술중 담도조영술이 꼭 필요한가?

김춘직(Chun Jik Kim),김상운(Sang Woon Kim),이수정(Soo Jung Lee),김홍진(Hong Jin Kim),심민철(Min Chul Shim),권굉보(Koing Bo Kwun),정문관(Moon Kwan Chung) 대한소화기학회 1994 대한소화기학회지 Vol.26 No.1

N/A Since operative cholangiography was introduced by Mirizzi in 1932, surgeons have used it routinely during cholecystectomy to find silent CBD stones. However, recent developments in preoperative evaluation techniques have led to debates regarding the routine use of operative cholangiography. The purpose of this study is to evaluate the necessity of the routine use of operative cholangiography. Of the 839 patients who underwent cholecystectomy, 625 patients underwent preexp- loratory cholangiography during the period from June 1983 to December 1991, at the Depart- rnent of Surgery, Yeungnam University Hospital. Unsuspected common duct stones were found in 5 out of 149 patients(5.9%) by preexploratoty cholangiography when emergency cholecystectomy was performed. Of the 448 cholangiography in patients without any abnor- mality in the preoperative test and no operative indication for CBD exploratiOn, the incidence of gall stones was only 1.1%. Of the 82 patients with minor abnormality of LFT or ultrasonogram, 38 cases of elective cholecystectomy were carried out without any other test. The incidence of gall stones in these patients was 28%. The ERCP was attempted on 163 pa- tients with one or more of the following abnormalities: LFT, ultrasonogram and past history of jaundice, pancreatitis or cholangitis. In 117 of these patients, CBD stones were found, in 2 of the patients, stricture were found, and in the rernaining 44, no stones were found. The ERCP performed on 35 patients with normal findings of preopeative LFT or ultrasonogram showed no evidence of CBD stone. Of the 79 whose ERCP was judged normal preoperatively, no stones were found at operative cholangiography. Therefore the following points may be concluded: First, operative cholangiography should be performed when emergency cholecystectomy is indicated. Secondly, it should also be done when the confirmatory test, such as ERCP, PTC and CT was not performed or failed in pa- tients with one or more of the following abnormalities such as LFT, ultrasonogram and past history of jaundice, pancreatitis or cholangitis. Finally, it should also be carried out on patients with dilated duct, small stones in the gallbladder and enlarged cystic duct.(Korean J Gastroenterol 1994; 26: 167-174)

Internal and External Draining Operations in Chronic Peripanchreatic Peculs of Pancreas

( Lukmonov Saidrakhim Nodirovich ),( Madatov Kurbanbay Abdullayevich ),( Usmanov Oybek Otabekovich ),( Ismailov Muzaffar Uktamovich ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Peripancreatic pseudocysts (PPC) are the most common complication (20-40%) in patients with chronic pancreatitis (CP). According to the literature, the timing of dynamic observation and the choice of surgical treatment options remain questions for discussion. Methods: Materials and methods. In the period from 2013 -2017. On the basis of the department of surgical hepatology, 29 patients were operated, who had chronic PPC on the background of HP. The lifetime of PPC Me = 17.4 ± [6.5-24] months. In parallel, the results of treatment of 34 patients who underwent laparotomy and external drainage of PPC were analyzed in connection with the fact that these patients were treated with a clinic for peritonitis or rupture of PPK. The lifetime of the PPC is Me = 14 ± [9-21.2] months. Before the operation, the examination protocol included transabdominal ultrasound (recently supplemented with endosonography), CKT OBP, MRI cholangiography. In the second group, only ultrasound was performed before the operation. Results: In the first group, consisting of 29 patients, the size of AUC with the presence of a liquid component and sequestrants was up to 60 mm in 4 cases, within 51-100 mm in 20 patients and more than 100 mm in five. In all cases, the fibrous membrane that bounds the AUC was formed. FOC center in 5 patients was located in the zone of the isthmus and the proximal third of the pancreas, the gland bag. In all patients, despite the treatment, the pain syndrome persisted, and there were signs of calcification and fibrosis of the prostate tissue. In this group of patients, cystogastroanastomosis (CGA) was applied with a diameter of at least 5 cm after cystotomy and non-secrecestrectomy. In 24 patients, PPC was located in the projection of the distal part of the body or tail of the prostate and adjacent to them peripancreatic cellulose tissue. In connection with the zone of localization of PPC, after performing nekrsekvestrektomii superimposed cystoenteroanastomosis (CEA) on the loop on the Root. All patients showed persistent relief of the pain syndrome and an improvement in the quality of life, which was assessed using the Russian version of the SF-36 v.2tm questionnaire. In 34 patients of the second group admitted to the hospital with a clinic of peritonitis against the background of long-lived PPC, laparotomy with non-secrecestrectomy and external drainage of foci of PPC was performed. The sizes of AUC with the presence of a liquid component and sequesters were up to 60 mm in 5 cases, within 51-100 mm in 22 patients and more than 100 mm in the seven. In connection with the progression of the necrotic process or bleeding from the residual cavity, 5 (14.7%) patients underwent a programmed relaparotomy and additional necrosecretrectomy or hemostasis. The lethal outcome occurred in three cases (8.8%). In surviving patients for more than 4-6 months, there were external pancreatic fistulas, which according to the results of the SF-36 v.2.tm questionnaire improved the quality of life to a lesser extent (P=0.009- 0.0061) than in the first group and worsened the prognosis of NP flow. Conclusions: Internal drainage operations (CEA, CSA) are preferred, since they provide a greater increase in the indices of physical and psychoemotional components of quality of life in operated patients, which confirms the correctness of active surgical tactics. External drainage after nekrsekvestrektomii are rather a forced option of surgical intervention, which is advisable to use in the presence of complications pseudocyst (rupture, peritonitis).

