Original Article pissn 1738-2637 J Korean Soc Radiol 2013;68(1):43-48 Penetrating Stab Injuries to the Anterior Abdomen: Use of Multi- Detector Computed Tomography to Predict the Need for Laparotomy Dae Hong Park, MD, Seung Joon Choi, MD, Yu Mi Jeong, MD, Hyung Sik Kim, MD, Hye-Young Choi, MD Department of Radiology, Gachon University, Gil Hospital, Incheon, Korea Purpose: The aim of this study was to determine how well multi-detector computed tomography (MDCT) scans predict the need for a laparotomy in patients with anterior abdominal stab injuries. Materials and Methods: Eighty patients with abdominal stab injuries who underwent MDCT scans were enrolled. MDCT was performed to identify active bleeding and injured organs and to assess the accuracy between MDCT and the laparotomy findings. MDCT was considered positive or negative with respect to the need for an exploratory laparotomy. The diagnostic performance of MDCT for identifying the need for laparotomy was estimated. Results: MDCT predicted bowel and mesentery injuries in 31 of 80 patients and 28 patients were truly positive. MDCT predicted active bleeding in 23 of 80 patients and 19 patients had active bleeding. MDCT predicted the need for laparotomy in 43 of 80 patients. A laparotomy was performed in 55 of the 80 patients and 42 were therapeutic. Overall, a MDCT scan predicted the need for laparotomy with 95% sensitivity, 92% specificity, and 93% accuracy. Conclusion: MDCT scans can be used to identify active bleeding and injured organs and are an effective tool for determining the need for surgical exploration. Index terms Wounds, Stab Multi-Detector Computed Tomography Laparotomy Received August 20, 2012; Accepted November 1, 2012 Corresponding author: Seung Joon Choi, MD Department of Radiology, Gachon University, Gil Hospital, 1198 Guwol-dong, Namdong-gu, Incheon 405-760, Korea. Tel. 82-32-460-3060 Fax. 82-32-460-3065 E-mail: sjchoi@gilhospital.com Copyrights 2013 The Korean Society of Radiology 서론 응급실에내원하는복부자상환자의치료는수상기전, 환자의전신상태에따라달라질수있으며현재까지도여러외상센터에서복부자상치료를두고논란의여지가많다. 1960 년대이후, Shaftan (1) 은음성개복률을줄이기위해복강천자술을이용하여복강내장기손상을확인한후처치하는선택적보존요법 (selective conservatism) 의개념을제시하였고이후로일괄적인개복술보다는선택적치료가증가하는추세로발전해왔다. 결국, 복부자상환자평가의일차목표는복강내장기손상을정확히진단하여개복술을할것인지아닌지를결정하는것이라할수있겠다. 저자들은실제수술소견을근거로전복부자상환자에게다중검출전산화단층촬영 (multi-detector computed tomography; 이하 MDCT) 이혈관의급성출혈, 손상장 기를얼마나정확하게진단하는지확인하고 MDCT 로개복수술의필요여부를얼마나정확하게결정할수있는지알아보고자하였다. 대상과방법 환자와 CT 검사 2007 년 1월부터 2012 년 7월까지전복부자상을주소로내원한환자중 MDCT 를시행한 80명의환자를대상으로후향분석을시행하였다. 환자들의의무기록을통해내원당시환자들의수상기전, 생체징후에대한정보를얻었으며수술기록의내용과본원에서시행한 MDCT 영상을비교분석하였다. 모든환자는동일하게 16채널다중검출전산화단층촬영기기 (Somatom Sensation 16 scanner, Siemens Medical Solutions, submit.radiology.or.kr 대한영상의학회지 2013;68(1):43-48 43
