전이를 동반한 진행성대장암의 항암 치료에 대한 접근

김현건,Hyun Gun Kim 대한소화기암연구학회 2013 Journal of digestive cancer reports Vol.1 No.1

식생활의 서구화와 대장암 검진의 증가로 인하여 국내의 대장암 유병률은 지속적으로 증가하고 있으며, 최근 보고에 의하면 남자에서는 종양 발생률 2위, 여자에서는 종양 발생률의 3위를 차지하고 있다. 비록 대장내시경이 대장암의 진단과 선별검사에 아주 효과적인 방법이지만, 여전히 대장암의 20-25%는 이미 진단 당시에 전이를 동반하고 있는 것으로 되어 있다. 최근 10년 동안 이러한 전이성대장암의 고식적인 치료로 irinotecan과 oxaliplatin 등의 약제들의 개발과 이들의 다양한 조합에 관련된 연구들이 보고되어 왔으며, 분자생물학적인 발전에 힘입은 표적 치료제의 개발과 이에 대한 다양한 연구들은 향후에도 진행성대장암 환자들의 종양 반응률과 생존기간을 증가시킬 것으로 기대된다.

대장 상피성 종양의 임상적 분류와 진단 코드 부여를 위한 제안

김현건 ( Hyun Gun Kim ),김진오 ( Jin-Oh Kim ),이석호 ( Suck-Ho Lee ),이창균 ( Chang Kyun Lee ),김현수 ( Hyun Soo Kim ),최황 ( Hwang Choi ),양동훈 ( Dong-Hoon Yang ),금보라 ( Bora Keum ),홍성필 ( Sung Pil Hong ),김성은 ( Seong-Eun 대한장연구학회 2011 Intestinal Research Vol.9 No.1

The Korean Standard Classification of Diseases (KCD), which reflects the International Classification of Diseases (ICD), is a fundamental coding system for the diagnosis of colorectal epithelial tumors. The KCD coding of colorectal lesions is entirely up to the clinician and is based on pathologic reports. However, coding discrepancies have arisen among physicians using the KCD and pathologists using the ICD for Oncology-3 (ICD-O-3). The Korean Society of Pathologists recently proposed a standardized pathology-reporting format and guidelines for the coding of colorectal cancer to decrease these discrepancies among pathologists. However, ICD and ICD-O are simple classification codes based on pathologic reports, and are neither intended nor suitable for indexing of distinct clinical entities. For appropriate diagnostic coding using the KCD, a corrected coding principle based upon pathologic reports is required,and unified coding between KCD and ICD-O is necessary. A standardized pathologic report format and communication with understanding between physicians and pathologists should be established. Additionally, the private medical insurance system for colorectal cancer should be revised to reduce conflicts among patients, clinicians,and insurance companies over the medical coding system. (Intest Res 2011;9:1-11)

증례 : 소화기 ; 백선(Dictamnus dasycarpus) 복용 후 발생한 급성 간염 1예

김성한 ( Sung Han Kim ),조원영 ( Won Young Cho ),김현건 ( Hyun Gun Kim ),장재영 ( Jae Young Jang ),심찬섭 ( Chan Sup Shim ),김부성 ( Bu Sung Kim ),진소영 ( So Young Jin ) 대한내과학회 2009 대한내과학회지 Vol.76 No.4