Comparison of intraductal ultrasonography-directed and cholangiography-directed endoscop­ic retrograde biliary drainage in patients with a biliary obstruction

( Soo-jung Rew ),( Du-hyeon Lee ),( Chang-hwan Park ),( Jin Jeon ),( Hyun-soo Kim ),( Sung-kyu Choi ),( Jong-sun Rew ) 대한내과학회 2016 The Korean Journal of Internal Medicine Vol.31 No.5

Background/Aims: Endoscopic retrograde biliary drainage (ERBD) has become a standard procedure in patients with a biliary obstruction. Intraductal ultraso­nography (IDUS) has emerged as a new tool for managing extrahepatic biliary diseases. IDUS-directed ERBD can be performed without conventional cholan­giography (CC). The goal of this study was to assess the effectiveness and safety of IDUS-directed ERBD compared to CC-directed ERBD in patients with an extra­hepatic biliary obstruction. Methods: A total of 210 patients who had undergone IDUS-directed ERBD (IDUS-ERBD, n = 105) and CC-directed ERBD (CC-ERBD, n = 105) between Oc­tober 2013 and April 2014 were analyzed retrospectively. The primary outcome measure was the procedural success rate. Secondary outcome measures included clinical outcomes, total procedure time, radiation exposure time, and overall complication rates. Results: The total technical success rate of ERBD was 100% (105/105) in the IDUS-ERBD and CC ERBD groups. Mean procedure time was slightly prolonged in the IDUS-ERBD group than that in the CC-ERBD group (32.1 ± 9.9 minutes vs. 28.4 ± 11.6 minutes, p = 0.023). Mean radiation exposure time was one-third less in the IDUS-ERBD group than that in the CC-ERBD group (28.0 ± 49.3 seconds vs. 94.2 ± 57.3 seconds, p < 0.001). No significant differences in complication rates were detected between the groups. Conclusions: IDUS-ERBD was equally effective and safe as CC-ERBD in patients with an extrahepatic biliary obstruction. Although IDUS-ERBD increased total procedure time, it significantly decreased radiation exposure.

