자궁내막증 치료에 있어 복강경술의 효용성 - 심재성 자궁내막증을 중심으로 -

박찬우(Chan Woo Park),박양서(Yang Suh Park) 대한산부인과학회 2000 Obstetrics & Gynecology Science Vol.43 No.2

목적: 자궁내막증은 1985년 개정된 미국 불임학회의 임상분류 (rAFS, Revised American Fertility Society Classification)에 의해 병변의 크기, 양상, 깊이, 자궁 부속기 유착 및 맹관의 폐쇄 정도에 따라 1기부터 4기로 분류할 수 있으며, 이와는 별도로 Martin등에 의해 복막으로부터 병변의 깊이에 따라 표재성(superficial, <1mm), 중재성(intermediate, 2∼4mm), 심재성(deep, >5mm), 중심재성(very deep, >10mm)으로 분류할 수 있다. 심재성 자궁내막증은 호르몬 수용체가 결여되고 주위 조직과의 유착으로 약물의 침투가 불가능하여 반드시 수술적 치료가 필요하다. 자궁내막증의 수술적 치료는 복강경술을 이용한 치료가 보편화 되고 있으나 심재성 자궁내막증의 경우 복강경술시 촉지가 불가능하여 병변의 깊이를 알기 어렵고, 심재성 자궁내막증 Type Ⅱ의 경우 직장이 맹관이나 자궁천골인대에 유착을 형성하여 해부학적 구조가 소실된 채 병변이 감추어 질 수 있으며, Type Ⅲ의 경우 병변이 골반저에 함몰되어 육안으로는 작은 병변으로 간과되어 볼완전한 수술이 될 수 있다. 본 연구에서는 자궁내막증의 치료에 있어 심재성 자궁내막증을 중심으로 복강경술과 개복술간의 장단점을 비교하여 심재성 자궁내막증의 치료시 복강경술의 효용성에 대해 알아보았다. 연구방법: 1992년 3월부터 1997년 3월까지 병력과 내진 및 초음파 소견에서 자궁내막증이 의심되어 수술받은 116례중 조직학적으로 자궁내막증으로 확진된 102례 가운데 심재성 자궁내막증 소견을 보인 30례 (복강경술 15례, 개복술 15례)를 대상으로 일반적 특성, 병력, 수술방법과 병기, Type에 따른 수술시간, 입원기간 등을 비교함으로써 자긍내막증 치료에 있어 복강경술의 효용성에 대해 알아보았다. 결과: 심재성 자궁내막증의 분류에 따른 수술시간은 TypeⅠ에서 복강경술시 148.5±21.2분, 개복술시 118.0±19.2분 소요되었으며, Type Ⅱ의 경우 각각 162.0±30.7분, 127.5±26.1분 소요되었고, Type Ⅲ에서는 각각 245.0±36.1분, 146.6±29.6분이 소요되어 병변의 Type이 진행될수록 수술시간이 길어졌으며 복강경술이 개복술에 비해 많은 시간이 소요되었지만, 입원기간은 심재성 자궁내막증의 경우 복강경을 시행한 군은 5.7±1.8일, 개복술을 시행한 군은 10.0±2.3일로 두 군간에 통계학적으로 유의한 차이가 있었다. 결론: 심재성 자궁내막증의 복강경술시 개복술에 비해 수술시간이 많이 소요되지만 조직 손상이 적으며, 장운동 회복이 빠르고, 수술후 동통이 적어 조기회복이 가능하여 술자의 복강경술 술기에 따라 적절히 환자를 선택한다면 복강경술은 심재성 자궁내막증의 치료에 있어 유용한 수술법으로 사료된다. Objective: To evaluate the efficacy of laparoscopic surgery in the treatment of deep endomtriosis, we have studied 30 cases of deep endometriosis. Endometriosis is classified into superficial(<1mm), intermediate(2-4mm), deep(>5mm) and very deep(>10mm) endometriosis by the infiltration depth from the peritoneal surface. In the treatment of deep endometriosis, medical hormonal therapy is not effective, so surgical treatment is required. There are many difficulties in surgiacal treatment ; hard lesion to excise, ditsorted pelvic anatomy after excision, easy to damage to ureter and uterine artery, and limitation for potentially morbid procedure to whom wants to conceive. Especially laparoscopic surgery in the treatment of deep endometriosis is very difficult because it is impossible to know the depth by palpation. In deep endometriosis type II, the lesion is concealed due to rectal adhesion to cul de sac, uterosacral ligament and in type III, the lesion is regarded as a small lesion or missed due to invagination into pelvic floor. The authors compared the laparoscopic surgery with laparotomy to evaluate the efficacy of laparoscopic surgery in the treatment of deep endomtriosis. Methods: Deep endometriosis, 30 cases out of 102 cases, which were histologically comfirmed as endometriosis were studied. The authors compared the laparoscopic surgery(15 cases) with laparotomy(15 cases) in the surgical treatment of deep endometriosis for operation procedure, operation time, hospital stay and symptoms improvement. Results: The mean operation time of laparoscopic surgeries in deep endometriosis was 178.7(±43.1)min while type I, II and III in deep endometriosis took 148.5(±21.2)min, 162.0(±30.7)min and 245.0(±36.1)min respectively and took a little more time than laparotomy. Mean hospital stay in laparoscopic surgeries was 5.7(±1.8)days and laparotomy took 10.0(±2.3)days that was statistically significant. Conclusion: If patients are chosen adequately and operator's skills are satisfactory, laparoscopic surgery is very valuable in the treatment of deep endometriosis. More datas will be required to confirm the efficacy.

