Longstanding postoperative fluid collection influences recurrence of pancreatic malignancy

Background/Aims@#Postoperative abdominal fluid collection (PAFC) is a frequent complication of pancreatobiliary cancer surgery. The effects of the existence and duration of PAFC are not well known. This study aimed to assess the effects of PAFC on patient prognosis after surgery for pancreatobiliary adenocarcinoma and the association of longstanding PAFC with the recurrence of pancreatic cancer. @*Methods@#We retrospectively analyzed the data of 194 consecutive patients with pancreatobiliary adenocarcinoma who underwent curative operations from August 2005 to December 2019. The presence of PAFC was assessed using computed tomography within a week of surgery; PAFC lasting > 4 weeks was defined as longstanding PAFC. @*Results@#Among 194 patients, PAFC occurred in 165 (85.1%), and 74 of these had longstanding PAFC. The recurrence rate of pancreatobiliary adenocarcinoma was significantly higher in patients with longstanding PAFC than in patients with non-longstanding PAFC (p = 0.025). Recurrence was also significantly associated with high T stage (T3, T4; p = 0.040), lymph node involvement (p < 0.001), perineural invasion (p < 0.006), and non-receipt of adjuvant chemotherapy (p = 0.025). Longstanding PAFC was significantly associated with the recurrence of pancreatic adenocarcinoma (p = 0.016). However, cancer-specific survival was related to neither the presence nor the duration of PAFC. @*Conclusions@#The presence of longstanding PAFC was associated with the recurrence of pancreatic adenocarcinoma. However, a larger prospective study is necessary to confirm the findings.

One hundred sixty pancreaticoduodenectomies for periampullary cancers in a growing-volume setting: a single-institution and a single-surgeon's experience

PURPOSE: Many studies have concluded that cancer patients may have better outcomes when their surgery is performed in high-volume centers, especially when the procedure is pancreaticoduodenectomy (PD). However, some studies concluded that experienced surgeons or incorporation of expertise from high-volume centers may achieve satisfactory outcomes after PD in low-volume centers. METHODS: I retrospectively collected and analyzed the outcomes of PD for periampullary cancers treated with curative intent in my center. RESULTS: From August 2, 2005 to December 10, 2018, 160 pancreatic resections were done with curative intent in my center. The number of operations per year was 1 in 2005 and gradually increased to 21 in 2018. Thirty-day mortality was 0, and 90-day mortality was 1 (0.6%). Morbidity was found in 65 cases (40.6%). The median follow-up period was 23.2 months and 5-year survival rates were 28.5% for pancreas head cancer, 48.2% for distal CBD cancer, and 72.6% for AOV cancer. I divided patients into 2 groups by the number of annual operations, which is more than 21 per 2 years. The 2 groups showed no differences in terms of morbidity and mortality. CONCLUSION: A well-trained low-volume surgeon may perform PD safely at a well-equipped low-volume center.

The Efficacy of High Dose Dexamethasone Therapy in Children with Immune Thrombocytopenic Purpura / 임상소아혈액종양

BACKGROUND: Few studies of high dose dexamethasone (HD-DXM) therapy in children with immune thrombocytopenic purpura (ITP) have been reported. The purpose of this study is to investigate efficacy and safety of repeated HD-DXM therapy as second-line treatment of ITP in childhood. METHODS: We retrospectively analyzed the medical records of patients < 18 years of age with primary ITP who received more than 2 cycles of HD-DXM therapy from May 2004 to January 2018. HD-DXM was given orally in 4-day pulses every 28 days as a 20–40 mg/1.73 m² daily dose. RESULTS: A total of 26 patients (male, 19; female, 7) were enrolled and their median age was 6 years (range, 1–15). All patients had received previous treatment for ITP. A median 6 cycles (range, 2–19) of HD-DXM was given. On the beginning of HD-DXM therapy, three patients satisfied the criteria for newly diagnosed ITP, 16 for persistent ITP and 7 for chronic ITP. Relapse-free survival (RFS) of responders (n=9) after the last HD-DXM cycle was estimated to be 38.1±17.2%, lasting for a median 9.1 months (range, 5.6–46.2). According to response after the 2nd cycle, RFS of responders (n=13) was significantly higher than non-responders (23.1±11.7% vs. 7.7%±7.4%, P=0.001). The most common adverse event was irritability (30.8%), followed by fatigue (19.2%). CONCLUSION: HD-DXM therapy in children was relatively tolerated and response after therapy was acceptable. More courses of HD-DXM may be feasible in responders after two cycles of HD-DXM.

