비절제 위암의 원인분석-전산화단층촬영(CT) 소견을 중심으로

윤혁진,신정혜,김갑철,유완식,정호영,Yoon, Hyuk-Jin,Shin, Jung-Hye,Kim, Gab-Chul,Yu, Wan-Sik,Chung, Ho-Young 대한위암학회 2006 대한위암학회지 Vol.6 No.4

목적: 위암으로 개복 후 절제 불가로 판단된 환자들에서 수술 전 병기가 낮게 판단된 원인을 조사하여 향후 정확한 병기 결정에 도움을 얻고자 하였다. 대상 및 방법: 2001년 8월에서 2005년 7월까지 경북대학교병원에서 개복술을 받은 위암 환자 중 절제가 가능하지 않아 폐복한 25예의 환자를 대상으로 하였다. 환자들의 수술 전 임상 병리학적 특성과 영상 소견을 수술소견과 비교하였고 비절제의 원인을 환자 인자, 기계 인자, 판독 인자로 분류하였다. 수술 전 전산화단층촬영(CT)은 2명의 방사선과 전문의가 독립적으로 판독 후 합의하였다. 결과: 전체 환자의 수술 전 병기는 Ib 3예, II 6예, IIIa 7예, IIIb 5예, IV 4예였고 육안형은 Borrmann III형 12예, IV형 13예였으며 조직학적 분류는 고분화형 1예, 중분화형 7예, 저분화형 8예, 인환세포암이 7예, 그리고 조직학적으로 분류되지 않은 경우가 2예였다. 수술에서 인접 장기 직접 침범이 확인된 경우는 25예 중 13예(52%)였으며, 침범된 장기로는 췌장 9예(36%), 간 3예(12%), 총담관 3예, 문맥 2예(8%), 횡행결장 2예(8%), 공장 2예(8%), 담낭 1예(4%)였다. 복막파종이 17예(68%), 원격 림프절 전이가 3예(12%)에서 있었다. 비절제의 원인을 본 결과 환자인자에서는 복강 내 지방 조직의 결핍으로 인해 인접장기 침범이나 복막 침범을 진단할 수 없었던 경우가 4예(16%)였다. 기계인자로는 두꺼운 스캔 절편(10 mm)으로 인해 인접장기 침범을 놓친 경우가 3예(12%), 외부 CT 필름의 불충분한 해상도로 인한 경우가 3예(12%), 이전 바륨 검사에 의한 잔존 바륨의 beam harding artifact로 복막파종을 놓친 경우가 2예(8%), 경구 조영제가 미충만된 위장관과 인접 전이성 결절을 오인한 경우가 1예(4%)였다. 판독인자로는 인접 장기와의 지방면 소실을 간과한 경우가 10예(40%), 경미한 복막비 후나 파종을 간과한 경우가 6예(24%), 장간막의 림프절 종대를 간과한 경우가 3예(12%)였다. 결론: 복강 내 지방 조직의 결핍, 불충분한 해상도의 CT, 판독 과정에서 경미한 복막파종이나 인접 장기와의 지방면 소실의 간과 때문에 CT에 의한 수술 전 병기결정의 정확도가 떨어지며 그 중 판독인자에 의한 것이 가장 많은 원인이 되므로 적절한 영상 관리와 함께 세심한 판독이 매우 중요하겠다. Purpose: The aim of this study was to investigate the causes of under-staging in patients with advanced gastric cancer that was proven to be unresectable after a laparotomy. Materials and Methods: We retrospectively analyzed 25 gastric cancer patients who had undergone a diagnostic laparotomy between 2001 and 2005. For the preoperative evaluation, spiral CT and multidetector-row CT were performed. We analyzed the clinicopathologic features of patients and compared the image findings and the results of surgery. The causes of under-staging were divided into 3 groups; patient factor, CT factor, and interpretation factor. Results: Grossly, there were 12 cases of Borrmann type-III tumors and 13 cases of Borrmann type-IV tumors. The most frequent histologic type was poorly differentiated adenocarcinomas (8 cases) and signet ring cell carcinomas (7 cases). There were 13 cases of adjacent organ invasion, and the pancreas was the most frequently invaded organ (9 cases). There were 17 cases of peritoneal metastasis, and 3 cases of distant lymph node metastasis. For the cause of under-staging, there were four cases of patient factor, 19 cases of interpretation factor, and 9 cases of CT factor. In three cases, the cause of under-staging could not be identified. Conclusion: CT interpretation factor was the most frequent cause of under-staging in the preoperative diagnosis with gastric cancer patients. Therefore, more cautious CT interpretation is necessary to avoid unnecessary laparotomies in gastric cancer patients.

