단일기관에서의 소아 ERCP 10예에 대한 임상적 고찰

박진우,박상흠,이태훈,심윤숙,황순오,김상필,이준영,이세환,이창균,박도현,이석호,정일권,김홍수,김선주 대한소화기내시경학회 2010 Clinical Endoscopy Vol.41 No.3

Background/Aims: ERCP is being used increasingly as a diagnostic and therapeutic tool for children with pancreaticobiliary disorders. Differences between thirteen pediatric ERCPs and adult ERCPs were reviewed with respect to their indications, method of anesthesia, choice of endoscope and complications. Methods: The medical records of 13 ERCPs for 10 children (age: 23 months to 14 years) done between 2005 and 2008 were reviewed retrospectively. Results: ERCP was indicated for gallstone pancreatitis (6), choledocholithiasis (3), and unexplained pain (1). The method of anesthesia was intravenous sedation with a single agent or a combination of midazolam, propofol or ketamine. The quality of sedation was satisfactory in 10 cases and unsatisfactory in three cases. These 3 cases were less than 8 years old and sedated with a combination of midazolam and propofol. Selective biliary cannulation was successful in 92.3% (12/13) of attempts. Therapeutic ERCP included sphincterotomy (4), endoscopic papillary balloon dilatation (3), and both (5). Complications occurred in 7.7% of attempts (1/13; 1 duodenal perforation) which was successfully managed by surgery. Conclusions: Pediatric ERCP is a feasible and useful technique. Special caution is needed, however, because of differences with adult ERCP in terms of the effectiveness of intravenous sedation, complications, and size of the gastrointestinal tract. 목적: 최근 소아에서의 담췌관 질환의 진단 및 치료를 위해 ERCP의 역할이 꾸준히 증가하고 있다. 저자들은 단일병원에서 10명의 소아환자에서 시행한 ERCP를 검토해 임상적 적응증, 진단 및 치료효과, 합병증과 마취 및 그 선택에 있어서 성인과의 차이점에 대하여 알아보고자 하였다. 대상 및 방법: 2005년 8월부터 2008년 6월까지 본원에 입원한 15세 이하의 소아 환자 중 담췌관 질환으로 치료적 ERCP를 시행한 10명의 환아를 대상으로 하였다. 결과: 총 10명(남:여=3:7, 평균나이 5.7세[23개월∼14세])에서 13회의 치료적 ERCP를 시행하였고, 적응증은 담도성 췌장염(n=6), 담도 결석(n=3) 및 담도성 동통(n=1)이었다. 마취방법은 midazolam, propofol, ketamine의 단독 또는 혼합 정맥마취를 사용하였다. 수면마취의 만족도는 만족 10, 불만족 3이었고, 수면마취에 불만족인 3예는 midazolam과 propofol을 복합투여하였던 8세 이하의 환아들이었다. 담도삽관 성공율은 92.3%(12/13)이었으며, 담도삽관에 성공한 예에서 시행된 치료적 시술은 내시경 유두괄약근절개술 4회, 내시경 유두 풍선확장술 3회, 두 시술 동시 시행 5회였다. 시술 관련 합병증은 7.7%(1/13, 십이지장 천공 1예)에서 발생하였으며, 췌장염이나 출혈은 없었다. 십이지장 천공환자는 수술적 치료 후 호전되었다. 결론: 소아에서의 ERCP는 성인에서와 마찬가지로 임상적으로 매우 유용한 시술이다. 그러나 정맥마취의 적용 및 그 효과, 합병증 발생시 대처방법, 소아 위장관의 해부학적 특성이 성인과 차이가 있어 주의를 요한다.

응급 내시경적 역행성 담췌관 조영술(Endoscopic Retrograde CholangioPancreatography)은 모든 담석 췌장염 환자에서 필요한가?

