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[Perforation]

1) Sign of gastric perforation
- severe abdominal pain during the EMR/ESD procedure
- prominent abdominal distension immediately after the procedure
- persistent pain after procedure
- free air on the chest X-ray after gastric EMR/ESD

2) õ°øÀÇ Á¾·ù: EMR/ESD¿¡ ÀÇÇÑ Ãµ°øÀº knife¿¡ ÀÇÇÑ °íÀ¯±ÙÃþ(proper muscle layer)ÀÇ Á÷Á¢ÀûÀÎ ¼Õ»ó ȤÀº snare¿¡ ÀÇÇØ °íÀ¯±ÙÃþÀÌ Æ÷ȹµÇ¾î º´º¯ºÎ¿Í ÇÔ²² Àý°³µÊÀ¸½á ¹ß»ýµÇ´Âµ¥, ±× ºóµµ´Â 0-5%·Î ¾Ë·ÁÁ® ÀÖ´Ù. EMR/ESD¿¡ ÀÇÇÑ Ãµ°øÀº Å©°Ô µÎ °¡Áö·Î ³ª´©¾îÁø´Ù.

(1) Frank perforation: EMR/ESD ½Ã¼ú µµÁß ¶Ñ·ÇÇÑ perforating holeÀÌ ¹ß°ßµÇ´Â °æ¿ì. °ú°Å¿¡´Â ¼ö¼úÀ» ½ÃÇàÇÏ´Â °ÍÀÌ ¿øÄ¢À̾úÀ¸³ª ÃÖ±Ù¿¡´Â ´ëºÎºÐÀÇ È¯ÀÚ¿¡¼­ endoscopic clipÀ» ÀÌ¿ëÇÏ¿© Áï½Ã ³»½Ã°æÀû Ä¡·á¸¦ ½ÃÇàÇÒ ¼ö ÀÖ´Ù.


Frank perforationÀ» Áï½Ã clipÀ¸·Î Ä¡·á

(2) Micro-perforation: EMR/ESD ½Ã¼ú µµÁß ¶Ñ·ÇÇÑ perforating holeÀÌ ¹ß°ßµÇÁö ¾Ê¾ÒÀ¸³ª, ½Ã¼ú Á÷ÈÄ¿¡ ½ÃÇàÇÑ chest X-ray¿¡¼­ º¹°­³» free air°¡ °üÂûµÇ´Â °æ¿ì¸¦ ¸»ÇÑ´Ù. ´ëºÎºÐÀÇ È¯ÀÚ¿¡¼­ ³»½Ã°æÀû Ä¡·á°¡ ÇÊ¿ä ¾øÀ¸¸ç, ±Ý½Ä ¹× IV Ç×»ýÁ¦·Î Ä¡·á°¡ µÈ´Ù (°ü·Ã SMC ³í¹®). °ú°Å¿¡ ¸¹ÀÌ »ç¿ëÇÏ´ø nasogastric tube´Â ÀÌÁ¦´Â »ç¿ëÇÏÁö ¾Ê´Â´Ù. º¹°­³» °ø±â°¡ ³Ê¹« ¸¹À¸¸é ¹Ù´Ã·Î Á¦°ÅÇϱ⵵ ÇÑ´Ù (EndoTODAY- º¹°­°ø±â Á¦°Å¹æ¹ý).


Microperforation. ¸çÄ¥°£ÀÇ ±Ý½Ä°ú Ç×»ýÁ¦ Áֻ縸À¸·Î peritoneal free air°¡ ÀúÀý·Î ¼Ò½ÇµÇ¾ú´Ù.