비신생물성 질환에 대한 췌십이지장 절제술의 안정성 및 수술 후 삶의 질에 대한 평가

은영아(Young A Eun),김상걸(Sang Geol Kim),윤혁진(Hyuk Jin Yun),김종렬(Jong Yeol Kim),김갑철(Gab Chul Kim),염현규(Hyun Kyu Ryeom),김성희(Sung Hi Kim),황윤진(Yun Jin Hwang),윤영국(Young Kook Yun) 대한외과학회 2007 Annals of Surgical Treatment and Research(ASRT) Vol.73 No.1

Purpose: Pancreaticoduodenectomy for mass-like lesions that are suspicious of malignancy sometimes reveals only nonneoplastic disease, especially in those cases where adequate tissues for biopsy are unavailable. In this study, we evaluated the outcomes and quality of life (QOL) after pancreaticoduodenectomy for treating nonneoplastic disease. Methods: The clinical data of 28 patients who underwent pancreaticoduodenectomy for nonneoplatic disease and trauma from Jan. 1992 to Feb. 2006 were reviewed retrospectively. The QOL was evaluated using the FACT-Hep questionnaire. The patients who underwent laparoscopic cholecystectomy for benign gallbladder disease were utilized as the control group. Results: 13.8% (28/203) of all the pancreaticoduodenectomized patients had nonneoplatic disease and trauma. Male patients were predominant (25/28) and all the trauma patients were male. The mean age was 48 (23∼72) years old. The indications for surgery included lesions suspicious for malignancy (16 cases), pancreaticoduodenal artery aneurysm (1 case), and pancreatoduodenal injury (11 cases). The histologic findings of the nonneoplastic lesions revealed benign inflammation of the bile duct (6 cases), chronic pancreatitis (8 cases), pancreatic pseudocyst (1 case), and fibrosis of the Ampulla of Vater (1 case). No surgical mortality occurred. However, the trauma patients group had higher morbidity (72.7% Vs 23.5%, respectively, P=0.01) and a longer hospital stay (68.0 days Vs 32.6 days, respectively, P=0.02) after surgery compared to the nonneoplastic disease patient group. The QOL of the patient who underwent pancreaticoduodenectomy for nonneoplatic disease was not different from that of the control group. Conclusion: Since pancreaticoduodenectomy for nonneoplastic disease was safe and the QOL of the patients was acceptable, it should be performed more often when malignancies can not be excluded from the differential diagnosis.

복강 내 결핵성 농양의 CT 소견과 임상경과

하창윤 ( Chang Yoon Ha ),김종열 ( Jong Yeol Kim ),김갑철 ( Gab Chul Kim ),염헌규 ( Hun Kyu Ryeom ),김혜정 ( Hye Jung Kim ),이희중 ( Hui Joong Lee ),강덕식 ( Duk Sik Kang ) 대한내과학회 2008 대한내과학회지 Vol.74 No.3