우리나라를 비롯한 동양권의 국가들에서는 과거로부터 전통의학에 기초한 여러 종류의 한약재가 널리 사용되어 지고 있다. 임상적으로 한약복용과 연관되거나 이로 인하여 악화되었다고 추정되는 간염은 흔히 경험할 수 있는 문제이나 원인약제를 정확하게 규명하기는 힘든 상태이다. 55세 남자 환자가 내원 1달 전부터 전신쇄약감이 있어 백선을 복용한 후 내원 5일 전부터는 전신쇄약감, 심와부 불쾌감 증세가 점점 심해지며 황달이 동반되어 외래를 통해 입원하였다. 진찰 소견은 황달, 간종대 외에 다른 이상은 없었으나 혈액검사에서 총 빌리루빈 16.0 mg/dL, ALP 288 IU/mL, AST 1,369 IU/L, ALT 1,660 IU/L으로 급성 간염 소견을 보였다. 간생검병리소견상 소엽 내 말단간세정맥 주변으로 담즙정체 및 간세포 재생변화, 쿠퍼세포의 광범위한 증식이 있었고, 문맥역은 염증세포의 침윤과 섬유화에 의해 확장되어 있으며 염증세포는 림프구, 조직구 및 호산구로 구성되어 있어 만성 알코올성 간섬유증에 급성 담즙정체성 간염의 소견을 보였다. 원인약물로 생각되는 백선 복용을 중지시키고 보전적 치료를 하였으며 이후 검사가 호전되어 퇴원하였다. 약제에 의한 간손상, 특히 한약에 의한 간손상의 진단은 쉽지 않으나, 세심한 임상적 관찰로 인과관계의 규명이 비교적 용이하다고 생각되며, 백선을 포함한 여러 한약제의 간독성 가능성에 대한 검토가 체계적으로 이루어지는 것이 꼭 필요하리라 생각된다. Few cases of hepatitis related to Chinese medicine have been reported in Korea. In such instances, since herbal medicines contain many ingredients, the component that causes the hepatitis to develop is unclear. A 55-year-old man was admitted with sudden-onset jaundice after taking the herbal medicine Dictamnus dasycarpus. The patient had consumed 70 g of alcohol daily and stopped drinking about a month earlier. The physical examination revealed no abnormalities other than scleral icterus. The patient`s blood chemistry showed a total bilirubin of 16.0 mg/dL, an ALP of 288 IU/mL, an AST of 1,369 IU/L, and an ALT of 1,660 IU/L. The viral studies were all negative. A liver biopsy showed acute cholestatic hepatitis superimposed on chronic alcoholic fibrosis. This case suggests the development of hepatitis due to an herbal medicine (Dictamnus dasycarpus). Moreover, we recently experienced a case of acute hepatitis that developed after the consumption of Dictamnus dasycarpus. (Korean J Med 76:476-480, 2009)

풍력터빈 구조물의 진동제어

최한순(Han Soon Choi),남윤수(Yoonsu Nam),김현건(Hyun Gun Kim) 대한기계학회 2011 대한기계학회 춘추학술대회 Vol.2011 No.5

크론병과 동반된 헤르페스 바이러스 십이지장염

이병후 ( Byung Hoo Lee ),엄욱현 ( Wook Hyun Um ),전성란 ( Seong Ran Jeon ),김현건 ( Hyun Gun Kim ),이태희 ( Tae Hee Lee ),김완중 ( Wan Jung Kim ),김진오 ( Jin Oh Kim ),진소영 ( So Young Jin ) 대한소화기학회 2013 대한소화기학회지 Vol.62 No.5

Herpes simplex virus (HSV) is a recognized cause of gastrointestinal infection in immunodeficient patients. Although a few cases of HSV gastritis and colitis in immunocompromised patients have been reported, there are no reports of HSV duodenitis in patients with Crohn`s disease (CD). A 74-year-old female was admitted with general weakness and refractory epigastric pain. She had been diagnosed with CD three years ago. Esophagogastroduodenoscopy (EGD) revealed diffuse edematous and whitish mucosa with multiple erosions in the duodenum. Considering the possibility of viral co-infection, cytomegalovirus (CMV) immunohistochemical staining, PCR, and cultures of duodenal biopsies were performed, all of which were negative with the exception of the isolation of HSV in culture. After administration of intravenous acyclovir for 1 week, follow-up EGD showed almost complete resolution of the lesions and the patient`s symptoms improved. In CD patients with refractory gastrointestinal symptoms, HSV, as well as CMV, should be considered as a possible cause of infection, so that the diagnosis of viral infection is not delayed and the appropriate antiviral treatment can be initiated. (Korean J Gastroenterol 2013;62:292-295)

소장 출혈이 의심된 문맥압 항진증 환자의 캡슐내시경 검사

천강일 ( Gang Il Cheon ),김진오 ( Jin Oh Kim ),홍성욱 ( Sung Wook Hong ),전성란 ( Seong Ran Jeon ),이태희 ( Tae Hee Lee ),김현건 ( Hyun Gun Kim ),조원영 ( Won Young Cho ),김완중 ( Wan Jung Kim ),김민정 ( Min Jeong Kim ),정승원 ( S 대한장연구학회 2011 Intestinal Research Vol.9 No.2

