확한기준이마련되어있지않은실정이다. 현재까지발표된유럽, 영국과미국의가이드라인을근간으로통상적인방법으로제거가어려운총담관결석에대한치료지침을살펴보면거대총담관결석과상부위장관의해부학적구조가수술로변형된총담관결석환자의치료로분류해볼수있으며, 재발성총담관결석의치료에대해서는반복적인내시경역행담관조영술 (Repeat ERCP) 과약물치료로분류해볼수있다. 본고에서는통상적인방법으로제거가어려운총담관결석이나재발성총담관결석의치료에대한외국의가이드라인을검토하고이를바탕으로우리나라에적합한가이드라인을제안하였다. 본론 I. 내시경적제거가어려운총담관결석의치료 (Management of difficult bile duct stones) 1) 기계적쇄석술권고사항기계적쇄석술은 EST 후바스켓과풍선도관을이용하는통상적인내시경적결석제거술로제거가어려운 3 cm 미만의거대총담관결석에대한일차적인치료로사용될수있다. - 근거수준및권고등급 : 1B 바스켓을이용하여포획된결석을유두부로부터제거할수없는거대결석의경우전통적으로기계적쇄석기를이용한쇄석술이사용된다. 기계적쇄석술은기본적인내시경적결석제거술과같은기본적인기술을필요로하며같은시술의일부로시행될수있기때문에거대결석의치료에효과적인방법으로사용될수있다. 19 따라서 EST를포함하는전통적인내시경적결석제거술을시행하는모든의사들은필요시기계적쇄석술을시행할수있어야한다. 19 통상적인방법으로제거되지못한결석에서기계적쇄석술의성공률은 79 92% 로보고되고있으며, 기계적쇄석술의가장흔한실패원인은결석의담관내감돈과결석이매우큰경우이다. 21-24 결석의크기가 3 cm 보다큰경우에는결석이바스켓에완전히잡힐수없으므로결석의크기가 3 cm 보다작은경우에기계적쇄석술을고려한다. 24,25 6 13% 로보고되고있는기계적쇄석술과관련된합병증으로는췌장염과출혈이가장흔한것으로알려져있으며바스켓의감돈이나바스켓의철사줄이끊어지는기술적인합병증도발생할수있다. 23,24,26 결석을포획한바스켓이감돈되는경우바스켓의손잡이부분을제거하고바스켓을그대로유치해놓은상태로내시경을빼낸후방사선투시하에시행하는응급기계적쇄석술이유용하게사용될수있다. 19 2) 담관내전기수압쇄석술, 레이저쇄석술권고사항담도내시경하에전기수압쇄석술또는레이저쇄석술은 EST 후바스켓과풍선도관을이용하는통상적인내시경적결석제거술로제거가어려운거대총담관결석에대한치료로유용하게사용될수있다. - 근거수준및권고등급 : 1B 1. 거대총담관결석 난치성담관결석의제거에사용될수있는담관내충격파쇄석술은대체로담도내시경하에전기수압쇄석술

총담관결석의진료가이드라인 : 난치성, 재발담관결석의내시경치료 23 (electrohydraulic lithotripsy, EHL) 또는레이저쇄석술 (laser lithotripsy, LL) 의탐침을결석에직접접촉시켜쇄석술을시행하여분쇄된결석조각을바스켓으로포획하여제거하는방법으로거대감돈결석에서가장유용하게사용될수있다. 20 통상적인방법으로내시경적제거가어려운담관결석치료에서 EHL은대개의경우 1회의치료로 74~95% 의성공률이보고되고있으며, 2,27-30 LL 역시 EHL 과유사한 88~97% 의성공률이보고되고있다. 31-35 LL에는 FREDDY(FRequency Doubled Double Pulse YAG Laser) 시스템을이용한쇄석술과 holmium 레이저를이용한쇄석술이주로사용되고있다. FREDDY 시스템은담관결석과접촉시에결석의표면에서 plasma 를형성하여충격파를만들어결석을분쇄하게되며생체조직과접촉시조직의손상을유발하지않아천공의위험이적다는장점이있다. 36 Holmium 레이저는비교적긴파장의레이저로담관결석분쇄에는효과적일수있으나연부조직에대한 holmium 레이저의온열효과로인해혈성담즙과같은합병증이발생할수있는것으로알려져있다. 37 EHL과 LL에서합병증은 3~19% 로보고되고있으며가장흔한합병증은담관염과출혈로알려져있다. 27-32,38 EHL과 LL을시행할때모자내시경 (mother-baby scope system) 이사용되어왔으나이경우에두명의숙련된시술자를필요로하고자내시경 (baby scope) 이쉽게손상될수있는단점이있다. 