원발성 경화성 담관염 2예

이은학(Eun Hag Lee),주재학(Jae Hak Joo),이명렬(Myung Lyel Lee),박찬욱(Chan Wook Park),송동화(Dong Hwa Song),이준성(Joon Seong Lee),이문성(Moon Sung Lee),조성원(Sung Won Cho),심찬섭(Chan Sup Shim) 대한소화기학회 1995 대한소화기학회지 Vol.27 No.1

Primary sclerosing cholangitis characterized by inflammation and fibrosis of the biliary tree with diffuse multifocal stricture formation is a chronic cholestatic liver disease that often progresses to cirrhosis and premature death from liver failure. Because histologic findings are not diagnostic in the majority of patients, the gold standard for diagnosis of primary sclerosing cholangitis is cholangiography. We present two cases of primary sclerosing cholangitis diagnosed by typical cholangiographic findings through the endoscopic retrograde cholangiography(ERC). (Korean J Gastroenterol 1995;27:138-143)

Primary Biliary Lymphoma Mimicking Cholangiocarcinoma: A Characteristic Feature of Discrepant CT and Direct Cholangiography Findings

윤민아,이정민,김세형,이재영,한준구,최병인,김선회,장자준 대한의학회 2009 Journal of Korean medical science Vol.24 No.5

Primary non-Hodgkin’s lymphoma arising from the bile duct is extremely rare and the reported imaging features do not differ from those of cholangiocarcinoma of the bile duct. We report a case of a patient with extranodal marginal zone B-cell lymphoma of mucosa associated lymphoid tissue (MALT), who presented with obstructive jaundice and describe the distinctive radiologic features that may suggest the correct preoperative diagnosis of primary lymphoma of the bile duct. Primary MALT lymphoma of the extrahepatic bile duct should be considered in the differential diagnosis when there is a mismatch in imaging findings on computed tomography or magnetic resonance imaging and cholangiography.

폐쇄성 황달 환자에 있어서 자기공명 담도 촬영술의 유용성

이선영(Sun Young Yi),백승연(Seung Yon Back) 대한소화기학회 1996 대한소화기학회지 Vol.28 No.5

N/A Backgound/Aims: The effectiveness of magnetic resonance cholangiography(MRC) for diagnosing obstructive jaundice, as a noninvasive alternative to direct cholangiography(endoscopic retrograde cholangiopancreatpgraphy; ERCP or percutaneous transhepatic cholangiography;PTC) is studied. The goal of the study is to evaluated the level of reliability and efficacy of MRC for identifying the obstruciton site and the cause of it. Methods: Thirty two consecutive patients with obstructive jaundice are included in the study. Non-breath-hold, heavily T2-weighted, fast spin echo MRC is used to obtain; 2D-axial, coronal, and 3D-images with maximal intensity projection protocol. We evaluated all patients retrospectively by ERCP, PTC, or operation to compare the results. Results: The causes of obstruction are 13 common bile duct cancer cases, 2 pancreatic cancer cases, 8 extrahepatic duct stone cases, 3 intrahepatic duct stone cases, and 3 intra and extrahepatic duct stone cases. The level of obstruction is correctly diagnosed with MRC for 100% of common bile duct cancer and pancreatic cancer cases, 90.9% of extrahepatic duct stone cases, and 66.7% of intrahepatic duct stone cases. MRC revealed the correct causes of obstrcution for 80% of common bile duct cancer and pancreatic cancer, 81.8% of extrahepatic duct stone, and 50% of intrahepatic duct stone. Conclusions: MRC provided a accurate level of obstruction and diagnosis for common bile duct cancer, pancreatic cancer, and extrahepatic duct stone but not for intrahepatic bile duct stone. Therefore, MRC may be used with caution as a noninvasive altemative to invasive cholangiography, if not as a cornplete replacement of it. (Korean J Gastroenterol 1996; 2S:690 - 696)