Background/Aims: In Korea, limited data are available on small bowel bleeding in patients with portal hypertension. This study reports on the use of capsule endoscopy in cases of suspected small bowel bleeding in patients with portal hypertension. Methods: Capsule endoscopy was used at our hospital to evaluate small bowel disease in 501cases from July 2003 to June 2010. Of those cases, nine patients with portal hypertension due to liver cirrhosis with suspected small bowel bleeding were selected for the study. A retrospective analysis was performed using data from medical records. Results: Six of the nine (66.7%) patients were males with an average age of 53.4 years. The average hemoglobin level was 8.1 g/dL. Abnormalities noted during capsule endoscopy included portal hypertensive enteropathy in all nine cases (100%), jejunal varices in four (44.4%), jejunal and ileal angiodysplasia in five (55.5%), multiple small bowel erosions in one (11.1%), granularity of the jejunal mucosa in one (11.1%),and small bowel erythema in three (33.3%). Active bleeding from jejunal varices was detected in two patients (22.2%). Despite having no obvious active bleeding during the capsule endoscopy, four patients (44.4%) were diagnosed with portal hypertensive enteropathy with obscure small bowel bleeding. Conclusions: Capsule endoscopy is a useful diagnostic tool for the evaluation of small bowel bleeding in patients with portal hypertensive enteropathy. Additional prospective and multicenter studies on the use of capsule endoscopy are needed to evaluate the incidence and clinical importance of portal hypertensive enteropathy. (Intest Res 2011;9:129-138)

원저 : 위장관 ; 조기 대장암의 내시경 절제 후 추적 결과 분석 -진행신생물의 발견율과 이에 영향을 미치는 인자를 중심으로

권순하 ( Soon Ha Kwon ),추진우 ( Jin Woo Choo ),김현건 ( Hyun Gun Kim ),전성란 ( Seong Ran Jeon ),이병후 ( Byung Hoo Lee ),이태희 ( Tae Hee Lee ),김완중 ( Wan Jung Kim ),고봉민 ( Bong Min Ko ),김진오 ( Jin-oh Kim ),조주영 ( Joo Yo 대한소화기학회 2013 대한소화기학회지 Vol.62 No.4