Forchheim, Germany) 를이용해검사를시행받았고촬영조건 은관전압 120 kvp, 관전류 170 mas, 절편두께 5 mm, 절편 간격 2.5 mm, pitch 는 0.8 이었다. 를비교하였다. 또한 MDCT 가개복수술의필요성을결정할수 있을지확인하기위해 CT 에서수술이필요한지아닌지를구분 하는기준을설정하였다. 자료의분석 MDCT 영상은환자의치료여부를모르는상태에서두명의 영상의학과의사에의해후향적으로분석되었고, 이견이있는 경우합의에의해판정하였다. MDCT 에서혈관손상에의한급 성출혈, 장기손상여부를판단하여실제수술소견과일치여부 Table 1. Location of Abdominal Stab Wounds External Wound Location No (%) Periumbilical area 15 (19) Upper central area 15 (19) Left lower quadrant 12 (15) Multiple wounds 11 (14) Right upper quadrant 10 (12) Right lower quadrant 9 (11) Left upper quadrant 8 (10) Table 2. Organ Injuries in 42 Patients with Abdominal Stab Wounds Injured Organ (n = 53) No (%) Mesentery 18 (34) Small bowel 13 (24) Liver 6 (11) Stomach 5 (9) Colon 3 (6) Large vessel 3 (6) Diaphragm 3 (6) Common bile duct 1 (2) Pancreas 1 (2) 영상의학소견의정의 MDCT 에서수술이필요하다고결정한기준은급성출혈, 출혈을동반한복강및후복강장기손상, 내장손상이의심되는경우를말하며수술이필요하지않다고판단한경우는소량의장간막출혈, 출혈을동반하지않는복강및후복강장기손상이있는경우로정하였다. 그외장기손상이보이지않는경우를정상으로분류하였다. 급성출혈은대동맥이나근처대혈관과비슷한음영을보이는조영제가선상혹은불규칙적으로혈종주변에보일경우진단하였다 (2). 내장이나장간막의손상은내장이나장간막의외부경계를따라보이는급성출혈및유리공기를확인하거나내장벽이나장간막의국소적단절및비대가있을경우로정의하였다 (3, 4). 수술소견의정의수술적으로치료가필요하다고생각한경우는내장이나장간막손상및괴사로혈관결찰이나분절절제술이필요한경우, 출혈이동반된고형장기손상이있을경우로정의했다. 내장열상은장벽전층이찢어진경우로간주하였고국소장막 (serosa) 손상만있는경우는열상에서제외하였다. 그외수술처치가필요치않은국소장간막출혈이나출혈이동반되지않은고형장기손상은수술이필요하지않은경우로정의하였다. 결과 A B Fig. 1. Stab wound to anterior abdomen in a 43-year-old man. A. CT scan shows defect (thin arrow) in anterior abdominal wall. Hematoma in both paracolic gutter (thick arrows) with contrast material extravasation (arrowhead) in the mesentery is seen. B. Lower section of the CT scan of the same patient shows bowel wall thickening (black thin arrow) and free intraperitoneal air (white thin arrows). Also seen is streaking of the mesenteric fat adjacent to the thickened bowel (white arrowhead). An injury to the mesenteric vessel and ileum was confirmed surgically. 연구에포함된 80 명의전복부자상환자는 17 세부터 62 세로구성되어있으며평균연령은 38 세였다. 30 대와 40 대가각각 30% 로총 60% 를차지했으며남자가 64 명, 여자가 16 명으로남자가 4배많았다. 전체환자중다발손상을입은경우는 11예로약 14% 에해당하였고부위는배꼽주변과심와부가각각 15 예로총 43% 를차지했으며그외좌하복부 (12 예 ), 우상복부 (10 예 ), 우하복부 (9예), 좌상복부 (8예) 순으로나타났다 (Table 1). 가장흔한손상장기는장간막으로 18예에해당하였고그다음으로소장이 13예, 간과위가각각 6예와 5예, 대장, 대혈관, 횡격막이각각 3예로나타났으며그외총담관 (1예) 이나췌장 (1예) 손상도관찰되었다 (Table 2). 이중위를포함한내장손상이 21예였는데이중 81% 에서설명되지않는복수, 장간막혈종및지방침윤이있었고 71% 의환자에서국소장벽비후와유리공기가보였다 (Fig. 1). 내장천공없이장간막손상만있었던 44 대한영상의학회지 2013;68(1):43-48 submit.radiology.or.kr