원발성 난소 이행세포암

박영순 ( Young Soon Park ),이상호 ( Sang Ho Lee ),정영환 ( Young Hwan Chung ),고준성 ( Sung Ko ),문종수 ( Zong Soo Moon ),서수형 ( Soo Hyung Seo ),박양서 ( Yang Suh Park ) 대한산부인과학회 2002 Obstetrics & Gynecology Science Vol.45 No.9

Primary ovarian transitional cell carcinoma (TCC) is extremly rare tumor and has been recently classified into the one of the histologic subtypes of ovarian epithelial cell carcinomas. Primary ovarian TCC has been proven to differ from malignant Brenner tumor (MBT) and TCC of th bladder for it`s histologic characteristics as well as therapeutic and prognostic implications. TCC of the ovary has been also recognized to have excellent response to chemotherapy and favorable prognosis although it`s aggressive properties. We experienced a case of primary ovarian TCC (stage; Ⅱc) in 57 year old woman who presented with low abdominal pain and report this case with a brief review of the concerned literatures.

임신중기 양수천자의 임상적 고찰

이상호(Sang Ho Lee),박영순(Young Soon Park),장재혁(Jae Hyuk Chang),문종수(Zong Soo Moon),서수형(Soo Hyung Seo),박양서(Yang Suh Park),윤숙경(Sook Kyung Yun) 대한산부인과학회 2002 Obstetrics & Gynecology Science Vol.45 No.7

목적 : 본 연구는 세포유전학 검사를 위한 임신중기 양수천자의 적응증과 염색체 핵형결과를 평가하고 이에 따른 염색체이상의 발생빈도와 상관관계를 분석하고 양수천자의 안정성 및 합병증을 평가하기 위하여 시행하였다. 연구 방법 : 본 연구는 1997년 1월부터 2001년 10월까지 한림대학교 강동성심병원 산부인과에서 세포유전학 검사의 적응증에 해당되어 양수천자를 시행받은 674명의 임신부를 대상으로 대상환자의 연령과 임신주수의 분포, 양수천자의 적응증과 염색체 핵형검사의 결과 그리고 각 적응증에 따른 염색체이상의 결과와 양수천자술의 안정성 및 합병증을 평가하였다. 결과 : 양수천자의 적응증은 산모 혈청표지자 선별검사의 이상이 46.2%로 가장 많았으며 고령산모 (≥35)가 44.8%, 초음파에서 이상소견을 보인 경우가 5.9%, 태아기형아의 가계력을 가진 경우가 2.8%, 염색체이상아의 출산력을 가진 경우가 0.3% 순이었다. 연령별로는 35~39세의 연령군이 34.6%로 가장 많았으며, 주수별로는 15∼19주 사이가 69.9%으로 가장 많았고 조기 양수천자에 해당하는 14주 이전에 실시한 경우가 1.0%였다. 염색체 핵형분석의 결과 비정상핵형은 3.6% (24/674)였으며, 이 중 수적이상이 18예, 구조적 이상이 6예였다. 수적이상에는 상염색체이상으로 다운증후군 7예 (전좌형 1예), 에드워드증후군 6예, 파타우증후군 1예와 그외 3예의 모자이시즘이 있었고, 성염색체이상으로 터너증후군이 1예 있었다. 적응증별 염색체이상 비율은 산모 혈청표지자 선별검사 이상에서 3.2% (10/311), 고령산모 중에서는 3.0% (9/302)로 유의한 차이를 보이지는 않았으나 초음파에서 이상소견을 보인 경우가 7.5% (3/40)으로 유의한 차이를 보였다. 염색체이상아의 출산력을 가진 경우는 2예 모두에서 비정상 핵형을 보였지만 그 대상 환자군이 적어 평가를 할 수 없었다. 결론 : 고령산모나 산모 혈청표지자 선별검사 그리고 초음파검사 등을 통하여 유전질환의 위험성이 높은 산모를 선별하고, 이들 산모를 대상으로 임신중기 양수천자를 통한 태아의 세포유전학적 검사는 산전 유전질환의 진단법으로 매우 유용한 검사이다. 또 이러한 세포유전학적 연구결과는 산전진찰 및 유전학적 상담의 중요한 자료로 활용될 수 있을 것이며 이에 대한 지속적인 연구와 보고가 더욱 필요하리라 사료된다. Objective : We performed this study to analyze the indications, distributions of maternal age and cytogenetic results of midtrimester amniocentesis and to determine the complications and risks of it. Methods : This study was retrospectively reviewed 674 cases of midtrimester genetic amniocentesis from January 1997 to October 2001 in Kangdong Sacred Hospital, Hallym University. We analyzed the indications, distributions of maternal and gestational age, chromosomal results, and of which accorded to indications of cytogenetic studies. Results : The indications of amniocentesis were abnormal maternal serum screening (46.2%), advanced maternal age (≥35: 44.8%), abnormal ultrasonographic findings (5.9%), familial history of fetal anomaly (2.8%) and previous history of fetal chromosomal abnormalities (0.3%), in order. The overall incidence of chromosomal aberration was 3.6% (24/674), which were composed of 18 cases of numerical aberrations and 6 cases of structural aberrations. In autosomal aberrations, there were 7 cases of Down`s syndrome, 6 cases of Edward syndrome, 1 case of Patau syndrome and 3 cases of Mosaicism. In sex chromosomal aberration, there was a case of Turner syndrome. In chromosomal aberrations according to indications, there was 7.5% (3/40) of chromosomal abnormalities in abnormal ultrasonographic findings group, 3.2% (10/311) in abnormal maternal serum screening group and 3.0% (9/302) in advanced maternal age group. There was statistical significance only in abnormal ultrasonographic findings group. There was no significant complication after amniocentesis except 0.3% (2 cases) of fetal loss. Conclusion : Maternal serum screening, advanced maternal age and antenatal ultrasonograms should be important screening methods for amniocentesis which is considered to the most effective diagnostic procedure for prenatal cytogenetic studies. The karyotyping analysis of midtrimester amniocentesis is efficacious method for evaluation of chromosomal aberrations and genetic counselling for parents.