염혜정,이선영 이화여자대학교 의과학연구소 2007 EMJ (Ewha medical journal) Vol.30 No.2

목적:내시경적 역행성 담췌관 조영술(Endoscopic Retrograde Cholangiopancreatography, 이하 ERCP)과 내시경적 유두 괄약근 절개술(Endoscopic Sphincterotomy,이하 ES)은 급성 담석 췌장염 환자의 진단과 치료에 유용하다. 이 연구에서는 담석 췌장염 환자에서 응급ERCP의 유용성에 관하여 알아보고자 하였다. 방법:1994년 7월부터 2002년 12월까지 본원에서 급성 담석 췌장염을 진단받고 ERCP를 시행 받은 환자 66명을 대상으로 후향적인 연구를 하였다. 담석으로 인한 폐쇄성 황달은 응급 ERCP의 명백한 적응증이 되므로 이 연구에서 제외하였다. 대상 환자를 A군(응급 ERCP군 ; 내원 72시 간 내에 ERCP를 시행 받은 군)과 B군(정규 ERCP군 ;내원 72시간 후에 ERCP를 시행 받은 군)으로 나누고 두 군 사이의 임상양상과 부작용 발생 빈도를 비교하였다. 결 과:두 군에서 생화학적 검사 결과, 췌장염의 정도, 췌장염의 부작용, 췌장 유두부의 특성. 입원 기간 사이에는 유의한 차이가 없었다. A군이(40.9%) B군에(24.2%) 비해 ERCP에서 육안적으로 담석이 확인된 경우가 많았다. 결 론:ERCP가 급성 담석 췌장염의 진단과 치료에서 매우 유용하지만. 명백한 폐쇄성 황달이 없을 경우에는 응급 ERCP가 반드시 필요하지는 않다. Objectives : Endoscopic Retrograde Cholangiopancreatogrphy (ERCP) and endoscopic sphincterotomy are useful for both diagnosis and treatment of patients with acute gallstone pancreatitis. In this study, we assessed the feasibility of emergency ERCP in patients with all gallstone pancreatitis. Methods : We retrospectively reviewed the medical records of 66 patients, who underwent ERCP with a diagnosis of acute gallstone pancreatitis between July 1994 and December 2002. Obstructive jaundice from gallstones is excluded, because it is a distinct indication of emergency ERCP. Patients were divided into the group A (emergency ERCP group : ERCP was performed within 72 hours after hospitalization, mean 37.0±16.4 hours, range 6-70 hours) and group B (elective ERCP group ; ERCP, over 72 hours after hospitalization, mean 124.0±49.3 hours, range 76-288 hours). Comparisons of the clinical characteristics and incidence of complications were made between these two groups. Results : There was no significant difference for biochemical measurements, severity of pancreatitis, complications of pancreatitis, characteristics of ampulla, and length of hospital stay between the two groups, Group A had more cases (40.9%) with macroscopic stones on ERCP than group B (24.2%). Conclusion : Although ERCP was a very useful modality for the diagnosis and treatment of patients having acute gallstone pancreatitis, an emergency ERCP would not be necessary unless there is definite obstructive jaundice.

여러 간외담도 질환에서 삼차원적 자기공명 췌담관 조영술과 내시경적 역행성 췌담관 조영술과의 비교: 진단적 정확성을 중심으로

김경숙,이문규,김명환,이승규,김표년,오용호 대한자기공명의과학회 1997 Investigative Magnetic Resonance Imaging Vol.1 No.1

