조기위암의 림프절전이에 관한 연구

박선미(Sun Mi Park),김해련(Hae Ryun Kim),민영일(Young Il Min),박건춘(Gun Chun Park),유은실(Eun Sil Yu) 대한소화기학회 1994 대한소화기학회지 Vol.26 No.1

N/A Early gastric cancer(EGC) is defined as gastric cancer confined to mucosa or submucosa re- gardless of lymph node metastasis. But lymph node metastasis affects the prognosis of pa- tients with EGC. And nowadays with increasing interest in endoscopic non-operative treat- ment such as laser therapy or strip biopsy, it is necessary to predict nodal metastasis in pa- tients with EGC. A total of 249 cases of EGC were reviewed post operatively according to their size of lesion, macroscopic classification, depth of invasion and cellular differentiation to identify the fac- tors for nodal metastasis in EGC which act as limitation of radical endoscopic treatment. Out of 805 curative resections for gastric adenocarcinoma frorn July 1989 to Jan 1993 in our institute, there were 249 cases of EGC(30.1%). Sex ratio of EGC was 1.8: 1 and ratio of EGC limited to mucosa to that of submucosal involvement was equal (1: 1). Proportion of EGC ac- cording to macroscopic classification was 20.3% of elevated type ( I, I + lIa, Iia, Iia+ Ilb, Iia + Iic), 5.9% of flat type (II b) and 73.8% of depressed bype (Iic, Lic+ Itl, III, III+ LI b, Iic+ Lia, II b + Iic). Out of 249 cases of EGC, there were 36 cases of lymph node metastasis (14.5%). The frequency of nodal rnetastasis of EGC limited to mucosa and submucosa was 5.9% (7/119) and 21.2k(25/118) respectively. The size of mucosal cancer was less than 2cm in 4cases of de- pressed type out of 7 cases of nodal metastasis while with cases of submucosal involvement, the size of lesion could not effect the frequency of nodal metastasis. The frequency of nodal metastasis in EGC limited to mucosa according to macroscopic classification was 11.1% of ele- vated type, 0% of flat type, 5.3% of depressed type and frequency of nodal metastasis in submucosal involvement was 23.3%, 0% and Z2.5% respectively. There was no significant dif- ference in frequency of nodal metastasis according to cellular differentiation. Though the frequency of nodal metastasis is much lower in EGC limited to mucosa than in cases of submucosal involvement, nodal metastasis is found in mucosal cancer especially in cases with small depressed type. Therfore it is suggested that radical endoscopic treatment be not always safe even in less than 1cm sized EGC limited to mucosa, and this type of treat- ment should be selectively considered in cases with small flat or elevated type of mucosal cancer.(Korean J Gastroenterol 1994;26: 56-62)

수술 후 장기적인 생리적 기능과 영양적 측면에서 본 원위부위절제술 후 재건술식의 비교; Billroth I 위십이지장문합술과 Roux-en Y 위공장문합술의 비교

정오,오성태,육정환,최지은,김갑중,임정택,박건춘,김병식,Jeong, Oh,Oh, Sung-Tae,Yuk, Jung-Hwan,Choi, Ji-Eun,Kim, Kab-Jung,Lim, Jung-Taek,Park, Gun-Chun,Kim, Byung-Sik 대한위암학회 2007 대한위암학회지 Vol.7 No.2