39 이러한단점을극복하기위해 SpyGlass Direct Visualization System (Boston Scientific Corp., Natick, MA, USA) 이나극세경내시경을이용한직접경구적담관내시경검사 (direct peroral cholangioscopy) 을사용할수있다. 40-42 ERCP를통한결석제거에실패하는경우경피경간적담도내시경을통한 EHL이나 LL을사용할수있다. 접근경로가되는누공의확장및완성에시간을요하지만결석의제거에있어높은성공률이보고되고있으며경구경유두로의접근이어려운경우에유용하게사용될수있다. 43,44 3) 내시경유두큰풍선확장술권고사항소절개내시경유두괄약근절개술후시행되는내시경유두큰풍선확장술은원위부담관협착이없는환자에서 EST 후바스켓과풍선도관을이용하는통상적인내시경적결석제거술로제거할수없는거대담관결석의치료로유용하게사용될수있다. - 근거수준및권고등급 : 1B 2003년 Ersoz 등 45 에의해 EST 후 12 20 mm의풍선도관을사용하는내시경유두큰풍선확장술 (endoscopic papillary large balloon dilatation, EPLBD) 을병용하는치료에대한효과가보고된이후, 여러연구에서 EST 후 EPLBD를시행하는방법은고식적인방법으로제거가어려운총담관결석환자에서안전하고효과적인치료방법으로보고되었다. 46-51 거대담관결석환자에서 EPLBD 시행후담관결석의완전제거율은 95 100%, 기계적쇄석술이필요했던경우는 1~27% 로보고되고있으며출혈, 천공, 췌장염등의합병증은 0~16% 로보고되고있다. 45-51 EPLBD 시행후발생한출혈의합병증은 0~9% 로보고되고있는데, 45-50,52,53 대절개 EST 시행후 EPLBD 를시행한경우 8.3~9% 의비교적높은빈도의출혈이보고되어, 45,47 EPLBD 전에소절개 EST가시행되고있다. EPLBD 시행후발생한합병증을분석한다기관후향적연구에서시술후 0.42% (4 / 946) 의사망률을보고하였다. 54 천공이발생한세명의환자는원위부담관에협착이있었거나풍선확장시지속적으로저항이있었던환자였으며한명의환자는대절개 EST 시행후 EPLBD (12 mm) 를시행하여결석을제거한후에심한지연출혈로사망하였다. 따라서 EPLBD는원위부담관협착이없는환자에서시행되어야하며 EPLBD 시행전대절개 EST는피해야한다. 최근선행하는 EST 없이 EPLBD 단독으로거대총담관결석을효과적으로치료했다는후향적연구들이있으나, 52,53,55 이를뒷받침할전향적비교연구들이필요하다. 4) 일시적담관스텐트삽입술권고사항 EST 후바스켓과풍선도관을이용하는통상적인내시경적결석제거술로제거할수없는거대담관결석이있는고령이거나수술에대한고위험군의환자에서일시적플라스틱담관스텐트의삽입은이차적인내시경적시술로결석제거성공률을높일수있는방법으로사용될수있다. - 근거수준및권고등급 : 2B 담관스텐트삽입술을이용한담관결석제거는아직명확한치료법으로알려져있지는않으나, 시술이비교적쉽고일차적으로담즙배액뿐아니라담관결석의감돈을방지하며, 이차적으로는마찰에의해결석의크기를감소시켜결석제거를용이하게한다는보고들이있다. 56-61 플라스틱스텐트를이용한총담관결석치료의적응증은내시경

황재철외 2 명 24 치료로제거하지못한 15 mm 이상의거대총담관결석환자에서, 특히고령이거나수술에대한고위험군으로수술에따른합병증위험도가높은경우이다. 62 플라스틱담관스텐트삽입후담관결석제거를시행한연구들에서이차적인내시경적시술로결석제거성공률은 44 92% 정도로보고되고있다. 57-61,63-68 결석제거를위한담관스텐트삽입시어느정도기간동안삽입해야하는지에대한명확한기준은없으나스텐트를장기간삽입시담관염의발생이높아지기때문에 3개월정도의일시적삽입이권장된다. 62 결석제거효과를증대시키기위한약물치료로서 ursodeoxycholic acid(udca) 와 terpene 의사용에관한연구들에서이러한약물의사용이통계적으로유의한결석크기감소와관련이없다는보고도있어서아직까지결석제거를목적으로담관스텐트삽입후추가적인약물치료에대한명확한근거는없다. 66,69 2. 