목적: 다양한 간외담도질환에서 3차원적 자기공명췌담도조영술(MR cholangiopancreatography, MRCP)의 진단적 가치를 내시경적 역생성 췌담도조영술(ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY, ERCP)와 비교하여 알아보고자 하였다. 대상 및 방법: 간외담도질환이 의심되는 46명의 환자에 대하여 MRCP와 ERCP를 각각 시행하였다. MRCP는 reverse fast imaging with a steady-state free precession(reverse FISP:PSIF) 기법을 이용하여 얻어낸 후 MIP algorithm을 이용하여 재구성하였다. 담도확장여부와 폐쇄부위 진단에 대한 MRCP의 정확성을 ERCP를 최적기준으로 하여 평가하였다. 또한 악성 및 양성병변의 감별과 종합적인 진단정확도를 MRCP와 ERCP간에 비교하였다. 결과: MRCP의 담도확장여부 예측은 민감도 94.6%, 특이도 75.0%, 정확도 91.1%였다. 폐쇄부위 예측의 정확도는 87.0%였다. 악성과 양성병변의 감별에 있어 MRCP와 ERCP의 민감도, 특이도, 정확도는 각각 76.2%, 87.5%, 82.2%와 71.4%, 83.3%, 77.8%였다. 각각의 지롼에 대한 전체적 진단의 정확도는 MRCP가 60.0%, ERCP가 55.6%였다. 결론: 3D MRCP는 간외담도질환에 있어 ERCP와 비교하여 손색없는 진단적 가치를 가지며, 앞으로 ERCP를 대체할 수 있는 좋은 검사방법이라고 생각된다. Purpose: To evaluate the diagnostic role of a three-dimensional MR cholangiopancreatography (MRCP) over endoscopic retrograde cholangio-pancreatography (ERCP) in various extrah-epatic biliary disease. Materials and Methods: MRCP and ERCP were performed in 45 consecutive patients with suspected extrahepatic biliary diseases. MRCP was obtained using a reverse fast imaging with a steady-state free precession (reverse FISP: PSIF) sequence, and then images were reconstructed by standard MIP algorithm. The predictability of biliary dilatation and level of obstruction of MRCP was evaluated using ERCP as a gold standard. The accuracy distinguishing malignant from benign lesions, and overall diagnostic accuracy were compared between MRCP and ERCP. Results: The sensitivity, specificity and accuracy of MRCP in predicting biliary dilatation were 94.6%, 75.0% and 91.1%, respectively. The level of obstruction was accurate in 87.0% with MRCP. The sensitivity, specificity and accuracy of MRCP and ERCP in distinguishing malignant from benign lesions were 76.2%, 87.5% and 82.2% and 71.4%, 83.3% and 77.8%, respectively. The overall diagnostic accuracy was 60.0% with MRCP and 55.6% with ERCP. Conclusion: 3D MRCP shows a good diagnostic value compared to that of ERCP, and can replace a ERCP.

내시경적 역행성 담췌관조영술 후의 발열에 대한 연구 - 위험인자와 예방적 항생제 사용 효과 분석 -

서승오(Seong O Seo),천재희(Jae Hee Chun),김상균(Sang Kyun Kim),김진(Jin Kim),장유현(Yoo Hyun Chang),김용태(Yong Tae Kim),윤용범(Yong Bum Yoon),김정룡(Chung Yong Kim) 대한소화기학회 2000 대한소화기학회지 Vol.36 No.3

Background/Aims : Fever and cholangitis can be serious complications after endoscopic retrograde cholangiopancreatography (ERCP). The risk factors of these complications and the efficacy of prophylactic antibiotics are not clearly verified yet. In this study, we investigated the frequency, risk factors, pathogens of the fever after ERCP, and evaluated the effect of prophylactic antibiotics. Methods : Retrospective analysis was performed on 674 patients who underwent ERCP between 1996 and 1999. Results : Fever after ERCP occurred in 68 of 674 cases (10.1%). Twenty-six kinds of bacteria were isolated in 23 of 68 febrile cases (33.8%). Fever occurred more frequently in patients (33.4%) in whom therapeutic ERCP failed to remove common bile duct (CBD) stones or to drain obstructed bile duct than in patients (7.3%) with effective drainage (p<0.001). Therapeutic procedure after ERCP caused fever more frequently (16.7%) than diagnostic ERCP only (4.2%)(p=0.03). Moreover, fever was also developed frequently after endoscopic retrograde biliary drainage (ERBD). Prophylactic administration of more than 2 kinds of antibiotics can reduce the rate of fever occurrence after ERCP. Conclusions : Therapeutic ERCP procedures especially after ERBD or unsuccessful biliary drainage were the high risk factors for fever after ERCP. Prophylactic antibiotic treatment using more than two kinds of antibiotics can reduce the incidence of the fever after ERCP. (Kor J Gastroenterol 2000;36:390 - 397)

