Mirizzi 증후군의 변형된 분류와 치료

김형철,강길호,채만규,김성용,백무준,이문수,박상흠,이문호,김창호,송옥평,조무식,박희주 순천향의학연구소;Soonchunhyang Medical Research Institute 2000 Journal of Soonchunhyang Medical Science Vol.6 No.1

Purpose : The Mirizzi syndrome is relatively rare and preoperative diagnosis of this disease is difficult. In 1978, Morelli suggested the subclassification of the Mirizzi syndrome into acute or chronic form. We experienced 5 cases of acute form. We analysed clinical features, preoperative radiologic findings and operative findings of 18 cases including acute forms which were diagnosed as Mirizzi syndrome and should suggest the modified classification of Mirizzi syndrome for choice of appropriate treatment. Method : From January 1995 to December 1998, 18 cases, of which 8 cases were diagnosed at Soonchunhyang University Chunan Hospital, and 10 cases were reported in the Korean Journal were retrospectively analysed with regard to clinical features, preoperative radiologic findings and operative findings. According to the clinical features, whole cases were divided into type Ⅰ(acute form) and type Ⅱ(chronic form) and then each type of cases were subclassified according to preoperative radiologic findings and operative findings. Results : Of 18 cases there were 5 cases in type Ⅰ(27.8%), 13 cases in type Ⅱ(72.2%). Type Ⅱb was most common. Type Ⅰa cases were treated only with cholecystectomy. We applied cholecystectomy, T-tube choledochostomy and patch technique in type Ⅰb and thpe Ⅰc cases. Cholectystectomies including removal of gallstones and internal drainage procedures were done in type Ⅱ chronic forms. Conclusion : The acute form(Type Ⅰ) of Mirizzi syndrome was suggested by Morelli might be subclassified into typeⅠa,Ⅰb and Ⅰc following the presence of the necrotic defect in common hepatic duct. Through the modified classification of Mirizzi syndrome based on clinical feature, preoperative radiologic findings and operative findings, we can choice appropriate treatment.

췌십이지장절제술 후 발생한 담즙누출의 치료

김태윤,김성용,백무준,이문수,조무식,김창호 순천향의학연구소 2004 Journal of Soonchunhyang Medical Science Vol.10 No.1

Operative morbidity and mortality of pancreaticoduodenectomy has been decreasing but remains high. Unintended postoperative cutaneous biliary fistula involving the major bile ducts is an uncommon complication of pancreaticoduodenectomy. Prolonged biliary drainage may lead to severe metabolic disturbances, renal failure and cardiovascular collapse, and usually requires operative reintervention. Among 90 patients who underwent pancreaticoduodenectomy from Feb. 1992 to Dec, 2000, 70 patients whose hospital records could be reviewed were included in this study. Cutaneous biliary fistula were observed in 19 cases(27.1%). In the 14 cases, a biliary drain was inserted around the injured duct via the biliocutaneous fistula. In these cases, biliary drainage alone resulted in resolution of the bile leak, because the injury was partial without a stricture. In the 5 cases, biliary stents were placed percutaneously across the injured portion of the bile duct. Pancreaticoduodenectomy is still associated with high mortality and morbidity even though there has been significant progress in the field of pancreatic surgery and postoperative follow-up. In the absence of organic stenosis, percutaneous drainage approach may be useful in patients with postoperative biliocutaneous fistula.

섬유층판 간세포암 1례

김태윤,김성용,백무준,이문수,조무식,김창호 순천향의학연구소 2004 Journal of Soonchunhyang Medical Science Vol.10 No.2

Fibrolamellar hepatocellular carcinoma is a distinct variant of ordinary hepatocellular carcinoma and is very rare in the Orient. Contrary to ordinary hepatocellular carcinoma, Fibrolamellar hepatocellular carcinoma has very good prognosis and usually occurs in adolescents and young adults without sexual preference. We report a case of fibrolamellar hepatocellular carcinoma, which occurred in a 79-year-old woman with normal liver function. Preoperative ultrasonography, computed tomography and magnetic resonance imaging depicted a large tumor in the right anterior and left madial segment, which was compatible with the typical radiological features of fibrolamellar hepatocellular carcinoma. she underwent central bisegmentectomy. Macroscopic findings of the resected liver demonstrated a well-defined whitish-yellow tumor with a central scar. Microscopic findings of the tumor showed cords of tumor cells, which were surrounded by abundant collagenous fibrous tissue arranged in a lamellar distribution. Two years later, she is asymptomatic and evidences no recurrence of the disease. The clinical, pathological, radiological features, treatment options and prognoses of fibrolamellar carcinoma were discussed.