박대홍외 경우 10예로장간막혈종 (80%) 이나지방침윤 (70%) 이보였으나유리공기가보인경우는없었다 (Fig. 2, Table 3). 내장및장간막손상이같이있었던경우는 7예였고이경우는모두내장천공에포함시켰다. 내장및장간막손상에대해 CT는 93% 의민감도와 94% 의특이도, 90% 의양성예측도, 96% 의음성예측도, 94% 의정확도를보였다. 2명의환자에서위음성을보였고 3명의환자에서위양성을보였다 (Table 4). 55명의수술환자중 CT에서급성출혈이의심되었던환자는 23명이었는데그중 19명이실제급성출혈을보여 4명에서위양성을보였고위음성을보인경우는없었다 (Fig. 3). 31명은 CT에서급성출혈이없었고수술에서이를확인하였으며수술 을받지않은나머지 25명은 CT에서급성출혈이없었고이후외래및입원관찰에서도급성출혈을시사하는소견은없었다. CT는급성출혈을진단하는데 100% 의민감도, 92% 의특이도, 80% 의양성예측도, 100% 의음성예측도및 94% 의정확도를보였다 (Table 4). 80명의환자중 55명이수술을받았는데 43명이 CT에서수술이필요하다고생각된경우였고나머지 12 명은 CT에서는복벽에심근막손상외에특별한이상이없었으나임상적으로복강내장기손상이의심되어개복술을진행하였다. CT에서수술이필요하다고생각한 43명중 40명에서실제수술이필요했으며 3명은위양성환자였다. CT에서수술이필요하지않다고판단 Table 3. Scan Findings in Patients with Perforation and Mesenteric Injuries* Finding Perforation (n = 21) No (%) Mesenteric Injury (n = 10) No (%) Mesenteric hematoma 17 (81) 8 (80) Mesenteric fat strands 17 (81) 7 (70) Unexplained intraperitoneal fluid 17 (81) 5 (50) Bowel wall thickening 15 (71) 3 (30) Pneumoperitoneum 15 (71) 0 Extravasation of vascular contrast 12 (57) 5 (50) Negative for BMI 1 (5) 0 Note.-*Percentages are shown in parentheses. BMI = bowel and mesenteric injuries Table 4. Diagnostic Performance of MDCT in Patients with Active Bleeding and Bowel or Mesenteric Injuries True Positive False Positive True Negative False Negative Sensitivity (%) Specificity (%) PPV (%) NPV (%) Extravasation of vascular contrast 19 4 57 0 100 93 82 100 95 Bowel or mesentery injury 28 3 47 2 93 94 90 96 94 Note.-MDCT = multi-detector CT, NPV = negative predictive value, PPV = positive predictive value Accuracy (%) Fig. 2. Stab wound to anterior abdomen in a 25-year-old man. CT scan shows defect (thin arrow) in anterior abdominal wall. Free intraperitoneal fluid in mesentery and right paracolic gutter (thick arrows) with linear contrast material extravasation (arrowhead) along right side anterior abdominal wall is seen. No free intraperitoneal air is seen on CT scan. At surgery, an injury to the mesenteric vessel was seen and no bowel injury was found. Fig. 3. Stab wound to anterior abdomen in a 33-year-old man. CT scan shows large mesenteric hematoma (thick arrows) including contrast material extravasation (arrowhead) adjacent inferior mesenteric artery (thin arrow). At surgery, transection of proximal inferior mesenteric artery was found. submit.radiology.or.kr 대한영상의학회지 2013;68(1):43-48 45