원위부 총담관폐쇄증의 진단에 64-Multidetector 전산화단층촬영(MDCT) 담관조영술의 유용성

최재현,이미연,전원중,채희복,박선미,윤세진,최재운,배일헌 대한소화기내시경학회 2009 Clinical Endoscopy Vol.39 No.1

Background/Aims: The aim of this study was to evaluate the diagnostic accuracy of 64-multidetector CT (MDCT) cholangiography for determining the causes of distal common bile duct (CBD) obstruction. Methods: Two hundred fifty consecutive patients underwent 64-MDCT for diagnosing the clinical and biochemical signs of bile duct obstruction. The causes of bile duct obstruction were assessed by the pre- and post-enhanced axial and coronal multiplanar reformation images of 64-MDCT. The results were compared with ERCP, biopsy and surgery. Results: The sensitivity and specificity of MDCT for CBD stones were 96.1% and 84.9%, respectively. In seven patients, The CBD stones in 7 patients could not be detected on MDCT. Eleven patients with stones in the distal CBD, as detected on MDCT, had no stones seen on ERCP. For malignant obstruction, the sensitivity and specificity of MDCT were 97.0% and 98.6%, respectively. Three patients who were diagnosed with periampullary cancers on MDCT were disclosed to have severe papillitis on ERCP. One patient who was diagnosed with CBD stone by MDCT was disclosed to have ampullary cancer. The overall accuracy of MDCT for determining the causes of biliary obstruction was 90.5%. Conclusions: MDCT cholangiography is a non-invasive method with relatively high sensitivity and high specificity for diagnosing the causes of distal CBD obstruction. 목적: 담관 폐쇄가 의심되는 환자에게 빠른 진단을 하여 적절한 치료를 시작하는 것이 중요하다. 본 연구의 목적은 원위부 총담관 폐쇄를 일으키는 원인 질환에 대하여 64-multidetector CT (MDCT) 담관 조영술의 진단 정확도를 알아보고자 했다. 대상 및 방법: 충북대 병원을 방문한 환자들 중에서 연속적으로 임상적, 간기능 검사로 담관 폐쇄가 의심되는 252명을 대상으로 하였다. 원위부 총담관 폐쇄를 일으키는 원인 질환을 조영 전후 축상 및 관상 다면재구성 MDCT 담관 조영술로 진단하였다. 기준검사는 48시간 내에 시행한 ERCP, 생검 및 수술 결과로 정하였다. 대상 환자들의 진단은 정상(34명, 13.5%), 담관석(179명, 71.0%), 팽대부주위종양(33명, 13.1%), 양성 폐쇄 질환(2명, 0.8 %), 혈액담즙증(2명, 0.8%) 및 담관낭종(4명, 0.8%) 등이었다. 결과: 총담관석에 대한 MDCT 담관조영술의 민감도 및 특이도는 각각 96.1%, 84.9%였다. MDCT 담관조영술은 7명의 환자에서 5 mm 이하의 작은 담석을 발견하지 못하였고, 11명의 환자에서 작은 담석으로 진단하였으나 기준 검사에서 담석이 발견되지 않았다. 악성 담관 폐쇄에 대한 MDCT 담관조영술의 민감도 및 특이도는 각각 97.0%, 98.6%였다. MDCT 담관조영술로 바터팽대부 종양과 원위부 담관암으로 진단한 3명은 기준검사에서 심한 유두염으로 진단되었고, 담관석으로 진단한 1명은 바터팽대부 종양이었다. 원위부 총담관 폐쇄 질환에 대한 MDCT 담관조영술의 진단 정확도는 90.5%였다. 결론: 64-MDCT 담관조영술은 원위부 총담관 폐쇄 질환을 진단하는 민감도 및 특이도가 높은 비침습적인 검사로 담관 질환을 진단하는데 유용하게 활용할 수 있을 것으로 생각한다. 그러나 작은 담석이나 유두부 병변은 ERCP를 통한 진단이 필요한 것으로 생각한다.

Intraductal Ultrasonography without Radiocontrast Cholangiogram in Patients with Extrahepatic Biliary Disease

임성옥,박창환,기원주,이정현,류수정,박선영,김현수,최성규,유종선 거트앤리버 소화기연관학회협의회 2015 Gut and Liver Vol.9 No.4