목적: 복강 내 결핵성 농양은 매우 드물지만 다양한 양상으로 발병하기 때문에 암성 복막염과의 감별이 쉽지 않다. 이 연구에서는 복강 내 결핵성 농양의 CT 소견과 임상경과에 대하여 후향적으로 분석해 보고자 하였다. 방법: 수술 혹은 조직 생검을 통해 병리학적으로 복강 내 결핵성 농양으로 확진되고 CT를 시행한 11명의 환자(남자 3명, 여자 8명, 평균 34.8세, 21~66세)를 대상으로 하였으며, 25 CT와 의무기록을 후향적으로 분석하였다. 평균 추적기간은 15개월(12~32개월)이었다. 결과: 11명의 환자에서 16개의 농양이 발견되었고, 이들 중 4개(25%)의 농양은 우측 간주위 공간, 4개(25%)는 좌측 간주위 공간, 3개(19%)는 비장주위 공간, 2개(13%)는 좌측 횡경막하 공간에 있었으며 우측 횡경막하 공간과 우하복부공간, 좌하복부 공간에 각각 1개씩 있었다. 농양의 크기는 1~8 cm(평균, 4 cm)이었으며, 농양의 모양은 12개가 난원형이었고, 4개는 구형이었다. 농양벽의 두께는 1~5 mm(평균, 3 mm)이었다. 16개의 농양 모두에서 농양벽이 얇고, 조영증강되었으며 농양벽 석회화는 보이지 않았으며 12개에서 내부의 격벽이 보였다. 림프절 종대가 2명, 복막의 비후와 대망 혼탁의 소견이 3명에서 있었으며 액체 저류의 소견은 모두 없었다. 복막의 조영증강 소견은 6개의 농양에서 보였다. 동반된 다른 장기의 결핵 이환은 4명에서 발견되었는데, 결핵성 흉막염 2명, 폐결핵과 장염 1명, 폐결핵과 경부 림프절 결핵 1명이었다. 11명 중 5명은 결핵의 병력이 없었으며 농양이 결핵의 일차 병변이었으며 6명은 결핵성 복막염으로 치료 중인 환자로 농양이 역설반응으로 생긴 새로운 병변이었다. 역설반응으로 진단된 6명의 농양 발현 시기는 치료 후 66~116일(평균, 88일)이었다. 모든 환자는 6~12개월동안 항결핵제 치료를 하였으며, 5명은 수술을 하였고, 모두 완치되었다. 추적기간은 12~32개월(평균, 15개월)이었다. 결론: 복강 내 결핵성 농양은 복부 결핵의 일차 병변 또는 결핵성 복막염의 역설반응으로 생길 수 있으며, 상복부 공간에 위치하는 다양한 크기의 조영증강되는 얇은 벽을 가진 낭성 병변의 소견을 보인다. Background/Aims: Intraperitoneal tuberculous abscesses develop infrequently. Because of overlapping features it is difficult to differentiate a tuberculous abscess from carcinomatosis peritonei. The aim of this study was to define the computed tomography (CT) findings and clinical course of the intraperitoneal tuberculous abscess. Methods: The study included 11 patients (3 males, 8 females, mean age 34.8 years) with a pathologically proven intraperitoneal tuberculous abscess. We analyzed the CT findings and reviewed the medical records retrospectively. Results: Sixteen abscesses were found in 11 patients. The locations of the abscesses were in the right subphrenic space (n=1), right perihepatic space (n=4), left perihepatic space (n=4), left subphrenic space (n=2), perisplenic space (n=3), right lower abdominal space (n=1), and left lower abdominal space (n=1). Five patients were proven to have abdominal tuberculosis while six patients had paradoxical responses to antituberculosis therapy for tuberculous peritonitis. The abscess lesions presented on the CT scan as thin walled cystic enhancing lesions without calcification (n=16), a septated mass (n=12), with enlargement of lymph nodes (n=2), and peritoneal and omental haziness (n=3). The mean duration from commencement of treatment to onset of a paradoxical response was 88 days. All patients had antituberculosis therapy for 6 to 12 months and five patients underwent surgery. The mean follow-up was 15 months. Conclusions: The intraperitoneal tuberculous abscess appeared as an ovoid cystic lesion with a slightly enhanced thin wall in the upper abdomen, in the perihepatic space on the CT scan; such as lesion can be the primary lesion of abdominal tuberculosis or associated with the paradoxical response of tuberculous peritonitis. (Korean J Med 74:243-249, 2008)