되었던 37 명의환자중 12명은임상적으로장기손상이의심되어수술을진행하였으며 2명에서소장천공과소장괴사를각각확인해부분절제술을시행하였다. 수술을받지않은 25명의환자중 17 명은입원후특별한증상을보이지않아퇴원하였으며입원경과중상태가악화되어지연개복술을한환자는없었다. 입원하지않은나머지 8명은응급실에서상처부위봉합후퇴원하였으며이후외래진료에서지연손상이없는것을확인하였다. 결과적으로 55명의환자중 42명의환자에서는치료적개복술이필요했으며나머지 13명은수술적치료가필요치않았던환자였다. 개복술여부를결정하는데있어 CT는 95% 의민감도, 92% 의특이도, 93% 의양성예측도, 94% 의음성예측도, 94% 의정확도를보였다. 고찰 복부자상에대한치료는각외상센터마다여전히논란의대상이되고있다. 1970 년대까지복부자상에의한관통이있을때개복술이의무적으로시행되어야하며이를통해유병률과사망률을감소시킨다고알려져있었다 (5). 그러나 1960 년대이후, 미국내여러외상센터에서선별적비수술적처치 (selective conservative management) 가도입되면서의무적인개복술 (mandatory exploration) 에의한음성개복률을줄이기위한노력은현재까지계속되고있다 (6, 7). 1978 년에 McAlvanah 와 Shaftan (8) 은 590 명의복부자상환자중개복술이필요없다고생각되는 414 명 (70.2%) 의환자를대상으로선별적비수술적처치를시도했으며이들에서낮은사망률을보고했다. 이때그들이개복술이필요하다고생각한경우는악화되는복막자극증상, 복근긴장 (muscle guarding), 설명할수없는쇼크, 위장관출혈등이있었다. Leppäniemi 등 (9) 은환자가혈역학적으로불안정하거나복막염과연관된압통이있을경우확실한개복적응증이된다고주장했으며, Salim 등 (10) 은입원기간중환자의임상증상이나혈류역학적변화가있을경우개복술이필요하다는것을증명하였다. 최근에미국에서 359 명의복부자상환자를대상으로진행된다기관연구에서쇼크나내장탈출, 명확한복막자극증상이있을경우개복술을시행해야하며위와같은증상이없다면자상으로인한위험은크지않으며수술없이치료가가능하다고주장하였다 (11). 결국, 복부자상환자의치료방향은응급개복술의적응이되는환자에게신속한수술치료를진행하고수술이필요하지않은환자의음성개복률을줄여불필요한수술에의해발생하는합병증이나경제적부담을줄이는방향으로진행되고있다. 응급개복여부를결정하는데국소자상조사법과 CT가도움 이될수있다. 국소자상조사법은자상이복직근보다깊을경우복막관통소견으로간주하여개복술을시행하는방법이다. 그러나이방법은우선숙련된외과의가있어야하며시술자체가환자에게심한통증을유발하고출혈및국소감염의위험이있다. 또한심한비만환자나복근이발달한환자에게시행하기어렵다는단점이있다. CT는개복술을결정하는데중요한역할을하며혈역학적으로문제가없다면우선적으로시행되는검사방법이다. CT 기술의발달로검사가빨라지면서호흡조절이안되거나협조가되지않는환자에서도비교적좋은영상을제공하여적절한치료계획을세우는데도움을주고있다. 그러나방사선노출이나조영제를사용해야하는단점이있으며고형장기에비해내장및장간막손상의진단하는데위양성이나위음성의가능성을염두해야한다 (10, 12). Dowe 등 (4) 은 CT에서 26 명의내장및장간막손상이있는환자를수술이필요하다고했으나그중 19% (5/26) 의환자가수술을필요로하지않는위양성을보였다. Sherck 등 (13) 은 CT로내장손상을진단하는데비교적높은민감도 (92%), 특이도 (94%), 음성예측도 (100%), 정확도 (94%) 를보였는데 6%(55/857) 의환자에서위양성률을보고하였다. 우리의경우, 총 31명의내장및장간막손상의환자중 3명의환자에서위양성, 2명의환자에서위음성을보였다. 위양성환자의경우내장이체외탈출되어손상이의심되었으나실제손상은없었던경우, 장간막주변에다량의복수가있어장간막손상을의심했으나없었던경우, 우측후복강에유리공기와혈종이있어상행결장손상을의심했으나내장손상이없었던경우였다. 위음성을보인경우는 CT에서심근막관통외에특이소견이없었으나입원후반동압통이악화되어개복술을시행하였고소장천공과소장괴사를각각발견하여소장절제술을시행하였다. 내장손상은유병률은높지않으나병변을놓치거나진단이늦어져수술이지연될경우심각한결과를초래할수있으므로그진단이매우중요하다고하겠다 (14). 위양성이나위음성을보인경우가모두내장손상이므로 CT에서음성을보인경우라도위음성의가능성을고려하여반복적인증상관찰과신체검사를시행해야할필요가있다. Fakhry 등 (15) 은소장손상을받았던 202 명을대상으로한다기관연구에서 8시간내로내장손상의진단이늦어질경우사망률이증가한다는결과를보고하였다. MDCT 에서수술이필요하지않다고판단되었던 37 명의환자중 12명은임상적으로장기손상이의심되어수술을진행하였다. 이들은 CT에서모두심근막관통이의심되었으나그외복강내장기손상은분명치않았다. 이중 10명에서는수술적치료가필요없었으며 2명에서소장천공과소장괴사를각각확 46 대한영상의학회지 2013;68(1):43-48 submit.radiology.or.kr