수술로변형된상부위장관의해부학적구조권고사항 Billroth II 수술, Roux-en-Y 문합술로해부학적인변화가발생한총담관결석환자는경험있는숙련가나상급병원에의뢰하는것을고려해야한다. - 근거수준및권고등급 : 1C Billroth II 수술, Roux-en-Y 문합술로해부학적인변화가발생한총담관결석환자에서 ERCP 를통한담석제거에실패하는경우에경피경간적담도내시경을통한쇄석술은수술적치료를피할수있는유용한대안으로사용될수있다. - 근거수준및권고등급 : 1B 성공적인총담관결석의제거를위해담관으로의선택적삽관은필수적이나 Billroth II 수술, Roux-en-Y 문합술등으로해부학적인변화가발생한환자의경우정상환자와비교하여낮은삽관성공률을보이는것으로알려져있다. Billroth II 수술, Roux-en-Y 문합술을받은환자의경우 ERCP 및관련된시술이어려운이유는구심성고리가너무길거나, 문합부위의심한예각, 또는트라이츠인대 (Treit s ligament) 에서의루프형성으로내시경의진입이어려운경우가있기때문이다. 70 또한일단내시경이유두부에도달하여도담관삽관이통상적인방향과는반대이기때문에선택적삽관및 EST 등의시술이정상구조의 환자와비교하여더어렵다. 39 특히 Roux-en-Y 문합술을받은경우에는선택적담관삽관의성공률이 33~67% 로 Billroth II 수술을시행받은경우의 60 90% 보다낮은것으로보고되고있다. 70,71 또한시술과관련하여출혈, 천공등의합병증의발생률이 5 17% 로정상해부학적구조를지닌환자와비교하여더높다. 72-76 따라서 Billroth II 수술, Roux-en-Y 문합술로해부학적인변화가발생한총담관결석환자는경험있는숙련가나상급병원에의뢰하는것이제시되고있다. 20 경피경간적담도내시경을통한쇄석술 (Percutaneous transhepatic cholangioscopic lithotomy, PTCSL) 은 ERCP에비해침습적이고시술에필요한시간이길다는단점이있으나결석의제거에있어높은성공률이보고되고있으며역행성접근이어려운경우에유용하게사용될수있다. 43,44 총담관결석환자에서는간내결석환자에서비교적흔하게관찰되는담관협착이나담관의급격한굴곡이없는경우가많기때문에총담관결석환자에서 PTCSL 을시행하면비교적어렵지않게총담관결석을제거할수있다. 77,78 Jeong 등 77 은 Billroth II 수술을시행받은총담관결석환자중 ERCP가실패한 20명의환자를대상으로 PTCSL을시행하여모든환자에서성공적으로결석을제거하였고시술관련중대한합병증이없음을보고하였다. 따라서 Billroth II 수술, Roux-en-Y 문합술로해부학적인변화가발생한총담관결석환자에서 ERCP를통한결석제거에실패하는경우에 PTCSL 은수술적치료를피할수있는유용한대안으로사용될수있다. 77-80 II. 재발성총담관결석의치료 (Management of recurrent bile duct stones) 1. 반복적인내시경역행담관조영술권고사항반복적인 ERCP는 ERCP 시행후발생한재발성총담관결석에대한일차적인치료로사용될수있다. - 근거수준및권고등급 : 1C 색소성결석이대다수를차지하는재발성총담관결석은 ERCP를통해높은성공률로치료될수있는것으로알려져있다. 8,15,81 또한재발성총담관결석의치료를위해시행되는 ERCP는이전에 EST가시행되어있는상태에서이루

총담관결석의진료가이드라인 : 난치성, 재발담관결석의내시경치료 25 어지므로출혈이나췌장염의발생가능성이낮아비교적안전하게시행될수있다. 82 성공적인결석제거후에총담관결석의재발이확인된환자에서담관결석의재발과관련된유두부주위의게실이나 15 mm 이상현저히확장된담관과같은담즙정체를유발하는인자들을근본적으로교정하기가어려운경우가많다. 18,20 Geenen 등의보고에의하면적어도두번이상결석이재발된환자에서매년감시내시경역행담관조영술 (Surveillance ERC) 을시행하여담관염이발생하기전에재발성결석을제거함으로써담관염의발생을줄일수있었다. 83 그러나이결과를확인할전향적무작위배정연구가필요하며환자의개별적상황에맞게적용되어야한다. 18,20 결론 EST 후바스켓과풍선도관을이용하는통상적인방법으로제거가어려운거대총담관결석의치료로서환자의상태, 결석및총담관의소견에따라기계적쇄석술, 담관내전기수압쇄석술또는레이저쇄석술, 소절개내시경유두괄약근절개술후내시경유두큰풍선확장술, 일시적담관스텐트삽입술을고려해볼수있다. Billroth II 수술, Roux-en-Y 문합술로해부학적인변화가발생한총담관결석환자에서 ERCP를통한결석제거에실패하는경우에수술적치료를피할수있는유용한대안으로경피경간적담도내시경을통한쇄석술을고려해볼수있다. 