주 담도 침습을 동반한 간세포암에서 간동맥 화학 색전술 후 성공적인 치료를 보인 폐쇄성 황달

류정훈 ( Chung Hoon Yu ),박정길 ( Jung Gil Park ),김규영 ( Gyu Young Kim ),황희영 ( Hee Young Hwang ),정민규 ( Min Kyu Jung ),배한익 ( Han Ik Bae ),김갑철 ( Gab Chul Kim ),조창민 ( Chang Min Cho ) 대한췌장담도학회 2014 대한췌담도학회지 Vol.19 No.1

Biliary invasion by hepatocellular carcinoma (HCC) is much less common. Patients manifest obstructive jaundice as the initial complaint, but most of them are inoperable. We report a case of completely improved biliary invasion in HCC after transcatheter arterial chemoembolization (TACE). A 61-year-old woman was referred for evaluation of jaundice. A biliary invasion of huge HCC was confirmed by image of abdominal computerized tomography (CT) and biopsy specimen. After improvement of jaundice by endoscopic retrograde biliary drainage and percutaneous transhepatic biliary drainage, she underwent TACE as a palliative treatment. Follow-up CT showed partial lipiodol uptake in hepatic tumor and its bile duct invasion. In follow-up endoscopic retrograde cholangiopancreatography, occluded cholangiogram showed neither luminal obstruction nor filling defect after removal of biliary stent. Our case suggests that obstructive jaundice, caused by inoperable huge HCC with biliary invasion, may be expected to resolve successfully biliary obstruction by a choice of TACE. Korean J Pancreatobiliary 2014;19(1):31-36

뇌 전이 소견을 보인 췌장암: 증례보고 및 문헌고찰

이상직 ( Sang Jik Lee ),조창민 ( Chang Min Cho ),정민규 ( Min Kyu Jung ),조승현 ( Seung Hyun Cho ),김갑철 ( Gab Chul Kim ),배한익 ( Han Ik Bae ) 대한췌담도학회 2018 대한췌담도학회지 Vol.23 No.2

췌장암에서 유래된 뇌 전이는 매우 드물며, 뇌 전이가 동반된 췌장암 환자의 예후는 매우 나쁜 것으로 알려져 있다. 뇌전이의 수술적 절제는 도움이 되나 제한적이며, 원발 췌장암이 조절되고 있는 환자에서 장기 생존이 가능하다. 저자들은 유문 보존 췌십이지장 절제술 후 간 전이에 대한 화학 요법의 완전 반응을 보인 췌장암 환자에서 새로 발생한 뇌 전이를 경험하였기에 문헌고찰과 함께 보고한다. 이 환자는 뇌 전이 병소가 성공적으로 절제되고, 췌장암에 대한 근치적 치료를 받았음에도 불구하고 상대적으로 생존 기간이 짧았다. 이 증례는 조절되고 있는 췌장암에서 유래된 뇌 전이 병소의 절제가 도움이 될 수 있지만, 그 절제 시기도 중요하다는 것을 알려주고 있다. Pancreatic cancer is well known as a relentlessly progressive and fatal disease. Although distant metastasis is common at the time of diagnosis, brain metastasis originating from pancreatic cancer is rare and its clinical manifestation remains poorly described. Additionally, it is generally known that the prognosis for patients with pancreatic cancer and brain metastasis is very poor. Surgical resection of brain metastasis may play a limited role or may allow long-term survival in patients for whom the primary pancreatic cancer is well controlled. We present a case of brain metastasis in patient with pancreatic cancer after pylorus-preserving pancreaticoduodenectomy and complete response to chemotherapy for hepatic metastases. Brain metastasis was resected successfully, but survival period was relatively short, even though the patient received curative treatment for pancreatic cancer. This case demonstrated that resection of brain metastatic lesion from pancreatic cancer being controlled may be helpful, but the timing of resection is also important.