목적: 원위부위절제술 후에 행하여지는 재건술은 Bill-roth I 문합술, Billroth II 문합술, Roux-en Y 위공장문합술이 있으며 이러한 술식들은 객관적 비교 평가가 어렵고 이에 대한 연구 또한 많지 않다. 이에 저자들은 원위부위절제술 후에 시행된 Billroth I 문합 술과 Roux-en Y 위공장문합술을 장기적인 생리적 기능과 영양적 측면에서 비교하였다. 대상 및 방법: 1999년부터 2002년까지 위암으로 수술을 시행 받은 환자 중 조기위암으로 원위부위절제술을 시행 받은 환자 663명을 대상으로 술 후 생리적 기능을 평가하는 설문지를 6개월 간격으로 작성하였다. 술 후 영양상태를 평가하기 위하여 혈중 총단백질, 알부민, 혈색소 농도를 측정하였으며 체중의 변화를 측정하였다. 결과: 생리적 기능 총합점수는 B-I 군에 비하여 RY 군에서 약간 낮았으나 통계학적인 차이를 보이지 않았다. 각 증상 별로 비교 시 역류 증상과 식 후 음식물 통과만이 차이를 보였으며 24개월 후에는 RY 군에서 음식물 통과가 양호한 것 외에는 차이를 보이지 않았다. 혈중 총단백질, 알부민, 혈색소는 모두 B-I 군에서 통계적으로 유의하게 높았으나 두군 모두 평균적으로 정상이상의 수치를 보였다. 몸무게 감소는 B-I 군에서 적은 것으로 나타났다. 결론: 장기적 생리기능의 측면에서는 RY 군이 일부 증상에서 우수하였고 영양적인 측면에서는 B-I 군이 우수하였다. 따라서 원위부위절제술 후 재건술의 선택은 이러한 장단점을 고려하여 시술자의 경험과 환자의 상태에 맞춰 선택해야 한다. Purpose: The only curative treatment for gastric carcinoma is surgery and it is still under debate which reconstruction method is better after performing gastrectomy for gastric carcinoma. The typical reconstruction methods after distal gastrectomy are Billroth I, Billroth II and Roux-en Y reconstruction. Yet it is difficult to compare these methods and not so much is known about which reconstruction is better in terms of the physiologic and nutritional function. With this background, we compared two reconstruction methods after distal gastrectomy (Billroth I versus Roux-en Y reconstruction) in terms of the long term physiologic function and nutritional status to create a reference for selecting reconstruction methods after distal gastrectomy. Materials and Methods: Between 1999 and 2002, 663 patients who underwent distal gastrectomy for early gastric carcinoma filled out questionnaires every six months after operation, and these questionnaires evaluated the physiologic function. To evaluate their nutritional status, blood tests were performed every six months to check their albumin, protein and hemoglobin levels, and we checked the body weight every 6 months as well. Results: The total score of the 15 questions on the questionnaire concerned with the physiologic function showed no difference between the two groups at every evaluation time, and both groups showed very low total scores, indicating tolerable physiologic function after operation. When comparing each question between two the groups, only symptoms of regurgitation and food passage showed a difference between the two groups, showing that the Roux-en Y group had better function in terms of these two symptoms. The Billroth I group showed a better nutrition status, indicating that the level of albumin, protein and hemoglobin were higher in the Billroth I group, with statistical significance. Body weight loss was severe in the Roux-en Y group. Conclusion: The physiologic function is slightly better in the Roux-en Y group in terms of some symptoms such as regurgitation and food passage. However, the nutritional status is better in the Billroth I group. In conclusion, because we cannot definitely ascertain which reconstruction is better when we consider both the physiologic and nutritional functions, it is reasonable that surgeon should choose reconstruction methods according to their experience and preference.

원형 자동문합기를 이용한 체외문합을 시행한 복강경 보조 위전절제술: 한 술자에 의한 연속적인 48명 환자의 수술성적분석

정오,김병식,육정환,오성태,임정택,김갑중,최지은,박건춘,Cheong, Oh,Kim, Byung-Sik,Yook, Jeong-Hwan,Oh, Sung-Tae,Lim, Jeong-Taek,Kim, Kab-Jung,Choi, Ji-Eun,Park, Gun-Chun 대한위암학회 2008 대한위암학회지 Vol.8 No.1