고령에서의 내시경적 역행성 췌담관 조영술의 안전성 및 유용성

이선영 이화여자대학교 의과학연구소 2007 EMJ (Ewha medical journal) Vol.30 No.1

Objectives : As the general population ages increase leading to an increase in the demand for therapeutic ERCP interventions. The aims of this study are to assess the outcomes, safety and complications associated with ERCP performed in elderly patients. Methods : ERCP was performed in 287 patients aged 70years or over from Jan. 2000 to Dec. 2005. All the patients were evaluated and retrospectively reviewed. The main indications, complications, success rate, mortality and risk factors of procedure were analysed. Results : 287 patients(162 females and 122 males, mean age 78years, range 70-94years) underwent diagnostic and therapeutic ERCP. Mortality rate was 0.03% and success rate was 91.7%. Minor complications including procedure-related complications such as pancreatitis(2.8%), minor bleeding(1.4%), and aggravated cholangitis(2.1%), mild hypoxia(SaO_(2) < 90%, 15.1%), premature ventral contraction(1.0%), and tachycardia(50.7%) were transient. Major events were presented as severe hypoxia(SaO_(2) < 85%) in three pts(1.0%), and atrial fibrillation in one patients (0.03%). Conclusions : This study showed that diagnostic and therapeutic ERCP is safe in elderly patients. Minor complications are usually transient and mortality is similar to previous reported rate. 목 적: 치료적 내시경을 목적으로 하는 ERCP는 고령인구는 상승에 따라 70세 이상의 고령에서 시행하는 경우가 많아지고 았다. 이에 고령 환자에서의 ERCP 시행을 분석하여, 시행 원인을 파악하고 질환의 변동추이를 확인하며 동시에 합병증이나 사망률을 확인함으로써, 이에 따른 위험성을 분석하고자 하였다. 방 법: 이화여자대학교 부속 목동병원에서 2000년 1월부터 2005년 12월까지 ERCP를 시행한 70세 이상의 환자 284명 (남자 122명, 여자 162명, 평균연령 78세, 범위 70-94세)을 대상으로 후향적으로 분석하였다. 환자들의 기존 질환틀인 고혈압, 심장질환, 폐질환, 흡연력, 그리고 고지혈증에 대한 여부를 확인하였고, 시술 중의 산소포화도 및 섬박수의 이상을 감시하였다. 결 과: 사망률은 0.03%이었고 성공률은 91.7%이었다. 작은 합병증틀은 시술과 관련된 훼장염(2.8%)이나 출혈 (1.4%), 또는 악화된 담관염(2.1%)과 경증의 저산소증 (Sa0₂<90%, 15.1%)과 심실조기수축(1.0%), 그리고 빈맥(50.7%) 등이 있었으나 일과성으로 호전되었다. 시술 중단의 이유는 3예가 중증의 저산소증(1.0%)과 1예의 심방세동(0.03%)이 있었는데 이들은 기존 질환이나 흡연 등의 위험인자와 상관관계는 없었다. 결 론: 고령 환자에서의 진단적 또는 치료적 ERCP에서 발 생한 합병증틀은 일과성으로 회복되었으며 사망률도 기 존의 보고와 차이가 없었다. 따라서 고령 환자에서 진단 적 또는 치료적 ERCP는 비교적 안전한 시술이므로 시행함에 있어 주저할 필요는 없을 것으로 판단된다.

ERCP로 진단된 총담관-십이지장 누공 97예의 임상적 분석

박중원,김형준,김재규,유병철,박실무 大韓消化器病學會 1998 大韓消化器病學會誌 Vol.31 No.1

Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure

Amy Tyberg,Jose Nieto,Sanjay Salgado,Kristen Weaver,Prashant Kedia,Reem Z. Sharaiha,Monica Gaidhane,Michel Kahaleh 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.2

Background/Aims: Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Roux-en-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS. Methods: All patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection. Results: Sixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg. Conclusions: EDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.

내시경 역행성 담췌관 조영술 후 발생한 췌장염의 예측인자로서 혈청 procalcitonin의 효용성

김종범,이봉규,서영호,이남훈,이정민,박승욱,안홍주,이상선,송호영 대한췌담도학회 2012 대한췌담도학회지 Vol.17 No.2

Backgrounds/Aims: Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). We wanted to evaluate serum procalcitonin as a marker for early prediction of post-ERCP pancreatitis. Methods: Prospective single center study of 94 patients undergoing ERCP between November 2011 and July 2012 were performed. Blood samples for serum procalcitonin were obtained immediately, 4 hours, and 24 hours after ERCP. The definition of post-ERCP pancreatitis and the grade of its severity were based on consensus criteria Result: The incidence of post-ERCP pancreatitis was 16.0% (15 patients). Thirteen had mild pancreatitis, 2 had moderate pancreatitis, and none had severe pancreatitis. The procalcitonin levels in post-ERCP pancreatitis group and no pancreatitis group were 0.28±0.38 vs. 0.47±0.58 ng/ml for immediately, 0.31±0.42 vs. 0.45±0.53 ng/ml for 4 hours and 0.28±0.39 vs. 0.46±0.46 ng/ml for 24 hours. The levels of serum procalcitonin were not significantly different between post-ERCP pancreatitis group and no pancreatitis group (p=0.129 for immediately, p=0.275 for 4 hours, and p=0.266 for 24 hours) Conclusion: There was no significant difference in the level of serum procalcitonin level between post-ERCP pancreatitis and no pancreatitis group.