만성췌장염에 침범한 방선균증: 증례 보고 및 문헌고찰

여승재 ( Seong Jae Yeo ),조창민 ( Chang-min Cho ),정민규 ( Min Kyu Jung ),김기주 ( Ki Ju Kim ),김명희 ( Myung Hi Kim ),조승현 ( Seung Hyun Cho ),김갑철 ( Gab Chul Kim ),서안나 ( An Na Seo ) 대한소화기학회 2017 대한소화기학회지 Vol.69 No.3

Actinomycosis is a slowly progressive, chronic infectious disease. It is caused by the genus Actinomyces, which are gram-positive anaerobic bacteria. It presents as a mass-like lesion, composed of bacterial nidus and characteristic granulomatous inflammatory fibrosis. As such, it has frequently been mistaken for a malignancy. Surgical resection is a common procedure in these patients prior to a definite diagnosis. Although actinomycosis can occur in a variety of regions, including oral-cervicofacial, thoracic, and abdominopelvic cavities, the involvement of the pancreas is very rare. We report a case of a 44-year-old male with a symptomatic actinomycosis caused by a mass in the tail of the pancreas. The diagnosis was made using an endoscopic ultrasound-guided fine needle aspiration biopsy without surgical resection. After the treatment with antibiotics, the pancreatic mass was confirmed to be resolved on the follow-up computed tomography. (Korean J Gastroenterol 2017;69:191-195)

진행된 원발 간세포암에서 FEM 요법을 이용한 국소 간동맥 항암제 주입요법의 효과

황준영 ( Jun Young Hwang ),장병국 ( Byoung Kuk Jang ),권기민 ( Ki Min Kwon ),정우진 ( Woo Jin Chung ),박경식 ( Kyung Sik Park ),조광범 ( Kwang Bum Cho ),황재석 ( Jae Seok Hwang ),안성훈 ( Sung Hoon Ahn ),김갑철 ( Gab Chul Kim ) 대한소화기학회 2005 대한소화기학회지 Vol.45 No.2

초등학교 초임교사의 수업 반성을 통한 게임 교수 가치관 변화

김갑철 한국초등무용학회 2000 한국초등무용학회지 Vol.5 No.1

The purpose of this study was to identify the perception and the change of a novice teacher's views on objective, content, method, and assessment through the reflection of game teaching. To accomplish this purpose, action research methods were applied to a novice teacher who had less than one year elementary teaching experience in order to examine his teaching perspective for 15 weeks. The case record and inductive categorical analysis method were used to analyze the data obtained from the videotaping of the class, participant observation, in-depth interview, journals and documents. The trustworthiness of data was validated through triangulation. The results of the study are as follows : The view on teaching objectives : At the beginning, the teacher focused on the students' skill development and demand. He ran a game class without understanding of teaching objectives and the relationship between the teaching objectives and the teaching points. As the study proceeded, his objective of a game changed into the synthetical and alternative one through the reflection. As he got some clear teaching objectives, he could conceive the relationship among the teaching content, teaching method, and assessment. As he understood the teaching objectives and the teaching points more synthetically, he could teach students the games more systematically. The view on teaching contents : At the early stage, he depended on the P.E text about his game class. He ran the game classes in a teacher-centered way. Reflecting the game teaching, he changed his thought on the focus of the game content from the skill-based game into the students' perception process. He tried to teach the students some insight based on the practical strategies to cope with the real game situation. To provide the students with the best game, he emphasized the game selection which corresponded with the students' needs and abilities. The view on teaching method : Before reflection he just showed the students a stereotypical theme in the ground. As he reflected his own game teaching, he came to use multimedia(computer, projection T.V, O.H.P, videotapes, and so on) for the effective demonstration of the content(in the ground or classroom). Considering the characteristics of the game content, students' developmental stages, individuality, he grouped the students into the small or middle size pack(group of 5∼ 10). He paid attention to considering the understanding of students' emotion, individuality, and the development level for grouping the students. He indicated that students' desire for victory was to be managed carefully during the game activity. He said that P.E teacher's role should be a guide or a supporter in the game activity. He signified that P.E teacher should accumulate the pedagogical knowledge of game to use it timely at any circumstances. Also, he showed that P.E teacher's open mind was needed to promote the students' activity. The view on assessment : Without considering the teaching objectives he applied the norm-referenced evaluation to the students before the reflection. Reflecting upon the game teaching, he comprehended the correspondence between teaching objectives and assessment objectives. Te normalize the assessment system, he urged the P.E teacher to apply the corresponding objectives to the students in the real game situation. To establish the right game teaching condition, he emphasized that the assessment system should be changed from the record for the achievement report into the individual assessment for the individual development. And he said that the improvement of teaching and learning method should be made for this. Also, he emphasized that the success of game teaching and the students' motivation should depend on the management of the assessment results.