목적: 복강경 보조 위전절제술은 기술적 어려움과 환자수가 많지 않음으로 인하여 복강경 보조 위원위부 절제술에 비하여 연구가 많지 않은 상황이다. 따라서 저자들은 본원에서 시행한 복강경 보조 위전절제술의 수술성적과 수술후 경과 및 합병증 발생 예측인자와 복강경 보조 위전절제술의 학습곡선에 관하여 분석하였다. 대상 및 방법: 2005년 1월부터 2007년 9월까지 술 전 검사상 위의 중 상부에 위치한 조기위암(cT1N0)을 진단받고 한 술자에 의해 복강경 보조 위전절제술을 시행 받은 연속적인 48명의 환자를 대상으로 의무기록을 바탕을 후향적으로 분석하였다. 결과: 수술 중 합병증이나 개복수술로의 전환은 없었고 평균 수술시간은 $212{\pm}67$분이었다. 평균 적출 림프절 개수는 $29{\pm}10$개였고 모든 환자에서 안전한 종양 경계 면이 확보되었다. 수술 후 가스배출, 식이시작, 퇴원시기는 각각 평균 2.98일, 3.67일, 7.08일이었다. 외과적 합병증은 5명(10.4%)에서 발생하였고 모두 보전적 치료로 호전되었다. 단변량 및 다변량 분석에서 합병증 발생에 영향을 주는 유일한 인자는 체질량지순(P=0.035, HR=2.462)였으며 수술 시간을 기준으로 한 학습곡선 분석에서 20예가 학습곡선인 것으로 나타났다. 결론: 복강경 보조 위전절제술은 위의 중 상부에 위치한 조기위암에 대한 적절한 술식이며 수술성적과 수술 후 경과가 양호하다. 그러나 학습곡선을 단축하기 위해서는 복강경 보조 위원위부절제술의 충분한 경험이 필요하며, 특히 초기경험에서는 수술 후 합병증을 줄이기 위하여 환자 선택에 있어서 체질량지수를 고려하는 게 도움이 될 것으로 생각된다. Purpose: Many recent studies have reported on the feasibility and usefulness of laparoscopy assisted distal gastrectomy (LADG) for treating early gastric cancer. On the other hand, there has been few reports about laparoscopy assisted total gastrectomy (LATG) because upper located gastric cancer is relatively rare and the surgical technique is more difficult than that for LADG, We now present our procedure and results of performing LATG for the gastric cancer located in the upper or middle portion of the stomach. Materials and Methods: From Jan 2005 to Sep 2007, 96 patients underwent LATG by four surgeons at the Asan Medical Center, Seoul, Korea. Among them, 48 consecutive patients who were operated on by asingle surgeon were analyzed with respect to the clinicopathological features, the surgical results and the postoperative courses with using the prospectively collected laparoscopy surgery data. Results: There was no conversion to open surgery during LATG. For all the reconstructions, Roux-en Y esophago-jejunostomy and D1+beta lymphadenectomy were the standard procedures. The mean operation time was $212{\pm}67$ minutes. The mean total number of retrieved lymph nodes was $28.9{\pm}10.54$ (range: $12{\sim}64$) and all the patients had a clear proximal resection margin in their final pathologic reports. The mean time to passing gas, first oral feeding and discharge from the hospital was 2.98, 3.67 and 7.08 days, respectively. There were 5 surgical complications and 2 non-surgical complications for 5 (10.4%) patients, and there was no mortality. None of the patients needed operation because of complications and they recovered with conservative treatments. The mean operation time remained constant after 20 cases and so a learning curve was present. The morbidity rate was not different between the two periods, but the postoperative course was significantly better after the learning curve. Analysis of the factors contributing to the postoperative morbidity, with using logistic regression analysis, showed that the 8MI is the only contributing factor forpostoperative complications (P=0.029, HR=2.513, 95% CI=1.097-5.755). Conclusions: LATG with regional lymph node dissection for upper and middle early gastric cancer is considered to be a safe, feasible method that showed an excellent postoperative course and acceptable morbidity. BMI should be considered in the patient selection at the beginning period because of the impact of the BMI on the postoperative morbidity.

환자의 비만도가 복강경 보조 위원위부절제술의 수술성적과 수술 후 경과에 미치는 영향

정오(Oh Cheong),김병식(Byung-Sik Kim),오성태(Sung-Tae Oh),육정환(Jeong-Hwan Yook),임정택(Jung-Taek Lim),박건춘(Gun-Chun Park),최지은(Ji-Eun Choi),김갑중(Kap-Jung Kim) 대한외과학회 2008 Annals of Surgical Treatment and Research(ASRT) Vol.74 No.2

Purpose: Despite known advantages of laparoscopy-assisted distal gastrectomy (LADG) over open surgery, including less blood loss, less pain, faster recovery, and shorter hospital stays, many surgeons still hesitate to perform LADG in overweight patients due to concerns about increased perioperative morbidity. We investigated whether surgical outcomes in LADG differ in overweight patients and normal patients, as well as the influence of surgical experience. Methods: Between April 2004 and December 2006, 331 consecutive patients underwent LADG for preoperatively diagnosed early gastric cancer. Using the definition of overweight by western criteria, patients were classified into a low (n = 187, BMI <25 ㎏/㎡) and a high (n=144, BMI >25 ㎏/㎡) group. We retrospectively analyzed surgical outcomes, including operation time, retrieved lymph nodes, hospital courses, and postoperative complications. Results: The only differences in overweight and normal patients were longer operation time, incision length, and fewer retrieved lymph nodes. As our surgical team accumulated experience (after 250 cases in our study), there were no differences at all between the two groups. Conclusion: Technical difficulty in overweight patients could hamper some surgical outcomes but didn"t worsen the postoperative courses or complications. Moreover, those difficulties can be overcome as the surgical team accumulates experience.