80세 이상 초고령환자에서 내시경 역행성 담췌관 조영술의 안전성 및 효과

김장언 ( Jang Eon Kim ),차병효 ( Byung Hyo Cha ),이상협 ( Sang Hyub Lee ),박영수 ( Young Soo Park ),김진욱 ( Jin Wook Kim ),정숙향 ( Sook Hyang Jeong ),김나영 ( Na Young Kim ),이동호 ( Dong Ho Lee ),황진혁 ( Jin Hyeok Hwang ) 대한소화기학회 2011 대한소화기학회지 Vol.57 No.4

Background/Aims: Endoscopic retrograde cholangiopancreatograpy (ERCP) is often used for the diagnosis and treatment of pancreaticobiliary diseases in the elderly patients. However, few studies have assessed its efficacy and safety in the very elderly. The purpose of this study was to evaluate the clinical outcomes of ERCP in the very elderly patients. Methods: Eight hundreds two patients who underwent ERCP at Seoul National University Bundang hospital were enrolled retrospectively. They were divided into three groups according to their ages (non-elderly group, elderly group and very-elderly group; <65, 65-79 and ≥80, respectively). The indications and clinical outcomes including the complications of ERCP were compared among groups. Results: The most common indication of ERCP was acute cholangitis in all the three groups. Periampullary diverticulum was more frequently observed in elderly and very-elderly patients than in younger patients. Mean duration of hospitalization was not different among three groups. ERCP success rate in all enrolled patients was approximately 90%, and there was no difference in terms of technical success rate between groups (p=0.1). However, the number of ERCP sessions was significantly higher in the very-elderly patients compared to in the non-elderly and elderly (1.38 vs. 1.13 and 1.18 respectively; p<0.001). There was no difference in mortality and complication rate between groups. Conclusions: ERCP can be performed safely in very-elderly patients. Therefore, only age should not be regarded as one of the major determining factors whether to perform ERCP. (Korean J Gastroenterol 2011;57:237-242)

왜 췌장담도내시경 인증의 제도 시행을 해야 하는가?

조광범 ( Kwang Bum Cho ) 대한췌장담도학회 2021 대한췌담도학회지 Vol.26 No.4

ERCP 시술을 성공적으로 수행하기 위해서는 대상 질환에 대한 이해와 함께 적절한 교육과 수련, 일정량 이상의 시술 경험이 뒷받침되어야 성공적인 시술 및 최소 합병증 가능성으로 환자에게 도움을 줄 수 있다. 그러나 ERCP 시술은 무거운 방사선 방호복을 입고 방사선 피폭과 합병증 발생의 위험성을 감수하면서, 집중력을 발휘해야 하는 시술로 내시경을 이용한 시술 중에서 가장 난이도가 높다고 여겨지고 있다. ERCP를 능숙하게 시행하기 위해서는 지도감독하의 적절한 수련 및 충분한 시술 경험, 적절한 대상 환자의 선택이 필요하다. 따라서 대한췌장담도학회에서는 ERCP 시술의 교육과 질관리 유지를 위하여 “췌장담도내시경 인증의” 제도를 시행하기 위하여 추진위원회를 구성하였고, 관련 규정 개발과 설문조사, 학술대회 발표 등을 통하여 제도 시행에 대한 청사진을 마련하였다. The endoscopic retrograde cholangiopancreatography (ERCP) procedure requires concentration while wearing a heavy radiation protective suit and taking the risk of radiation exposure and complications. In order to successfully perform an ERCP procedure, it is necessary to understand the target disease, as well as appropriate education and training, and a certain amount of experience in the procedure. The Korean Pancreatobiliary Association organized a promotion committee to implement the “ERCP Certification” system to maintain education and quality control of ERCP procedures. A blueprint was prepared. Korean J Pancreas Biliary Tract 2021;26(4):211-215