위장관 간질종양의 임상 및 병리학적 고찰

김영호,장우영,이순진,손희정,최규완,도재혁,백승운,이준행,이풍렬,이종철,박철근,임윤정,김갑철,김재준,임효근 대한소화기학회 2001 대한소화기학회지 Vol.37 No.3

Background & Aims: Gastrointestinal stromal tumor (GIST) constitutes primary nonepithelial neoplasms of the gastrointestinal tract and includes most tumors previously designated as leiomyomas/leiomyosarcomas. GIST is pathologically divided into benign, borderline and malignanct tumor. This study was carried out to delineate the clinical and pathologic features of GIST and to establish the features predicting malignancy. Methods: Clinicopathologic data of 84 patients who had GIST from 1995 to 1999 were reviewed. Results: The subjects were 42 men and 42 women, and their mean age was 59.3±13.2 years. We located fifty-two tumors in the stomach, 28 tumors in the small intestine and 4 tumors in the colorectum years. Histopathology revealed benign tumors in 23 of the 84 patients, borderline tumors in 22, malignant tumors in 39. The average size of tumors was 6.23 cm in diameter (range, 0.6-26 cm). Metastasis was noted in 15.5% of the patients at diagnosis. On endoscopy, ulceration was more common in malignancy. Endsonographic findings except size were not significant statistically. On contrast enhanced computed tomography, malignancy showed more irregular shape and variable attenuation than benign lesions, which seemed to be valuable factor. Conclusions: The variables predicting malignancy were large tumor size (≥5 cm), location of the colorectum, palpable abdominal mass, ulceration on endoscopy, and less uniformity in shape and variable attenuation on computed tomography.

허혈성 대장염의 임상 양상과 예후 인자

이미숙,손희정,강태욱,최규완,박동일,백승운,이준행,고광철,이종철,임윤정,이풍렬,김갑철,김재준 대한소화기내시경학회 2001 Clinical Endoscopy Vol.22 No.2

Background/Aims: Colonic ischemia is recognized as the most common vascular disorder of the intestines in the elderly. The severity of the disease may vary considerably with the prevalent benign transient forms, being amenable to conservative treatments and the severe gangrenous forms, requiring surgery. Correct diagnosis is usually made after the ischemic episode is over and colonic ischemia is frequently misdiagnosed. The aim of this study is to identify the clinical patterns and prognostic factors of ischemic colitis. Methods: We found 60 patients with nonoccusive ischemia of the large intestine, We analyzed age, sex, symptoms, signs, associated disease, location, endoscopy, hematologic, histologic, radiologic finding and treatment, retrospectively. Results: The mean age was 60.2±6.3 years. The most common symtoms were abdominal pain or bloody diarrhea. The most common sign was diffuse abdominal tenderness. The most common hematologic findings were anemia and leukocytosis. Associated medical illnesses wer diabetes, rhematoid arthritis and cerebrovascular accident, et al. Both computed tomography (CT) and endoscopy were useful diagnostic tools. The most common involved site was sigmoid colon. 46 patients were treated conservatively and 14 patients were managed surgically. Conclusions: Male gender, those with rebound tenderness, severe anemia, right or total colon involvement as well as rheumatoid arthritis had a poor prognosis. Both CT and endoscopy were useful in predicting prognosis.