C.C > No symptom P. I > 특이병력 없던 자, 약 두 달전 목욕탕에서 넘어지면서 우 측 옆구리쪽 통증 지속되어 Abd CT 촬영하였으며 CT 에 서 우연히 pancreatic mass 발견되어 수술적 치료 위해 입원함. PMHx > DM/HTN/Tb/Hepatitis (-/-/-/-) OPHx > (-) 김 O 자 (F/69)

Review of Systems 1.General Fever(-) Chill(-) Fatigue(-) Wt.loss (-) 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)

Review of Systems 5. Abdomen A/N/V/D/C(-/-/-/-/-) Abd pain(-) Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-)

Physical Examination 1.General Alert Mentality Acute ill appearance 2.E/ENT Isocoric Pupil with PLR (++/++) 3.H/Neck NVE(-) LNE(-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale

Physical Examination 5. Abdomen Soft & Flat Abdomen Normoactive Bowel Sounds Abd Td/rTd (-/-) Muscle Guarding (-) CVA Td (-/-) Organomegaly (-)

Initial Lab. finding CBC 4330 – 14.3 – 43.4 – 310K (seg. 54.0%) Pro/Alb 7.4 /4.5 TB/DB 0.32/0.10 AST/ALT 18/15 ALP / GGT 64/18 BUN/Cr 12/0.6 Na/K/Cl 143/4.5/103

Work up Pancreas CT S

r/o Pancreas Castleman’s disease Impression

Operation Lap. Stomach wedge resection  PostOp. & Final path. Dx.: Stomach GIST

C.C > Anal discharge Adm: P. I > 특이병력 없는 자, 2011 년 5 월 23 일 Rectal ca. 로 ISR c loop ileostomy 시행 후 anal discharge 지속되어 management 위해 입원함. PMHx > DM/HTN/Tb/Hepatitis (-/-/-/-) OPHx > (+) ISR c loop ileostomy 30 년 전 cholecystectomy 최 O 호 (M/64)

Review of Systems 1.General Fever(-) Chill(-) Fatigue(-) Wt.loss (-) 2.Skin Itching(-) Rash(-) Pigmentation(-) Jaundice(-) 3.H/Neck Headache(-) Stiffness(-) Sore Throat(-) 4.Cardiopulmonary Dyspnea(-) Cough(-) Sputum(-) Hemoptysis(-) PND(-) Chest Pain(-) Palpitation(-)

Review of Systems 5. Abdomen A/N/V/D/C(-/-/-/-/-) Abd pain(-) Hematemesis(-) Melena(-) Hematochezia(-) Stool Caliber Change(-) Anal discharge(+): pus-like

Physical Examination 1.General Alert Mentality Not so-ill looking appearance 2.E/ENT Isocoric Pupil with PLR (++/++) 3.H/Neck NVE(-) LNE(-) 4.Chest Symmetric Expansion RHB without Murmur, CBS without Rale

Physical Examination 5. Abdomen Soft & Flat Abdomen Normoactive Bowel Sounds Abd Td/rTd (-/-) Muscle Guarding (-) CVA Td (-/-) Organomegaly (-)

Initial Lab. finding CBC 8620 – 11.2 – 27.8 – 514K (seg. 59.9%) Pro/Alb 7.8 /4.2 TB 0.26 AST/ALT 29/35 ALP 162 BUN/Cr 10/0.7 Na/K/Cl 135/4.6/97

Work up 외부 abd CT Pelvic MRI Chest CT PET CT Abd general CT 외부 colonoscopy EUS Sigmoidoscopy Sigmoidoscopy

Anastomosis site disruption s/p rectal cancer s/p ISR state Impression

Operation Primary closure at anastomosis site VAC (Vacuum assisted closure) apply / / / / ( 총 5 회 ) VAC removal

VAC (Vacuum assisted closure) - Fleischmann, 1993 년 최초 감염되거나 개방된 상처의 치료에 조절된 음압 (controlled subatmospheric pressure) 을 사용 - Argenta 와 Morykwas, 1997 년 국소적 음압을 2 차 치유에 의 해 상처 회복을 촉진시키는 하나의 방법으로 사용하면서 Wound VAC 장치를 발전 - suction canister, suction tube, polyurethane foam VAC advanced therapy system (ATS) Disease review

VAC (Vacuum assisted closure) - Negative pressure: intermittent mode, continuous mode (optimal pressure: 125 mmHg) - Polyurethane foam: μ m 의 기공 크기. 삼출물을 제거하고 음압을 상처부위에 균일하게 분배. Foam sponge 는 치료가 끝날 때까지 매 시간마다 교환 Disease review

VAC (Vacuum assisted closure) - complex diabetic foot wounds, traumatic wounds, postoperative infected wounds or complex perineal wounds - 조직에 응력 (stress) 을 가하여 조직의 세포 분열과 성장인자 합 성을자극 부종을 형성하는 과도한 간질액을 적극적으로 배출시켜 미세 순환을 활성화 상처 내 세균의 수를 감소시켜 감염을 예방 - significant reduction in wound closure time, mild to moderate discomfort and possibly shorter hospitalization Disease review