제64회 내시경 집담회 순천향대학교병원 소화기내과 송해정 박정훈 정인섭 유창범 조주영 이문성 심찬섭 순 천 향 대 학 교 의 1 9 7 4 소 화 기 내 병 클 리 닉 제64회 내시경 집담회 순천향대학교병원 소화기내과 송해정 박정훈 정인섭 유창범 조주영 이문성 심찬섭 INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

CASE 1 INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

73세 여자 환자가 1주일 전 갑작스럽게 발생한 심와부 동통으로 주소 : Abdominal pain 현병력 : 73세 여자 환자가 1주일 전 갑작스럽게 발생한 심와부 동통으로 인근 병원에서 위내시경 검사를 시행하고 조기위암 의심되어 정밀검 사 위해 전원. 음주력 및 흡연력 : (-). 과거력 : 관절염으로 1년 전 입원 가족력 : 특이소견 없음 INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

AST/ALT : 18/12 U/L , T-Bill : 0.5 mg/dL, ALP : 61 U/L 검사실 소견 : CBC : 8,100-13.8/39.5-151000  AST/ALT : 18/12 U/L ,  T-Bill : 0.5 mg/dL, ALP : 61 U/L  Bun/Cr : 13.6/0.5 mg/dL                           CEA : 6.02 ng/ml (0-4.0 ng/ml) INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Gastroscopy INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

EUS & Abdominal CT INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

EISD (Endoscopic incision and submucosal dissection) INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Pathology 7.7cm 5.9cm INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Pathology INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Aspiration pneumonia INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

F/U Gastroscopy After 20days After 30days After 3months After 6months INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Post-EISD antral stenosis INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

How do you management in this patient ? Conservative treatment 2. Bougie dilatation 3. Steroid injection 4. Operation INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

CASE 2 INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

부 통증을 주소로 내원하였음. 외래에서 시행한 상부위장관내시경 검사에서 조기 위암 의심되어 입원함. 55세 남자 주소 : Epigastric discomfort 현병력 : 55세 남자 환자가 수 개월 전부터 발생하고 새벽에 악화되는 심와 부 통증을 주소로 내원하였음. 외래에서 시행한 상부위장관내시경 검사에서 조기 위암 의심되어 입원함. 음주력: social drinking, 흡연력: 30 P.Y.. 과거력 및 가족력: 특이소견 없음 INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

AST/ALT : 23/26 U/L , T-Bill : 0.5 mg/dL, ALP : 105 U/L 검사실 소견 : CBC : 6,200-14.3/39.3-173,000  AST/ALT : 23/26 U/L ,  T-Bill : 0.5 mg/dL, ALP : 105 U/L  Bun/Cr : 16.0/0.6 mg/dL                           CEA: 0.4 ng/ml INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Gastroscopy A D C B INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

EUS & Abdominal CT INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Endoscopic sentinel lymph node navigation (99m-Tc tin colloid) INSTITTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

EISD C A B D INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

C B A A D C B D Comparing Gastroscopy with pathologic specimen 1 3.4cm INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Pathology A C D B C A B D INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Pathology INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Pathology Cytokeratin Factor VIII-related antigen INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

1st pathologic interpretation (Not GI pathologist) PATHOLOGIC REPORT 1st pathologic interpretation (Not GI pathologist) 1. Adenocarcinoma, moderately differentiated. 2. Depth : confined to mucosa(M3) (superficial muscularis mucosa) 3. Free lateral margin ≥0.2cm INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

B A C D After 40days After 60days F/U Gastroscopy INSTITUTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

F/U biopsy after 40days Adenocarcinoma, well differentiated INSTITTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Adenocarcinoma (moderate differentiated) Pathologic mapping (reinterpretation by GI pathologist) 260 270 280 190 170 160 290 250 80 70 60 140 130 120 110 100 90 10 220 240 20 230 210 200 150 300 310 320 330 340 350 180 30 40 50 De novo Adenocarcinoma (moderate differentiated) 33 x 17mm, M3 layer Lat. Margin : involved ( 0˚-10˚, 18-21mm, 0-3mm ) C B D 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 A 진소영 교수님- slice 개수- 1번부터 번호 확인. D D INSTITTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

EISD specimen protractor 190 170 160 290 250 80 70 60 140 130 120 110 100 90 220 240 20 230 210 200 150 300 310 320 330 340 180 30 40 50 EISD specimen protractor 10 350 INSTITTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL 260 270 280

Residual EGC after EISD and misinterpreted pathologic specimen INSTITTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

How do you management in this patient ? Re-EISD (endoscopic incision and submucosal dissection) 2. EDT (endoscopic destructive therapy) 3. operation INSTITTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL

Thank you for attention INSTITTE FOR DIGESTIVE RESEARCH - SOON CHUN HYANG UNIV. HOSPITAL