반복적인 ERCP는 ERCP 시행후발생한재발성총담관결석에대한일차적인치료로사용될수있다. 국문초록 내시경역행담췌관조영술을이용한내시경치료는현재총담관결석의주요한치료법으로사용되고있으며내시경유두괄약근절개술시행후바스켓이나풍선카테터를이용하는전통적인내시경적방법을이용하여약 90% 에서결석의제거가가능하다. 그러나이러한통상적인방법으로도 10% 정도에서는완전한결석제거가불가능한것으로알려져있다. 내시경역행담췌관조영술에서담관결석이완전히제거되었음이확인되어도 5년이상장기간추적관찰연구들에서는 3~15% 정도의결석의재발을보고하고있다. 아직까지국내에서는통상적인방법으로제거가어려 운총담관결석이나재발성총담관결석의내시경치료에대한권고안이마련되어있지않아현재까지발표된이에대한유럽, 영국과미국에서의가이드라인을검토하고이를근간으로대한췌담도학회의진료권고안을제안하고자한다. 색인단어 : 담관결석, 내시경유두괄약근절개술, 기계적쇄석술, 전기수압쇄석술, 레이저쇄석술 참고문헌 1. Cotton PB. Non-operative removal of bile duct stones by duodenoscopic sphincterotomy. Br J Surg 1980;67:1-5. 2. Binmoeller KF, Bruckner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy 1993;25:201-206. 3. Lauri A, Horton RC, Davidson BR, Burroughs AK, Dooley JS. Endoscopic extraction of bile duct stones: management related to stone size. Gut 1993;34:1718-21. 4. Kim MH, Lee SK, Lee MH, et al. Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope. Endoscopy 1997;29:82-85. 5. Okugawa T, Tsuyuguchi T, K CS, et al. Peroral cholangioscopic treatment of hepatolithiasis: Long-term results. Gastrointest Endosc 2002;56:366-371. 6. Gluck M, Cantone NR, Brandabur JJ, Patterson DJ, Bredfeldt JE, Kozarek RA. A twenty-year experience with endoscopic therapy for symptomatic primary sclerosing cholangitis. J Clin Gastroenterol 2008;42:1032-1039. 7. Lopes TL, Wilcox CM. Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. Gastroenterol Clin North Am 2010;39:99-107. 8. Lai KH, Peng NJ, Lo GH, et al. Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy. Gut 1997;41:399-403. 9. Kim HJ, Choi HS, Park JH, et al. Factors influencing the technical difficulty of endoscopic clearance of bile duct stones. Gastrointest Endosc 2007;66:1154-1160. 10. Keizman D, Shalom MI, Konikoff FM. An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction. Surg Endosc 2006;20:1594-1599. 11. Hawes RH, Cotton PB, Vallon AG. Follow-up 6 to 11

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