목적: 대장암의 예방에 있어서 대장내시경 검사는 가장 효과적인 검사법이지만 적절한 질 관리와 추적 관찰이 전제가 되어야 한다. 즉 조기 대장암을 진단하고 내시경으로 완전 절제 하였던 경우에도 추적검사에서 조기 대장암이 발견되는 경우가 있어 적절한 추적검사가 반드시 필요하다. 이번 연구에서는 조기 대장암 내시경 절제 후 대장내시경 추적검사 결과를 분석하여 진행 샘종과 점막암의 발견율 및 발견율과 관련된 인자를 알아보고자 하였다. 대상 및 방법: 2003년 5월부터 2011년 12월까지 순천향대학교 서울병원에서 대장내시경을 시행하고 대장 폴립을 내시경으로 절제한 후 조직검사에서 조기 대장암으로 진단된 환자 중에 1회 이상 대장내시경 추적검사를 받은 환자를 대상으로 추적검사 결과를 분석하였다. 수술을 받은 경우와 추적 관찰이 되지 않은 경우는 제외하였다. 조기 대장암은 림프절 전이에 관계없이 암세포가 점막 또는 점막하층까지만 침범한 경우로 정의하였고, 진행 샘종과 점막암을 통칭하여 진행 신생물로 정의하였다. 조기 대장암 내시경 절제 후 첫 번째 대장내시경 검사에서 진행 신생물의 발견율을 알아보고, 지표 대장내시경 검사에서 진행 신생물 발견율에 영향을 주는 인자를 분석하였다. 결과: 총 305명의 조기 대장암 환자 중에 추적 관찰이 불가한 환자 50명, 내시경 절제 후 수술을 받은 환자 44명을 제외하고 211명의 환자를 대상으로 분석하였다. 총 211명의 환자 중에 첫 번째 대장내시경 추적검사에서 진행 신생물은 15명(7.1%)에서 발견되었다. 1년 이내 첫 번째 대장내시경 추적검사를 하였던 경우는 198명(93.8%)이었고, 진행 신생물은 14명(7.0%)에서 발견되었다. 1년 이내 첫 번째 대장내시경 추적 검사에서 진행 신생물이 발견된 군과 발견되지 않는 군 사이에서 지표 대장내시경 검사 당시 부적절한 대장 청결도(OR, 18.237; 95% CI, 3.741- 88.895; p<0.001)와 대장 폴립이 3개 이상인 경우(OR, 9.479; 95% CI, 1.103-81.452; p=0.040)가 대장내시경 추적검사에서 진행 신생물 발견율의 증가와 관련이 있었다. 결론: 1년 이내 대장내시경 추적검사에서 대부분의 진행 신생물이 발견된 점을 생각할 때, 조기 대장암을 내시경 절제 후 대장내시경 추적검사를 1년 이내에 시행하는 것을 고려해야 한다. 최적의 추적검사의 시기는 장 정결도와 폴립의 수를 고려하여 결정하여야 하며 특히 조기 대장암 진단 당시 대장 청결도가 부적절한 경우 및 대장 폴립이 3개 이상인 경우에는 1년 이내 대장내시경 추적검사를 시행할 것을 고려해야 한다. Background/Aims: Early colon cancer can be effectively diagnosed and treated by colonoscopy, and surveillance colonoscopy is necessary to detect precursor lesions or new early colon cancer. We analyzed the surveillance results of patients with endoscopically resected early colon cancer to evaluate the detection rate of advanced neoplasia and its associated factors. Methods: We conducted a retrospective study at Soonchunhyang University Seoul Hospital, from May 2003 to December 2011. Patients who underwent endoscopic resection for early colon cancer, showed mucosal and submucosal invasion on histopathologic examination, and received surveillance colonoscopy at least once were enrolled in the current study. Patients who underwent operation and those who were lost during surveillance period were excluded. Results: Among a total of 305 patients diagnosed with early colon cancer, 211 patients met our inclusion criteria. Of these patients, 15 (7.1%) advanced neoplasias were detected at first colonoscopy. One hundred ninety-eight patients (93.8%) underwent surveillance colonoscopy within one year and 14 (7.0%) advanced neoplasias were detected in this group of patients. When patients with and without advanced neoplasia at first surveillance colonoscopy performed within one year were compared, inadequate bowel preparation (OR, 18.237; 95% CI, 3.741-88.895; p<0.001) and three or more colon polyps (OR, 9.479; 95% CI, 1.103-81.452; p=0.040) were significant risk factors for detecting advanced neoplasia. Conclusions: Considering the high detection rate of advanced neoplasia at first surveillance colonoscopy in patients with endoscopically resected early colon cancer, surveillance interval should be within one year, especially when the bowel preparation has been inadequate and three or more colon polyps have been detected. (Korean J Gastroenterol 2013;62:219-226)

Multidisciplinary and Multisociety Practice Guideline on Reprocessing Flexible Gastrointestinal Endoscopes and Endoscopic Accessories

Dae Young Cheung,Byung Ik Jang,김상욱,김지현,김현건,Jeong Eun Shin,윤원재,Yong Kang Lee,정광현,조수정,신현필,조선영,신운건,Kee Don Choi,김병욱,권중구,양희찬,권태근,Hyun Gun Kim,안동원,Kwang Bum Cho,Sun Hee Kim,Kyong Hwa Hwang,Hee Hyuk Im 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.3

The area of endoscopic application has been continuously expanded since its introduction in the last century and the frequency ofits use also increased stiffly in the last decades. Because gastrointestinal endoscopy is naturally exposed to diseased internal organsand contact with pathogenic materials, endoscopy mediated infection or disease transmission becomes a major concern in this field. Gastrointestinal endoscopy is not for single use and the proper reprocessing process is a critical factor for safe and reliable endoscopyprocedures. What needed in these circumstances is a practical guideline for reprocessing the endoscope and its accessories whichis feasible in the real clinical field to guarantee acceptable prevention of pathogen transmission. This guideline contains principlesand instructions of the reprocessing procedure according to the step by step. And it newly includes general information and updatedknowledge about endoscopy-mediated infection and disinfection. Multiple societies and working groups participated to revise;Korean Association for the Study of the Liver, the Korean Society of Infectious Diseases, Korean College of Helicobacter and UpperGastrointestinal Research, the Korean Society of Gastroenterology, Korean Society of Gastrointestinal Cancer, Korean Associationfor the Study of Intestinal Diseases, Korean Pancreatobiliary Association, the Korean Society of Gastrointestinal Endoscopy Nursesand Associates and Korean Society of Gastrointestinal Endoscopy. Through this cooperation, we enhanced communication andestablished a better concordance. We still need more researches in this field and fill up the unproven area. And our guidelines will berenewed accordingly.