3) õ°ø½Ã ´ëó¹æ¹ý: EMR/ESDÀÇ °æÇèÀÌ ÃàÀûµÇ¸é¼­ frank perforationÀ̳ª microperforationÀÇ ºóµµ°¡ ¸ðµÎ °¨¼ÒµÇ¾ú´Ù. ÃÖ±Ù¿¡´Â frank perforationº¸´Ù microperforationÀÇ ºóµµ°¡ ´õ ³ô´Ù. ³»½Ã°æÀ¸·Î Ä¡·áÇÑ frank perforationÀ̳ª microperforationÀÇ Ä¡·á¿øÄ¢Àº µ¿ÀÏÇÏ´Ù. EMR/ESD ½Ã¼ú µ¿¾È frank perfoationÀÌ ÀÖ¾î clipÀ¸·Î Ä¡·áÇÑ °æ¿ì³ª, chest X-ray¿¡¼­ ¿ì¿¬È÷ pneumoperitoneumÀÌ ¹ß°ßµÈ °æ¿ì¿¡´Â ¾Æ·¡¿Í °°ÀÌ °ü¸®ÇÑ´Ù.

- Àӻ󰭻糪 staff¿¡°Ô Áï½Ã º¸°íÇÑ´Ù.
- Intravenous antibiotics, usually ceftriaxone + metronidazole. Åð¿ø½Ã¿¡´Â ciprofloxacinÀ» Åõ¿©ÇÑ´Ù. Ç×»ýÁ¦ Åõ¿©±â°£ ÃÑ 10ÀÏÀÌ µÇµµ·Ï Á¶ÀýÇÑ´Ù. °¨¿°³»°ú¿¡¼­´Â UnasynÀ» ±ÇÇÏ°í ÀÖ´Ù (°ü·Ã EndoTODAY).
- Nasogastric tube´Â »ðÀÔÇÏÁö ¾Ê´Â´Ù.
- NPO: Åë»ó EMR/ESD ½Ã¼ú 48-72½Ã°£±îÁö ±Ý½ÄÇÏ°í, Áõ»óÀÇ È£ÀüÀÌ ÀÖÀ¸¸é SOWºÎÅÍ ½ÃÀÛÇÑ´Ù. õ°øÀÌ ¾ø¾ú´ø Åë»óÀûÀÎ EMR/ESD¿¡ ºñÇÏ¿© 1ÀÏ ´Ê°Ô diet°¡ ½ÃÀ۵Ǵ ¼ÀÀÌ´Ù.
- ÅëÁõÀÇ Á¶Àý: ½Ã¼ú ´çÀÏÀ̳ª ´ÙÀ½ ³¯ ÅëÁõÀÌ Áö¼ÓµÇ¸é IV Demerol 1/2 ampuleÀ» Åõ¿©ÇÑ´Ù. º¹°­³»¿¡ free air°¡ ³Ê¹« ¸¹¾Æ¼­ º¹ºÎ ºÒÆí°¨ÀÌ Áö¼ÓµÇ´Â ȯÀÚ¿¡¼­´Â º¹¼öõÀÚ¿Í ºñ½ÁÇÑ ¹æ¹ýÀ¸·Î º¹°­³» free air¸¦ Á¦°ÅÇϱ⵵ ÇÑ´Ù (EndoTODAY- º¹°­°ø±â Á¦°Å¹æ¹ý).
- Ç÷¾×°Ë»ç: ½Ã¼ú ´ÙÀ½ ³¯ CBC¿¡¼­´Â ¾à°£ÀÇ leukocytosis¸¦ º¸À̱⵵ ÇÏÁö¸¸ 1-2ÀÏ ÈÄ ´ëºÎºÐ Á¤»óÈ­µÈ´Ù.
- ¹ß¿­ÀÇ Á¶Àý: ½Ã¼ú ´çÀÏ È¤Àº ´ÙÀ½ ³¯±îÁö °æÇÑ ¹ß¿­À» º¸À̱⵵ ÇÏÁö¸¸ ´ëºÎºÐ È£ÀüµÈ´Ù.


Microperforation ÈÄ ÀüÇüÀûÀÎ °æ°ú. ¾à°£ÀÇ leukocytosis¿Í ¹ß¿­ÀÌ °¡´ÉÇÏÁö¸¸ À̳» ÁÁ¾ÆÁø´Ù. ÇÏ·ç ÀÌ»ó ÅëÁõ°ú ¹ß¿­ÀÌ Áö¼ÓµÇ¸é ¼ö¼úÀ» °í·ÁÇØ¾ß ÇÑ´Ù.