간 세포암에서 VEGF, TGF-β1, b-FGF 발현의 의의

김성용,남충현,주종우,채만규,백무준,이문수,김형철,안현철,김홍수,김창진,김창호 순천향의학연구소 2001 Journal of Soonchunhyang Medical Science Vol.7 No.1

Purpose: Angiogenesis is important for the proliferation and the metastasis of solid tumors. The growth of a solid tumor is widely recognized to depend on the process of neovascularrozation. Without angiogenesis, tumors cease to grow beyond even a few milimeters in diameter. It has been shown that tumor vascular density is an independent prognostic marker in several types of human tumors and is known to correlate with poor prognosis. To date, many angiogenic factors have been identified, such as transforming growth factor-α(TGF-α), transforming growth factor-β(TGF-β), fibroblast growth factor family(FGF), vascular endothelial growth factor(VEGF), platelet derived endothelial cell growth factor(PD-ECGF), tumor necrosis factor-α(TNF-α), and angiogenin. Hepatocellular carcinoma(HCC) is the second most common tumor in Korean males and is known as a typical hypervascular tumor with frequent portal vein invastion. The authors identified the expreesion of VEGF, TGF-β1, and b-FGF in HCC specimens and evaluated the relationship between these growth factors and the clinicopathologic characteristics of HCC. Method: We reviewed the medical records of 30 patients who were diagnosed as hepatocellular carinoma treated with hepatic resection between January 1994 and December 1998 in Soonchunhyang University Chunan Hospital. The selection of the cases was decided according to the condition of paraffin block fixation. The prognostic factors such as age, sex, tumor size, concentration of serum α-fetoprotein, presence of liver cirrhosis, presence of tumor emboli in portal vein, TMN stage, amount of transfusion during the operation, hepatitis B virus(HBV) infection, and Edmonson-Steiner(E-S) grade were investigated. Relationship between the prognostic factors and the immunopathologic expression of the TGF-β1, b-FGF, and VEGF was examined. Result: Thirty patients (24 males, 6 females) were included in the current study. The patient's mean age was 50.6 years and the age ranged from 36 to 65 years. The mean size of the tumor was found to be 5.2cm. All the patients were follewed up for 7 to 63 months. Child's classification A patients were 23(76.7%)cases, B patients were 7(23.3%)cases, and C was none. Immunohistochemical staining of HCC tumor mass in VEGF expression patients were 17(56.7%), b-FGF expression patients were 10(33.3%), and TGF-β1 expression patients were 10(33.3%). VEGF expression or more than one positive expression among the three factors correlated with tumor size and the stage of HCC but did not correlated with other clinicopathological characteristics. TGF-β1 and b-FGF did not correlate with any clinicopathological characteristics. Conclusion: The results suggest that the expression of VEGF or more than one positive expression among the three factors in HCC cells may be a significant prognostic factor of HCC.

간절제술 후 발생한 기관지 담도 누공 2예

김태윤,김성용,백무준,이문수,조무식,김창호 순천향의학연구소 2004 Journal of Soonchunhyang Medical Science Vol.10 No.2

A bronchobiliary fistula (BBF), which is defined by an abnormal communication between the biliary system and the bronchial tree, is an uncommon complication after hepatic resection, trauma, hydatid disease, choledocholithiasis and other causes of biliary obstruction. Bronchobiliary fistulae are rare complications of hepatic resection that can present from days to years after operation. Endoscopic retrograde cholangiopancreatography and PTC are the diagnostic studies of choice and offer the possibility of therapeutic intervention. We report the cases of a 56-year-old woman with cholangiocarcinoma, who developed a BBF 7 months after right hepatic lobectomy and 64-year-old man with intrahepatic duct stones who underwent hepatic resection.

수술 전 고빌리루빈혈증 환자에서 췌십이지장 절제술의 안정성

김태윤,김성용,백무준,이문수,조무식,김창호 순천향의학연구소 2004 Journal of Soonchunhyang Medical Science Vol.10 No.1

Backgrounds: Pancreaticoduodenectomy is accompanied by a considerable risk of postoperative complication and potential death. Pancreaticoduodenectomy in patient with obstructive jaundice carry on increased risk of postoperative complication. Preoperative biliary drainage has been developed to reduce this morbidity and mortality but the benefit of preoperative biliary drainage is still questioned for several reasons. This study evaluated postoperative outcomes following pancreaticoduodenectomy in relation to patients with hyperbilirubinemia. Methods: Ninety two patients who underwent pancreaticoduodenectomy between 1992 and 2001 were divided into two groups. Group A included 11 cases in patient with preoperative hyperbilirubinemia (serum bilirubin > 10 mg/dl), and the other 81 cases (serum bilirubin < 10 mg/dl) were Group B. In group A, 6 patients underwent preoperative biliary drainage. In group B, 31 patients underwent preoperative biliary drainage. Postoperative morbidity and mortality were anlaysed comparing with two groups by chi-squared test retrospectively. Results: In group A, whose average value of serum bilirubin was 15.2 mg/dl (range 10.2-20.3 mg/dl), wound complications were seen in 9.0%, hemorrhage in 18.1%, delayed gastric empting in 18.1%, anastomosis leakage in 18.1%, abscess in absent, and mortality in 9%. In group B, whose average value of serum bilirubin was 2.3 mg/dl (range 0.8-7.3 mg/dl), wound complications were seen in 14.8%, hemorrhage in 8.6%, delayed gastric empting in 9.8%, anastomosis leakage in 22.1%, abscess in 4.9%, and mortality in 4.9%. There was no significant difference in morbidity and mortality between two groups. Conclusion: Preoperative hyperbilirubinemia did not influence the incidence of postoperative outcomes following pancreaticoduodenectomy. It can be performed safely in patient with hyperbilirubinemia.