크기가 큰 측방발육형종양의 치료 전략: 분할점막절제술 혹은 점막하박리술

강상구 ( Sang Goo Kang ),이석호 ( Suck Ho Lee ),정승규 ( Seung Kyu Chung ),신재민 ( Jae Min Shin ),전성란 ( Seong Ran Jeon ),이태희 ( Tae Hee Lee ),김현건 ( Hyun Gun Kim ),김진오 ( Jin Oh Kim ) 대한장연구학회 2011 Intestinal Research Vol.9 No.3

Background/Aims: The therapeutic strategy between endoscopic piecemeal mucosal resection (EPMR) and endoscopic submucosal dissection (ESD) for large laterally spreading tumors (LSTs) has not been clearly defined. The aim of this study was to compare the clinical outcomes between EPMR and ESD in patients with large LST. Methods: From July 2006 to September 2010, 106 patients who underwent endoscopic resection for large (>20 mm) LSTs were included in our retrospective analysis. Results: Baseline characteristics of the patients and tumors were not different between two groups except for location (EPMR-right colon, ESD-rectum). The en bloc resection rate and complete resection rate were significantly higher in the ESD group than those in the EPMR group (EPMR vs. ESD, 53.5% vs. 88.6, P<0.01, 45.1% vs. 71.4%, P=0.01, respectively). However, total procedure time was significantly shorter in the EPMR group (21.3 min vs. 44.4 min, P<0.01). Furthermore, the rates of complication including perforation and bleeding were significantly lower in the EPMR group than those in the ESD group (perforation, 1.4% vs. 11.4%, P=0.02; bleeding, 4.2% vs. 17.1%, P=0.03, respectively). During 19.9 months of follow-up, no significant difference was observed in terms of recurrence (1.5% vs. 3.2%). Non-granular, pseudo-depressed type (LST-PD) showed a significantly higher presence of adenocarcinoma and deeper submucosal invasion than other types of LSTs. Conclusions: The therapeutic strategy for choosing between EPMR and ESD for large LST lesions should be determined based on the macroscopic findings of their subtype. En bloc resection with ESD should be applied to LST-PDs due to their higher rate of submucosal invasion. (Intest Res 2011;9:211-216)

내시경점막하박리술 후 검체를 이용한 육안소견, 입체현미경소견 및 병리지도화 간의 검체 절제방향의 비교

조영관 ( Young Kwan Cho ),조주영 ( Joo Young Cho ),진소영 ( So Young Jin ),조원영 ( Won Young Cho ),정윤호 ( Yoon Ho Jung ),이태희 ( Tae Hee Lee ),김현건 ( Hyun Gun Kim ),김진오 ( Jin Oh Kim ),이준성 ( Joon Seong Lee ) 대한소화기학회 2010 대한소화기학회지 Vol.56 No.5

Background/Aims: The correct pathologic review is very important after endoscopic submucosal dissection. The cut direction of specimen should be the right angle of the closest area between the lesion and the lateral margin for the correct pathologic review. The aim of this study was to evaluate the concordance of the gross finding and stereoscopic finding compared to the pathologic mapping in the setting of the cut direction. Methods: Between December 2008 and May 2009, the objects were 48 specimens in 46 patients who were diagnosed with early gastric cancer and high grade adenoma after endoscopic submucosal dissection. The specimens were stained with hematoxylin and observed by the stereoscopy and analyzed by the image analysis system. The cut direction was divided by an angle of 45 degree based on the oral side of the specimen, and the cut directions of the gross finding, the stereoscopic finding, and the pathologic finding were compared. Results: The concordance of the gross finding in the setting of the cut direction was 68% (33/48), and the kappa value was 0.626, and the concordance of the stereoscopic finding in the setting of the cut direction was 87% (33/48), and the kappa value was 0.874. The accuracy of the gross finding was significantly lower than that of the stereoscopic finding in the setting of the cut direction (p<0.05). Conclusions: The endoscopist needs the careful observation and close attention in the setting of the cut direction of the specimen by gross finding, and stereoscopic analysis may be a useful tool for decision of the cut direction. (Korean J Gastroenterol 2010;56:293-298)