[Âü°í¹®Çå]

1) Management of Complications during ESD (Àü¼º¿ì. Diagn Ther Endosc 2012)

2) Non-surgical management of microperforation (Á¤±Ô. Digest Liver Dis 2006)


¾îÁ¦¿¡ À̾î ESD ¹è¿ì±â¿¡ ´ëÇØ Á» ´õ °í¹ÎÇØ º¸¾Ò½À´Ï´Ù. ÈçÈ÷ learning curve¶ó´Â °ÍÀÌ ¾Æ·¡¿Í °°ÀÌ ¸Å²öÇÒ °ÍÀ¸·Î »ý°¢ÇÕ´Ï´Ù. Á¤¸» ±×·²±î¿ä?

Àú´Â °³ÀÎÀÌ ¾î¶² °ÍÀ» ¹è¿ö³ª°¡´Â °úÁ¤ÀÌ ±×¸® ¸Å²ô·¯¿ï °ÍÀ̶ó »ý°¢ÇÏÁö ¾Ê½À´Ï´Ù. Á¦ °æÇèÀº ¿ÀÈ÷·Á ¾Æ·¡ ±×¸²°ú °°½À´Ï´Ù. ÀÌ¿¡ ´ëÇÑ º¸´Ù ÀÚ¼¼ÇÑ ¼³¸íÀº The Role of Emotions In LearningÀ» Âü°íÇϽñ⠹ٶø´Ï´Ù.


½±Áö ¾ÊÀº topicÀÎ ESD ¹è¿ì±â¿¡ ´ëÇÑ ÂªÀº ±Û µÎ°³¸¦ ¼Ò°³ÇÕ´Ï´Ù. ÁÁÀº ±ÛÀÔ´Ï´Ù. ÇÑ °¡Áö ¾Æ½¬¿î Á¡ÀÌ ÀÖ±â´Â ÇÕ´Ï´Ù. Á¦¸ñÀº learningÀε¥ ³»¿ëÀº ÁÖ·Î teachingÀÎ °Í °°½À´Ï´Ù. ÁøÁ¤ ESD learning¿¡ ´ëÇÑ ±ÛÀº ¾ÆÁ÷ º¸±â ¾î·Æ½À´Ï´Ù.

1) ±èÀº¿µ, Àü¼º¿ì, ±è±¤ÇÏ ¼±»ý´Ô²²¼­ ¾²½Å Chicken soup for teaching and learning ESD¿¡´Â ÀÌ·± ¸»ÀÌ ³ª¿É´Ï´Ù. ÀûÀýÇÑ supervision ÇÏ¿¡¼­ trainingÀ» ¹Þ¾Æ¾ß ÇÔÀ» °­Á¶ÇÏ°í ÀÖ½À´Ï´Ù.

"It has been reported that closely supervised trainees can perform advanced surgery such as sophagogastrectomy, hepatectomy, or pancreatectomy with similar outcomes to consultant surgeons. In those studies, surgeons with a large workload encouraged trainees to accept more opportunities to participate in such complex operations, with appropriate supervision, because this improved their learning of the surgical methods and did not jeopardize patient care. Similarly, proficiency in ESD cannot be achieved without the availability of a highly experienced supervisor, because a significant number of cases were not completed by the trainee alone and complications such as perforations were generally managed by the supervisor."

2) Coman, Gotoda, Draganov²²¼­ ¾²½Å Training in endoscopic submucosal dissection¿¡¼­´Â structured training programÀÌ ÇÊ¿äÇÔÀÌ °­Á¶µÇ¾î ÀÖ½À´Ï´Ù. ±×¸®°í ƯÀÌÇÏ°Ôµµ trainerµµ trainingÀ» ¹Þ¾Æ¾ß ÇÑ´Ù´Â ÁÖÀåµµ ÀÖ½À´Ï´Ù.

"TRAINING PROGRAMS FOR TRAINERS. This is a relatively new but important concept, as the training program for trainers is highly demanded for permeation of ESD worldwide and it is also necessary for trainers to be evaluated and rewarded."