침형 절개도를 이용한 유두 예비절개술 후 발생되는 급성 췌장염 발생에 있어서의 위험 인자 분석 = Risk Factors for Post-ERCP Pancreatitis after Needle Knife Sphincterotomy following Repeated Probing

다국어 초록 (Multilingual Abstract)

Background/Aims: Needle knife sphincterotomy (NKS) following repeated probing due to difficult cannulation during ERCP increase the risk of post-ERCP pancreatitis. However, the risk factors for post-ERCP pancreatitis are not well-known. The aim of this study is to investigate the incidence and risk factors of post-ERCP pancreatitis in patients who underwent NKS. We also evaluated the effect of gabexate on the prevention of post-ERCP pancreatitis. Methods: Medical records from a total of 200 patients who underwent NKS following repeated probing during ERCP were reviewed retrospectively. The potential risk factors for post-ERCP pancreatitis were investigated. The effect of gabexate infusion after ERCP procedure on the incidence of post-ERCP pancreatitis was also evaluated. Results: A total of 13 (6.5%) patients out of 200 patients developed post-ERCP pancreatitis. Gender, age, the presence of pancreatitis at procedure, underlyng disease, direction of sphincterotomy, success or failure of cannulation, diameter of CBD, pancreatic duct status and the presence of acinar filling were proved unrelated with pancreatitis. Post-ERCP pancreatitis developed in 9 out of 38 (23.7%) when gabexate was given, while 4 out of 160 (2.5%) experienced pancreatitis without administration of gabexate. Conclusions: We couldn't determine any risk factor for pancreatitis in patients who underwent NKS following repeated probing during ERCP. The gabexate infusion after ERCP procedure might be associated with the increased risk of pancreatitis. (Korean J Gastrointest Endosc 2006;32:266-270)

국문 초록 (Abstract)

목적: 내시경 역행성 담췌관조영술(ERCP)을 시도하면서 삽관이 어려워 반복적인 삽관 시도 후에 침형절개도를 이용한 유두 예비절개술(precut papillotomy)을 시행하는 경우 췌장염 발생이 높아진다. 그러나 이 경우 어떤 요인에 의해 췌장염이 잘 일어나는지 그 위험 인자에 대해서 아직 잘 밝혀지지 않은 상태이므로 본 연구에서는 이러한 환자들을 대상으로 하여 췌장염의 발생 빈도를 알아보고 그 위험 인자를 분석하였다. 또한 ERCP 시행 직후 투여하는 gabexate가 췌장염 예방에 효과가 있는지 살펴보았다. 대상 및 방법: 1998년 9월부터 2004년 5월까지 ERCP 도중 삽관이 어려워 침형절개도를 이용하여 유두 예비절개술을 시행 받은 환자들을 대상으로 급성 췌장염 발생 여부를 조사하였다. 급성췌장염의 발생에 성별, 나이, 급성 췌장염의 과거력, 원인 질환, 절개 방향, 절개 후 삽관 성공 여부, 총담관 직경, 췌관의 이상 여부, 췌선방 조영충실 발생 여부 등의 인자가 췌장염의 발생에 영향을 미치는지를 분석하였다. 또한 ERCP 시행 후 gabexate가 투여된 군과 투여되지 않은 군 사이의 급성 췌장염의 발생 빈도의 차이를 살펴보았다. 결과: 반복적 삽관 시도에 이어 침형절개도를 사용한 예비절개술을 시행 받은 대상 환자 200명 중 13명(6.5%)에서 시술 후 급성 췌장염이 발생하였고 위험인자 분석 결과 통계적으로 유의한 위험 인자는 발견되지 않았다. ERCP 시행 후 gabexare가 투여된 38명 중 9명(23.7%)에서 췌장염이 발생한 반면, 투여되지 않았던 160명 중 4명(2.5%)에서 췌장염이 발생하였다. 결론: ERCP 시술 중 반복적 삽관 시도에 이어서 침형절개도를 사용한 예비절개술을 시행하는 경우에 시술 후 급성 췌장염의 발생을 예측할 수 있는 위험 인자는 발견할 수 없었으며 ERCP 시행 후 투여된 gabexate의 췌장염에 대한 예방 효과는 확실하지 않았다.

참고문헌 (Reference)

• 1 "What are the risks of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography?" 70 : 778-782, 2000
• 2 "Risk factors for post-ERCP pancreatitis" 54 : 425-434, 2001
• 3 "Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography" 35 : 830-834, 2003
• 4 "Risk factors for complications after performance of ERCP" 56 : 652-656, 2002
• 5 "Protease-activated receptors" 21 : 103-108, 2000
• 6 "Protease-activated receptor 2 exerts local protection and mediates some systemic complications in acute pancreatitis" 126 : 1844-1859, 2004
• 7 "Prevention of post-ERCP pancreatitis" 51 : 100-103, 2000
• 8 "Predictors of post-ERCP complications in patients with suspected choledocholithiasis" 30 : 457-463, 1998
• 9 "Precut papillotomy--a risky technique for experts only" 35 : 578-579, 1989
• 10 "Post-ERCP pancreatitis and hyperamylasemia" 34 : 286-292, 2002
• 11 "Pharmacological prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis" 63 : 1799-1812, 2003
• 12 "Pharmacologic treatment can prevent pancreatic injury after ERCP" 51 : 1-7, 2000
• 13 "Needle-knife papillotomy revisited" 46 : 282-284, 1997
• 14 "Needle-knife access papillotomy" 28 : 365-366, 1996
• 15 "Major early complications from diagnostic and therapeutic ERCP" 48 : 1-10, 1998
• 16 "Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry (SOM)" 94 : 387-390, 1999
• 17 "Gabexate or somatostatin administration before ERCP in patients at high risk for post-ERCP pancreatitis" 56 : 488-495, 2002
• 18 "Gabexate for the prevention of pancreatic damage related to endoscopic retrograde cholangiopancreatography" 335 : 919-923, 1996
• 19 "Endoscopic sphincterotomy-induced pancreatitis:increased risk associated with nondilated bile ducts and sphincter of Oddi dysfunction" 89 : 327-333, 1994
• 20 "Endoscopic papillotomy for common bile duct stones:factors influencing the complication rate" 26 : 209-216, 1994
• 21 "ERCP and biliary endoscopic sphincterotomy-induced pancreatitis" 8 : 87-114, 1998
• 22 "Delayed onset of inflammation in protease-activated receptor-2-deficient mice" 165 : 6504-6510, 2000
• 23 "Complications of endoscopic sphincterotomy.A prospective series with emphasis on the increased risk associated with sphincter of Oddi dysfunction and nondilated bile ducts" 101 : 1068-1075, 1991
• 24 "Complications of endoscopic biliary sphincterotomy" 335 : 909-918, 1996
• 25 "Complications of diagnostic and therapeutic ERCP" 96 : 417-423, 2001
• 26 "Bedside scoring system to predict the risk of developing pancreatitis following ERCP" 34 : 483-488, 2002
• 27 "Analysis of the risk factors associated with endoscopic sphincterotomy techniques" 32 : 10-19, 2000
• 28 "A clinically based classification system for acute pancreatitis Summary of the International Symposium on Acute Pancreatitis September 11 through 13" 586-590, 1992