다발성 위종양에 대한 동시적 내시경 점막하 박리술의 안전성 및 적합성

Dept. of Medicine/석사Background: Synchronous gastric neoplasms are not infrequently detected, thus endoscopic submucosal dissection (ESD) for multiple early gastric neoplasia is occasionally considered. However, there have been few investigations of the safety and feasibility of simultaneous ESD for multiple gastric lesions. This study aims to evaluate the safety and feasibility of simultaneous ESD for multiple gastric neoplasia. Methods : A total of 1,823 patients who underwent ESD for 1,929 gastric adenomas or early gastric cancers were retrospectively reviewed in this study. Two hundred gastric adenomas or early gastric cancers among 94 patients were treated by ESD simultaneously (multiple group) and 1,729 patients were treated with ESD for a single lesion (single group). Results: En bloc resection (P = 0.060), complete resection (P = 0.362) and curative resection (P = 0.108) rates did not differ between the two groups. Rates of adverse events including bleeding (P = 0.317), perforation (P = 0.316) and aspiration pneumonia (P = 0.563) were not higher in the multiple group. Long-term follow up showed more frequent local recurrence (P < 0.001), synchronous neoplasia (P = 0.041) and metachronous neoplasia (P < 0.001) per patient in the multiple group; however, local recurrence per lesion did not differ between the two groups (P = 0.103). Conclusions: Simultaneous ESD for multiple synchronous gastric neoplasms is safe and feasible compared to single ESD. However, thorough examination for local recurrence and synchronous and metachronous neoplasia is required. 배경: 다발성 위종양은 비교적 흔하게 발견되며 이들을 치료하기 위해 동시에 내시경 점막하 박리술을 시행하는 경우가 종종 있다. 하지만 다발성 위종양에 대한 동시적 내시경 점막하 박리술을 시행하는 것이 안전하고 적합한지에 대한 연구는 거의 없는 실정이다. 목적: 본 연구에서는 다발성 위종양에 대한 동시적 내시경 점막하 박리술의 안정성과 적합성에 대해 조사하였다. 방법: 총 94명의 환자가 200 개의 위선종 혹은 조기위암에 대해 동시에 내시경 점막하 박리술을 시행받았으며 (다발성 병변군), 1,729명의 환자가 단일 병변에 대해 내시경 점막하 박리술을 시행받았다 (단일 병변군). 두 환자군의 합병증, 시술 성과, 장기적인 치료 결과에 대해 비교하였다. 결과: 완전 절제율 (P = 0.362), 일괄 절제율 (P = 0.060), 근치적 절제율 (P = 0.108) 면에서 두 군의 차이는 없었으며 출혈 (P = 0.317), 천공 (P = 0.316) 및 흡인성 폐렴 (P = 0.563) 등의 합병증 면에서도 두 군간의 유의한 차이가 없었다. 장기적인 추적관찰 결과, 다발성 병변군에서 통계학적으로 유의하게 국소 재발 (P < 0.001), 동시성 병변 (P = 0.041) 및 이시성 병변의 (P < 0.001) 발견 빈도가 높았다. 결론: 다발성 위종양에 대한 동시적 내시경 점막하 박리술은 안전하고 적합하다. 그러나 장기적으로 국소 재발과 동시성 및 이시성 병변에 대해 유의하여 추적해야 한다.ope

A Case of Actinomycosis in a Patient Treated with Chemotherapy Due to Recurrent Pancreatic Cancer

A 46-year-old male patient with recurrent pancreatic cancer was admitted with a newly developed abdominal mass. The patient had a history of diabetes and underwent total pancreatectomy with partial gastrectomy followed by adjuvant concurrent chemoradiation therapy and palliative chemotherapy. Abdominal CT scan during palliative chemotherapy showed an abdominal wall mass. We performed excisional biopsy for diagnosis. Histological examination revealed actinomycosis of the abdominal wall. The patient was treated with penicillin G. This case showed that actinomycosis can occur in a patient receiving chemotherapy and may mimic cancer recurrence. Therefore, when evaluating a newly developed abdominal mass in patients who are receiving chemotherapy or radiotherapy, the probability of actinomycotic infection must also be considered, especially in patients with a history of surgery and diabetes mellitus.ope

Ventricular Tachyarrhythmias in a Patient with Andersen-Tawil Syndrome

Andersen-Tawil syndrome (ATS), a rare autosomal dominant disorder, is characterized by periodic paralysis, dysmorphic features and cardiac arrhythmias. This syndrome is caused by mutations of KCNJ2 gene, which encodes inward rectifying potassium channel. Here, we report an 18-year-old girl who was presented with life-threatening cardiac arrhythmia and acute respiratory distress. She was diagnosed with ATS, based on dysmorphic features, ventricular arrhythmia, and periodic paralysis. This is the first case to be reported in Korea who experienced a fatal cardiac arrest and respiratory failure caused by ATS.ope