SEMM 식 자궁적출술에 대한 임상적 고찰

우소영(So Young woo),박영순(Young Soon Park),이상호(Sang Ho Lee),문종수(Zong Soo Moon),서수형(Soo Hyung Seo),박양서(Yang Suh Park) 대한산부인과학회 2001 Obstetrics & Gynecology Science Vol.44 No.10

N/A Objectives : We performed this study to review the clinical availability of the classical intrafascial SEMM hysterectomy (CISH), and report our experience for 2 years restrospectively. Methods : From March 1999 to February 2001, 100 cases of CISH were performed at the Department of Obstetrics and Gynecology, College of Medicine, Kangdong Sacred Heart Hospital, Hallym university. We performed this procedure by 3 steps. The dissection of uterus was done by classical suture methods (including extracorporeal and intracorporeal suture techniques) to uterine isthmic portion. And then transvaginal cylindrical coring out of the cervical tissue was done using a cervix corer, the Calibrated Uterine Resection Tools (CURT) for resection of cervical tissue especially transformation zone. Finally, the dissected uterus was extracted by using a Serrated Edged Macro-Morcellator (SEMM) without colpotomy. We reviewed the patient's data retrospectively and made phone calls to each patients. Results : The indications for CISH, based on the pre-and intraoperative diagnosis, were leiomyoma, adenomyosis, endometrial hyperplasia and chronic pelvic inflammatory disease or pelvic pain, in order of frequency. The mean operative time was 126 minutes and the mean hemoglobin change was 1.27 gm/dL. The mean hospital days were 5.7 days and the mean age of the patients was 44.6 years old. There were no definite intra- and postoperative complications except for 3 cases of CO2 retentions and 2 cases of delayed bleeding on cervical stump. The mean days to first sexual contact after surgery were 34.5 days. In view of sexual feeling, 86% of the patients didn't feel any difference and only 13% felt worse than before. During postoperative follow-up, the cervical cytologic study were found no endocervical cells at all of 44 checked patients. Conclusion : The CISH procedures can be safely performed by well-trained laparoscopists, and this technique minimally alters the anatomy and integrity of the pelvic floor and vagina. Therefore the reductions of surgical morbidity, blood loss, hospitalization and postoperatve discomfort were obtained. Through the preservation of the anatomical relations of the pelvic floor and the function of female sexuality, this technique is the new proposal in gynecologic surgery.

