초심자에서 투명캡 장착 직시경을 이용한 ERCP
Cap-assisted ERCP in Surgically Altered Anatomy
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목적: 내시경 역행성 담췌관 조영술시 선택적 담도 삽관의 성공률은 숙련된 시술자에서 85∼95% 정도이나 Billroth II, 루앵Y연결, 휘플 수술 등을 시행받은 경우 성공률이 높지 않다. 저자들은 기본적인 내시경 역행성 담췌관 조영술 훈련을 마치고 비교적 경험이 적은 초심자에서 과거에 수술로 인한 해부학적 변이가 있는 환자를 대상으로 투명캡을 장착한 직시경을 이용한 내시경 역행성 담췌관 조영술의 임상적 유용성에 대하여 연구하였다. 대상 및 방법: 2008년 4월부터 2010년 3월까지 수술로 해부학적 변화가 있는 환자 16명을 대상으로 시술 후 결과를 후향적으로 분석하였다. 결과: 총 16명(20회)의 환자를 대상으로 투명캡을 장착한 직시경으로 내시경 역행성 담췌관 조영술을 시행하였다. 시술의 적응증은 담도 확장을 동반한 담낭염(1예), 전이성 암(3예), 총담관 결석(9예), 담도 협착(3예)이었다. 총 24회의 시술 중 구심성 고리로의 삽입 성공률은 24회 중 20회(83.3%)였고, 삽관 성공은 19회(79.1%)에서 성공하였다. 평균 시술 소요시간은 20분이었다. 루앵Y연결을 시행 받은 4예는 모두 삽입에 실패하였다. Billroth II 수술을 시행 받은 환자들의 경우에는 구심성 고리 삽입에는 모두 성공하였으나 1예에서 선택적 삽관에 실패하였다. 시술과 관련된 합병증으로 십이지장 천공 1예가 발생하여 수술하였다. 사망 예는 없었다. 결론: Billroth II 수술을 받은 환자에서 투명캡을 장착한 직시경으로 내시경 역행성 담췌관 조영술을 시행하여 높은 시술 성공률을 보였다. 특히 경험이 적은 시술자에게 도움이 될 것으로 생각한다.
Abstract
Background/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is a difficult procedure to perform on patients who have undergone a Billroth II gastrectomy, Whipple’s operation or Roux-en-Y gastrobypass surgery. Our study was designed to evaluate the clinical usefulness of cap-assisted ERCP for beginner endoscopists in cases of surgically altered anatomy. Methods: From April 2008 to March 2010, 16 patients with biliary diseases and who had previously undergone abdominal surgery such as Billroth II gastrectomy or Roux-en-Y operation were analyzed. A single endoscopist performed all the procedures using a cap-assisted gastroscope, after ERCP training. Results: Cap-assisted ERCP was attempted in 24 sessions of 16 patients. Afferent loop intubation and selective bile duct cannulation was successfully achieved in 19 sessions (79.1%). Among the patients who had undergone a Billroth II gastrectomy, 19 out of 20 sessions were successfully conducted. Only 4 patients who had undergone a previous Roux-en-Y operation failed afferent loop intubation. Duodenal free wall perforation developed in one case. There were no cases of mortality. Conclusions: Therapeutic cap-assisted ERCP was useful in patients who had previously undergone a Billroth II gastrectomy and this may be helpful for inexperienced endoscopists.
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