Background/Aims: Intraductal ultrasonography (IDUS) has been performed as an adjunct to endoscopic retrograde cholangiography (ERC) during radiocontrast cholangiography (RC). Radiation exposure during RC poses a health risk to both patients and examiners. We evaluated the feasibility of IDUS without RC in various extrahepatic biliary diseases. Methods: IDUS was performed with the insertion of an IDUS probe from the papilla of Vater to the confluent portion of the common hepatic duct without fluoroscopy. The technical success rate and procedure-related complications were evaluated retrospectively. Results: Wire-guided IDUS without RC was performed in 105 patients. The mean age was 66.5 years, and 50 (47.6%) were male. The IDUS diagnoses included choledocholithiasis (73, 69.5%), benign biliary stricture (11, 10.5%), choledocholithiasis with biliary pancreatitis (9, 8.6%), bile duct cancer (5, 4.8%), pancreatic cancer (1, 0.9%), and others (6, 5.7%). After IDUS, 66 (62.8%) underwent stone removal, 19 (18.1%) underwent biliary drainage, and 7 (6.6%) underwent brush cytology and biopsy. No significant complications such as perforation or severe pancreatitis occurred. Conclusions: IDUS without RC was a feasible and safe approach in patients with various extrahepatic biliary diseases. We anticipate a potentially important role of IDUS in various ERC procedures because it lacks the hazards of RC.

담낭절제술시 경담낭관 조영술의 의의

이명복(Myung Bog Lee),이민혁(Min Hyuk Lee),허경열(Kyung Yul Hur),송영식(Young Sik Song),허경발(Kyung Bal Hur) 대한소화기학회 1994 대한소화기학회지 Vol.26 No.6

N/A The routine use of operative cystic duct cholangiography(OCDC) has been advocated by nu- merous authors. In these studies, the value of OCDC in the detection of unsuspected small stones of the common bile duct was demonstrated. The procedure also appears to be of value in reducing unnecessary exploration of the common bile duct in patients otherwise having clin- ical indications for such exploration. But opinion is divided as to whether cholangiography should be performed in all cholecystectomies or only in selected cases. To determine the clinical usefulness of routine OCDC, we analyzed 307 patients undergoing cholecystectomy with routine OCDC for gallstone disease were retrospectively screened for the presence of 8 parameters of possible choledocholithiasis. Of the 307 patients studied, 241 pa- tients(78.5%) had a negative OCDC(group I ), 22(7.1%) had false positive findings (group II), two(0.7%) had false negative findings(group III), and 42(13.7%) had findings positive for stones(group IV). In group I, 81 pat.ients(33.6%) had one or more parameter of possible choledocholithiasis. In group II, 16 patients(72.7% ) had one or more parameter. In group III, 2 patients(100%) had one or more parameter. In group IV, 5 patients(11.9%) without any positive parameter had choledocholithiasis. The sensitivity of OCDC was 95.5%, specificity 91. 4%, efficiency 92.2%, predictability of a negative test 99.2%, predictability of a positive test 65.5%, and accuracy 92.8%. Routine OCDC showed unsuspected common bile duct stones in 5 patients(2.9%). Unnecessary common bile duct explorations were avoided in 81 of the 136 pa- tients(59.5%). As a result of these findings, we recommend the use of OCDC routinely in pa- tients undergoing cholecystectomy. (Korean J Gastroenterol 1994; 26: 952 961)

영아기 담즙정체성 황달 질환 중 담도폐쇄증의 조기 배제 진단

최병호,Choe, Byung-Ho 대한소아소화기영양학회 2011 Pediatric gastroenterology, hepatology & nutrition Vol.14 No.2

The persistence of jaundice beyond the first 2 weeks of life require further investigation and this can be determined if the conjugated bilirubin levels are greater than 1.5 mg/dL or greater than 20% of the total bilirubin level. There is a diverse differential diagnosis for the cause of neonatal cholestasis due to hepatobiliary disease including biliary atresia, which eventually leads to liver cirrhosis if uncorrected before 60~80 days of life. Long-established initial studies include abdominal ultrasonography, hepatobiliary scintigraphy and liver biopsy, but better diagnostic methods are needed. Promising new options are described including MRCP (magnetic resonance cholangiography), ERCP (endoscopic retrograde cholangiography), and PCC (percutaneous cholecysto-cholangiography). Though no single test can differentiate biliary atresia from other neonatal cholestasis with confidence, a combination of diagnostic methods is usually consistently beneficial. By excluding biliary atresia as early as possible, the risk of unnecessary explolaparotomy with intraoperative cholangiography is decreased. Further evaluation would be required for the diagnosis of neonatal cholestasis after excluding biliary atresia.