변형된 Shirodkar법을 이용한 양막탈출을 동반한 자궁경부 무력증의 처치 2 예

이지영(Ji Young Lee),박찬우(Chan Woo Park),장봉림(Pong Rheem Jang),박양서(Yang Suh Park),김유곤(You Kon Kim),윤태숙(Tae Suk Yoon) 대한산부인과학회 1998 Obstetrics & Gynecology Science Vol.41 No.12

Two patients, bulging fetal membrane accompanied with cervical dilatation & effacement in the late second-trimester, were treated by modified Shirodkar method. Pregnancies were prolonged effectively and viable fetuses were delivered in both cases. Our cases may help make objective decision prior to attempting cerclage placement when cervix is markedly dilated and something should be done to save pregnancy.

고위험 임산부에 있어서 임신 제 1 삼분기 중 염색체 이상 진단을 위한 Nuchal Translucency 의 유용성

이지영(Ji Young Lee),최규하(Kyu Ha Choi),박찬우(Chan Woo Park),윤태숙(Tae Suk Yun),박주진(Choo Jin Park),장봉림(Pong Rheem Jang),박양서(Yang Suh Park) 대한산부인과학회 1998 Obstetrics & Gynecology Science Vol.41 No.11

N/A Objective: To determine the value of sonographic nuchal translucency measurement for the detection of chromosomal abnormalities in high risk pregnancies. Method: The feasibility of nuchal translucency was tested in a prospective study of 1260 pregnancies at 10- 13 weeks' gestation. Results: The nuchal translucency of 3 mm or greater was identified in 41 fetuses (3.2%), 19 of whom proved subsequently by either amniocentesis or postnatal follow-up have chromosomal abnormalities. The sensitivity of nuchal translucency for chromosomal abnormalities was 82.6% (19 of 23 cases), the positive predictive value of nuchal translucency for chromosomal abnormalities detection was 46.3% (19 of 41 cases). Conclusion: The observed sensitivity, false-positive rate and predictive value suggest that sonographic nuchal translucency should be undertaken at 10 to 13 weeks of gestation.

임신 중 발생한 결핵성 복막염

이존익(John Ik Lee),권민연(Min Yeon Kwon),송성욱(Sung Wook Song),박주진(Choo Jin Park),문종수(Zong Soo Moon),서수형(Soo Hyung Seo),박양서(Yang Suh Park) 대한산부인과학회 2000 Obstetrics & Gynecology Science Vol.43 No.1

The tuberculous peritonitis, especially in pregnancy, is very rare and difficult to diagnose since there is no diagnostic clue and limitation of diagnostic means. The clinical features may vary such as fever, chill, tachycardia, abdominal tenderness or rebound tenderness which are not controlled easily with antibiotics. It is possible to diagnose by AFB culture and biopsy through exploro-laparotomy which is done due to uncontrolled symptoms even to unstable vital signs. It's clinical symptoms and signs are dramatically improved with antituberculotic therapy. Recently we have experienced a case of tubeculous peritonitis at 29 weeks gestation which was diagnosed through exploro-laparotomy including cesarean section. So we report this case with a brief review of literature

복막에 발생한 원발성 유두양 장액성 악성종양

권민연(Min Yeon Kwon),이존익(John Ik Lee),우소영(So Young Woo),최규하(Kyu Ha Choi),박주진(Choo Jin Park),김덕환(Duck Hwan Kim),문종수(Zong Soo Moon),서수형(Soo Hyung Seo),박양서(Yang Suh Park) 대한산부인과학회 1999 Obstetrics & Gynecology Science Vol.42 No.8

Primary papillary serous carcinoma of the peritoneum(PPSCP) is vere rare. It has been suggested that PPSCP derives from embryonal coelomic epithelium with m llerian ducts potential. PPSCP can develop from a single or multicentric focus. The clinical and histologic disease entities are similar to those of primary papillary serous carcinoma of the ovary, but PPSCP involves the ovarian surface only minimally(microscopic disease) or spares the ovaries entirely. We have experienced a case of primary papillary serous carcinoma of the peritoneum and report this case with brief review of the concerned literature.

초기임신 자연유산의 태아 핵형분석에 관한 고찰

권민연 ( Min Yeon Kwon ),우소영 ( So Young Woo ),윤숙경 ( Sook Kyung Yun ),이지영 ( Ji Young Lee ),문종수 ( Zong Soo Moon ),서수형 ( Soo Hyung Seo ),박양서 ( Yang Suh Park ) 대한주산의학회 2000 大韓周産醫學會雜誌 Vol.11 No.3

임신과 합병된 췌장염 1 예

김은주 ( Eun Ju Kim ),백종철 ( Jong Chul Baik ),정지윤 ( Ji Youn Chung ),권용일 ( Yong Il Kwon ),문종수 ( Jong Soo Moon ),박양서 ( Yang Suh Park ) 대한산부인과학회 2005 Obstetrics & Gynecology Science Vol.48 No.8