침형 유두절개술시 체관내인공관의 임상적 유용성 = Biliary Tract & Pancreas;The Needle-Knife Sphincterotomy over Pancreatic Stent:A Safe and Effective Technique?

다국어 초록 (Multilingual Abstract)

Background/Aims: Needle-knife sphincterotomy (NKS) is an alternative technique to EST when selective bile duct cannulation can not be achieved with a variety of techniques or accessories. The risk of post-procedure pancreatitis is high, however, when papillary edema, sphincter of Oddi spasm, and the resulting restriction of pancreatic juice flow are induced by both mechanical injury associated with repeated cannulation attempts and possible burn injury due to NKS itself. Recently, nasopancreatic drainage and pancreatic stenting were suggested to be effective in preventing pancreatitis in patients with high risk of postprocedure pancreatitis and in patients who underwent NKS, respectively. The purpose of this study is to evaluate the role of pancreatic stenting on the clinical outcomes in patients with high risks of postprocedure pancreatitis who undergo NKS. Methods: Of the 119 patients who had undergone NKS, pancreatic stenting with 2-4 cm, 7Fr polyethylene biliary stent was performed prior to NKS in 13 patients (pancreatic stent group), and an incision was begun without pancreatic stenting at the papillary roop avoiding trauma of the papillary orifice and thus, reducing the risks of pancreatitis in 15 patients (control group). Both groups were at high risks of pancreatitis associated with repeated, unsuccessful bile duct cannulation attempts. In the two groups, the success rate of bile duct cannulation and the incidence of pancreatitis were analyzed and compared. Results: 1) The mean age was 57.1 years in pancreatic stent group and 54.6 years in control group, and the sex ratio of men to women was 5:8 and 9:10, respectively. 2) The most common risk factors for post-procedure pancreatitis, such as the use of needle-knife sphincterotomy, repeated cannulation, and any pancreatography, were present in 100% of both pancreatic stent group and contral group. This was followed by papillotome cannulation and/or guide wire trauma in 76.9% and 13.3% of the groups, respectively, pain on pancreatography in 30.7% and 6.7%, and a history of pancreatitis and submucosal injection of contrast agents in 15.4% of pancreatic stem group only. Overall, the total number of risk factors was at least 3 in 100% of both pancreatic stent group and control group, at least 4 in 76.9% and in 13.3%, at least 5 in 30.7% .and in 6.7%, respectively, and at least 6 in 15.4% of pancreatic stent group only. 3) Major papillas were unusually small and flat in 53.8%, prominent in 46.2% of pancreatic stent group, but prominent in 86.7 % and normal in 13.3 % of control group. After successful cholangiography, the common diagnosis was malignant stricture of distal CBD (38.4%), followed by CBD stones) (30.8%) in pancreatic stmt group, whereas CBD stones) (53.3%), followed by malignant stricture of distal CBD (20.0%) were found in control group. The diameter of CBD was normal ( $lt; 8 mm) in 69.2 % and dilated in 30.8 % of pancreatic stent group, but dilated in 73.3% and normal in 26.7% of control group. 4) The success rate for bile duct eannulaton at initial attempt was higher in pancreatic stmt group than control group (100% vs 80.0%), but not statistically significant. The incidence of post-procedure pancreatitis was 0% in pancreatic stent group and 6.7% in control group. Minor bleeding occurred in 1 patient of both groups. 5) The common endoscopic procedures after NKS were biliary drainage for malignant obstructions in 38.4% of pancreatic stent group and 33.5% of control group, and stone extractions for CBD stones) were in 30.8% and 46.7%, respectively. NKS was used for diagnosis only in 7.7% of pancreatic stent group and 13.3 % of control group. Conclusions: Pancreatic stenting prior to NKS may improve success rate of NKS and prevent acute pancreatitis in patients with high risks of post-ERCP pancreatitis. Further studies with larger numbers of patients are required before the usefulness of pancreatic stenting can be fully evaluated.