박대홍외 인하였다. 이는이전연구에서심근막관통만으로개복술의적응증이될수없다는점을뒷받침한다고하겠다. 과거연구들에서복막관통이있는환자중 30~50% 는수술적치료를필요로하지않았으며저자들은이를바탕으로복강내급성출혈이나분명한내장손상이동반되지않는복막관통은개복술의적응증이되지않는다고주장하였다 (9, 11, 16). 이전연구들에서 CT는개복술을결정하는데높은민감도 (94~100%), 특이도 (90~96%), 정확도 (94~97%) 를보여자상환자의치료계획을결정하고음성개복률을줄이는데중요한역할을하고있다 (17-19). 본연구에서도 CT는비교적높은민감도 (95%) 와특이도 (92%), 양성예측도 (93%), 음성예측도 (94%), 정확도 (94%) 를보였다. 기존의연구들에서자상환자에게조영제의정맥내주입외에구강과항문에조영제를넣고검사하는 triple contrast CT를시행하여 95% 이상의높은정확도를보고하였다. 그러나, triple contrast CT는소장벽비후및장간막출혈을확인하는데도움을주었으나실제 CT에서내장외조영제유출을확인한경우는 15~19% 에불과하였다 (17, 18, 20). 또한, 조영제주입후장관내조영제가적절하게찬경우가 59% 에불과할정도로위장관내조영제의이동속도를맞추기어려워원하는부위의내장손상을평가하는데제한점이있다 (21). Ramirez 등 (19) 이 single contrast CT에서도 93% 의정확도를보여정맥내조영제주입만으로도효과적인접근이가능하다고주장했으며우리의검사결과도위장관에추가적인조영제주입없이 94% 의정확도를보여이를뒷받침하고있다. 이연구의제한점으로는첫째, 환자대상군이적어민감도나특이도에영향을미쳤을것으로생각된다. 또한, 후향연구였기때문에수술을하지않은환자들의경우퇴원후재내원시동일한외과의사에의해신체검사가진행되지않았고이내용들또한의무기록에의존하고있어한계점으로지적될수있다. 결론적으로전복부자상환자의개복술을결정하는데 MDCT 는높은진단민감도, 특이도및정확도를보인만큼음성개복률을줄이기위해서 MDCT 가중요한역할을할수있다. 여러연구에서보듯이일부내장및장간막손상에서나타날수있는위양성을줄이기위해임상의와영상의학과의사간에긴밀한협조와토론이수반되어야하고위음성을줄이기위해환자의통증양상과신체검사의변화를주의깊게관찰하는것이필요하겠다. 참고문헌 1. Shaftan GW. Indications for operation in abdominal trauma. Am J Surg 1960;99:657-664 2. Shanmuganathan K, Mirvis SE, Sover ER. Value of contrastenhanced CT in detecting active hemorrhage in patients with blunt abdominal or pelvic trauma. AJR Am J Roentgenol 1993;161:65-69 3. Rizzo MJ, Federle MP, Griffiths BG. Bowel and mesenteric injury following blunt abdominal trauma: evaluation with CT. Radiology 1989;173:143-148 4. Dowe MF, Shanmuganathan K, Mirvis SE, Steiner RC, Cooper C. CT findings of mesenteric injury after blunt trauma: implications for surgical intervention. AJR Am J Roentgenol 1997;168:425-428 5. Adams DB. Mandatory exploration for penetrating abdominal wounds. Arch Surg 1991;126:115 6. Nance FC, Cohn I Jr. Surgical judgment in the management of stab wounds of the abdomen: a retrospective and prospective analysis based on a study of 600 stabbed patients. Ann Surg 1969;170:569-580 7. Nance FC, Wennar MH, Johnson LW, Ingram JC Jr, Cohn I Jr. Surgical judgment in the management of penetrating wounds of the abdomen: experience with 2212 patients. Ann Surg 1974;179:639-646 8. McAlvanah MJ, Shaftan GW. Selective conservatism in penetrating abdominal wounds: a continuing reappraisal. J Trauma 1978;18:206-212 9. Leppäniemi AK, Voutilainen PE, Haapiainen RK. Indications for early mandatory laparotomy in abdominal stab wounds. Br J Surg 1999;86:76-80 10. Salim A, Sangthong B, Martin M, Brown C, Plurad D, Inaba K, et al. Use of computed tomography in anterior abdominal stab wounds: results of a prospective study. Arch Surg 2006;141:745-750; discussion 750-752 11. Biffl WL, Kaups KL, Cothren CC, Brasel KJ, Dicker RA, Bullard MK, et al. Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 2009;66:1294-1301 12. Soto JA, Morales C, Múnera F, Sanabria A, Guevara JM, Suárez T. Penetrating stab wounds to the abdomen: use of serial US and contrast-enhanced CT in stable patients. Radiology 2001;220:365-371 13. Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of computed tomography in the diagnosis of blunt smallbowel perforation. Am J Surg 1994;168:670-675 submit.radiology.or.kr 대한영상의학회지 2013;68(1):43-48 47
14. Dauterive AH, Flancbaum L, Cox EF. Blunt intestinal trauma. A modern-day review. Ann Surg 1985;201:198-203 15. Fakhry SM, Brownstein M, Baker CC, Watts DD, Oller D. Relatively short diagnostic delays produce morbidity and mortality in blunt small bowel injury (SBI): an analysis of time to operative intervention in 202 patients from a multicenter experience. J Trauma 1999;47:207 16. Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds. A prospective study of 651 patients. Ann Surg 1987;205:129-132 17. Chiu WC, Shanmuganathan K, Mirvis SE, Scalea TM. Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography. J Trauma 2001;51:860-868; discussion 868-869 18. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Scalea TM. Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. AJR Am J Roentgenol 2001;177: 1247-1256 19. Ramirez RM, Cureton EL, Ereso AQ, Kwan RO, Dozier KC, Sadjadi J, et al. Single-contrast computed tomography for the triage of patients with penetrating torso trauma. J Trauma 2009;67:583-588 20. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJ, Scalea TM. Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients. Radiology 2004;231:775-784 21. Tsang BD, Panacek EA, Brant WE, Wisner DH. Effect of oral contrast administration for abdominal computed tomography in the evaluation of acute blunt trauma. Ann Emerg Med 1997;30:7-13 박대홍 최승준 정유미 김형식 최혜영 목적 : 전복부의자상환자의개복술을결정하는데있어다중검출전산화단층촬영 (multi-detector CT; 이하 MDCT) 의유용성을알아보고자하였다. 대상과방법 : 전복부자상을주소로내원한환자중 MDCT 를시행한 80 명의환자를대상으로연구를진행하였다. MDCT 를이용하여급성출혈및장기손상여부를확인하고이를토대로수술의필요여부를판단하여실제수술소견과비교하여개복술을결정하는데있어 MDCT 의민감도, 특이도및정확도를알아보고자하였다. 결과 : MDCT 에서내장및장간막손상이의심된 31예중 28예가수술실에서실제손상으로확인되었고급성출혈이의심되었던 23예중 19예에서급성출혈을확인하였다. 80명중 43명에서 MDCT 에서수술이필요할것으로판단했고, 37 명에서수술이필요하지않을것이라고판단했다. 실제개복술을시행한 55명의환자중 42명에서수술이필요했으며나머지 13명은수술이필요하지않은경우였다. MDCT 는개복술을결정하는데 95% 의민감도, 92% 의특이도, 93% 의양성예측도, 94% 의음성예측도와 94% 의정확도를보였다. 결론 : MDCT 는장기손상과급성출혈을진단하는데효과적이며이를토대로전복부자상환자의개복술을결정하는데효율적인검사방법이라하겠다. 가천대학교의학전문대학원길병원영상의학과 48 대한영상의학회지 2013;68(1):43-48 submit.radiology.or.kr