간세포암에서 중앙 2구역 절제술의 유용성

김태윤,김성용,백무준,이문수,조무식,김창호 순천향의학연구소 2004 Journal of Soonchunhyang Medical Science Vol.10 No.1

Liver resection for hepatocellular carcinoma(HCC) is now popular. For treatment of centrally located hepatocellular carcinoma, central bisegmentectomy is recommended as a radical surgical procedure and may have an important advantage. Five patients with HCC underwent central bisegmentectomy with an operating time of 380-420 minutes. One patient who had undergone preoperative live artery embolization died by car accident. Four patients survived without relapse 13-35 months postoperatively. Central bisegmentectomy is a safe and effective operative procedure for the treatment of centrally located HCC.

조기위암 천공 1예

이문수,김태윤,김성용,백무준,김창호,조무식 순천향의학연구소;Soonchunhyang Medical Research Institute 2004 Journal of Soonchunhyang Medical Science Vol.10 No.2

An exceedingly rare case of perforated early gastric cancer is reported. A 68-year-old man developed a peritonitis due to perforation of early gastric cancer. Emergency radical operation was performed and followed by uneventful recovery. The histologic examination of the surgical specimen showed early gastric cancer of typeⅢ, composed signet ring cell carcinoma. 5 years of surgery, the patients survived with no evidence of tumor recurrence. The rarity of this complication in early gastric cancer is discussed and the literature reviewed.

위 MALT 림프종에서 다발성 림프절 전이로 오인된 동시성 림프절 결핵 1예

김성은,김규종,김도현,송준영,문대성,장리라,유찬희,문원,박무인,박선자,김영옥 고신대학교의과대학 2008 고신대학교 의과대학 학술지 Vol.23 No.2

28세 남자가 내시경적 점막절제술을 통해 저등급 위MALT 림프종으로 진단되었다. 병기설정을 위해 18F-FDG PET 검사를 시행하였고 우측 쇄골상부, 우측상/하부 기관주위, AP window 부위에 강한 섭취가 관찰되어 전이성 림프절로 판단하였다. 그러나, 우측 쇄골상부 림프절에서 시행한 절제생검에서 만성육아종성염증소견이 관찰되었고 조직의 결핵 중합효소연쇄반응에서도 양성 반응을 보였다. 2개월간 항결핵제의 사용 후 시행한 추적 컴퓨터단층촬영 검사에서 림프절 크기의 감소를 보여 최종적으로 위 MALT 림프종에서 광범위 림프절 전이로 오인된 동시성 림프절 결핵으로 진단되었다. A 28-year-old man was diagnosed as gastric MALT lymphoma in diagnostic EMR (endoscopic mucosal resection). He subsequently underwent an 18F-FDG PET. 18F-FDG PET showed intense multifocal uptake in right supraclavicular, right upper and lower paratracheal, and AP window areas that was considered radiologically to represent widespread metastatic lymphadenopathy. Excisional biopsy of a supraclavicular lymph node, however, revealed chronic granulomatous lymphadenitis with a positive reaction of Tb-nested PCR. After antituberculosis treatment for 2 months, a follow-up CT scan showed complete resolution of the lesions. Intense 18F-FDG uptake could be due to an infectious process such as synchronous tuberculous lymphadenitis. Therefore, this could mimic a malignant condition such as lymphoma with extensive lymph node metastasis due to a false-positive finding, which may lead to a misdiagnosis.

위암으로 오인된 악성 흑색종 수술 1 예 : A case report

이문수,김태윤,김성용,백무준,김창호,조무식 순천향의학연구소;Soonchunhyang Medical Research Institute 2004 Journal of Soonchunhyang Medical Science Vol.10 No.2

The malignant melanoma matastatic to the stomach is a rare tumor. Its treatment is controversial and median survival after diagnosis is usually <1year. Here a case of malignant melanoma metastatic to the stomach is reported in a 77 years old woman who presented with epigastric discomfort for three months, and was diagnosed as ademocarcinoma at preoperation. The patient was performed subtotal gastrectomy, gastroduodenostomy, omentectomy, and was discharged with no complication on the twenty-one posoperation day. We report a case of malignant melanoma metastatic to the stomach with a review of the literature.