The Rebleeding Risk and Prognostic Factors of Acute Hemorrhagic Rectal Ulcer

Background/Aims: Acute hemorrhagic rectal ulcer (AHRU) is an important etiology of lower gastrointestinal bleeding in intensive care unit patients and hospital inpatients. Moreover, with increasing elderly populations, and improved survival in critically ill patients, the incidence of AHRU has increased. The aim of this study is to determine rebleeding risk and prognostic factors of AHRU patients. Methods: We retrospectively reviewed 32 patients with AHRU in Severance Hospital from February 2006 to October 2010, collected clinical data, and analyzed their association with the recurrence of bleeding and mortality of patients. Results: The mean age of patients was 65.5 years, and 27 patients (84.4%) showed Eastern Cooperative Oncology Group performance status 3-4. Nineteen patients (59.4%) had recurrent bleeding. Hypoalbuminemia (≤2.5 g/dL) was a risk factor of rebleeding in univariate and multivariate analysis. For patients with chronic liver disease, hypoalbuminemia (≤2.5 g/dL), renal dysfunction (>2 mg/dL) and thrombocytopenia (40 seconds) increased mortality (P=0.028, P=0.008 and P=0.027, respectively) and the patients with rebleeding showed a tendency toward higher mortality, compared to those without (57.9% vs. 23.1%, P=0.051). Conclusions: In AHRU patients, hypoalbuminemia was a risk factor of rebleeding, and chronic liver disease, hypoalbuminemia, renal dysfunction, thrombocytopenia and no endoscopic treatment at the first bleeding event was correlated with relatively earlier rebleeding.ope

Prospective validation of FibroTest in comparison with liver stiffness for predicting liver fibrosis in Asian subjects with chronic hepatitis B

BACKGROUND AND AIMS: Diagnostic values of FibroTest (FT) for hepatic fibrosis have rarely been assessed in Asian chronic hepatitis B (CHB) patients. We aimed to validate its diagnostic performances in comparison with liver stiffness (LS). METHODS: From 2008 to 2010, 194 CHB patients who underwent liver biopsies along with FT and transient elastography were prospectively enrolled. Fibrosis stage was assessed according to the Batts and Ludwig system. RESULTS: To predict significant fibrosis (F≥2), advanced fibrosis (F≥3), and cirrhosis (F = 4), areas under receiver operating characteristic curves (AUROCs) of FT were 0.903, 0.907, and 0.866, comparable to those of LS (0.873, 0.897, and 0.910, respectively). Optimized cutoffs of FT to maximize sum of sensitivity and specificity were 0.32, 0.52, and 0.68 for F≥2, F≥3, and F = 4, while those of LS were 8.8, 10.2, and 14.1 kPa, respectively. According to FT and LS cutoffs, 123 (63.4%) and 124 (63.9%) patients were correctly classified consistent with histological fibrosis (F1, F2, F3, and F4), respectively. Overall concordance between each fibrosis stage estimated by FT and LS was observed in 111 patients, where 88 were correctly classified with histological results. A combination formula adding LS to FT (LS+FT) showed similar AUROC levels (0.885, 0.905, and 0.915), while another multiplying LS by FT (LS×FT) showed the best AUROCs (0.941, 0.931, and 0.929 for F≥2, F≥3, and F4, respectively). CONCLUSIONS: FT provides good fibrosis prediction, with comparable outcomes to LS in Asian CHB patients. FT substantially reduces need for liver biopsy, especially when used in combination with LS.ope

Sedation methods can determine performance of endoscopic submucosal dissection in patients with gastric neoplasia

BACKGROUND: Although proper sedation is mandatory for endoscopic procedures such as endoscopic submucosal dissection (ESD), there is no research investigating the effects of sedation on ESD performance and complications. We aimed to evaluate the relationship among sedation methods, clinical outcomes, and complications after ESD for gastric neoplasia. METHODS: We retrospectively reviewed clinical data of 1,367 patients with 1,485 lesions who had undergone ESD for gastric adenoma or early gastric cancer at our tertiary teaching hospital in Seoul, Korea, between January 2008 and May 2011. Of these, 1,035 lesions in 958 patients were included in the intermittent midazolam/propofol injection by endoscopists (IMIE) group, and 450 lesions in 409 patients were included in the continuous propofol infusion with opioid administration by anesthesiologists (CPIA) group. RESULTS: En bloc resection and complete resection rates were higher in the CPIA group than in the IMIE group (CPIA vs. IMIE; en bloc resection, 99.8 and 95.0 %, P < 0.001; complete resection, 94.2 and 88.3 %, P < 0.001). Duration of procedure was shorter in the CPIA group than in the IMIE group (CPIA vs. IMIE; 48.2 ± 32.5 and 57.6 ± 41.3 min, P < 0.001). In multivariate analysis, sedation method was an independent factor associated with en bloc resection and complete resection. Additionally, sedation with CPIA was not a risk factor for bleeding (P = 0.403) or perforation (P = 0.474); however, aspiration pneumonia developed more frequently in patients sedated with CPIA (CPIA vs. IMIE, 4.4 and 1.5 %, P = 0.002). CONCLUSIONS: Sedation with CPIA can improve ESD performance.ope