Neurological Outcome of Ischemic Stroke in Children: a Single Center Study / 대한소아신경학회지

PURPOSE: Ischemic stroke is rarely seen in children, but it could cause mortality and result in developmental disabilities such as motor paralysis, cognitive dysfunction, and epilepsy. In this study, the neurological outcomes of ischemic stroke in children were reviewed and the factors associated with the neurological outcomes were to be analyzed. METHODS: Medical records of patients younger than 15 years of age who were newly diagnosed with ischemic stroke between January 2006 and December 2016 in Chonnam National University Hospital were reviewed. RESULTS: This study consisted of 38 patients with ischemic stroke (male/female= 18/20, mean age=6 years 1 month±4 years 8 months). Neurological outcomes assessment was done at least 1 year after the onset of ischemic stroke. 10 patients (26.3%) had no neurological impairments. Motor paralysis was noted in 22 (57.9%), cognitive dysfunction was in 9 (23.7%), and epilepsy in 20 (52.6%). Among the possible risk factors for neurological impairments (age, sex, early seizures, characteristics of the infarcted lesions, abnormal electroencephalogram (EEG) findings), abnormalities on EEG findings were significantly associated with cognitive dysfunction (P=0.026) and the occurrence of early seizures with epilepsy (P=0.000). CONCLUSION: Neurological impairments were remained in 73.7% of children one year after ischemic stroke. Cognitive dysfunction was associated with abnormalities on EEG findings within 2 weeks after the onset of ischemic stroke and epilepsy with the occurrence of early seizures.

Adjuvant Chemotherapy for Advanced Gastric Cancer in Elderly and Non-elderly Patients: Meta-Analysis of Randomized Controlled Trials / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study evaluated the benefits of adjuvant chemotherapy on elderly patients with advanced gastric cancer (AGC) using meta-analysis of well-designed randomized controlled clinical studies. MATERIALS AND METHODS: PubMed, Embase, and Cochrane were searched to retrieve clinical studies evaluating the benefits of adjuvant chemotherapy in the elderly with AGC. Hazards ratios (HRs) with 95% confidence intervals (CIs) were pooled across studies using a fixed-effects model. RESULTS: Two studies were included in this meta-analysis to estimate HR for the overall survival (OS), and relapse-free survival (RFS) between adjuvant chemotherapy and surgery in elderly and non-elderly patients. HR for OS in the elderly and non-elderly was 0.745 (95% CI, 0.552 to 1.006, p=0.055) and 0.636 (95% CI, 0.522 to 0.776; p < 0.001), respectively, which showed no heterogeneity regarding HR between the two groups (p(interaction)=0.389). HR for RFS in the elderly and non-elderly was 0.613 (95% CI, 0.466 to 0.806; p < 0.001) and 0.633 (95% CI, 0.533 to 0.753; p < 0.001), respectively (p(interaction)=0.846). CONCLUSION: Meta-analysis suggests that the benefit of adjuvant chemotherapy to the elderly is not big enough to reach statistical significance while the HR for OS is less than 1 (0.745) and no heterogeneity are observed regarding the HR between the elderly and non-elderly patients.

Ileal Fecaloma Presenting with Small Bowel Obstruction / 대한소아소화기영양학회지

A fecaloma refers to a mass of accumulated feces that is much harder than a mass associated with fecal impaction. Fecalomas are usually found in the rectosigmoid area. A 10-year-old male with chronic constipation was admitted because of increasing abdominal pain. An abdominal computed tomography scan and a simple abdominal x-ray revealed rapidly evolving mechanical obstruction in the small intestine. Most of the fecalomas are successfully treated by conservative methods such as laxatives, enemas and rectal evacuation. When conservative treatments have failed, surgical intervention may be needed. In this case, an emergency operation was performed and a 4x3x2.5 cm fecaloma was found in the distal ileum. We thus report a case of ileal fecaloma inducing small bowel obstruction in a patient with chronic constipation, who required surgical intervention. When symptoms of acute small intestinal obstruction develop in a patient with chronic constipation, a fecaloma should be considered in differential diagnosis.

Anthocyanins From the Fruit of Vitis coignetiae Pulliat Potentiate the Cisplatin Activity by Inhibiting PI3K/Akt Signaling Pathways in Human Gastric Cancer Cells

BACKGROUND: Cisplatin (cis-diaminedichloroplatinum, CDDP) is a widely used chemotherapeutic agent for the treatment of many cancers. However, initial resistance to CDDP is a serious problem in treating these cancers. Vitis coignetiae Pulliat (Meoru in Korea) have shown anti-nuclear factor kappa B and anti-epidermal growth factor receptor activities in cancer cells. METHODS: In this study, in order to seeking an approach to increase the anti-cancer effects of CDDP with natural products. Here, we investigated anthocyanins isolated from Vitis coignetiae Pulliat (anthocyanidins isolated from meoru, AIMs) can enhance anti-cancer effects of cisplatin (CDDP) in stomach cancer cells. The cell viability of SNU-1 and SNU-16 cells after treated with AIMs and CDDP were analyzed by MTT assay. The expressions of Akt and X-linked inhibitor of apoptosis protein (XIAP) proteins were examined by western blot in AIMs- and CDDP-treated cells. RESULTS: We found that AIMs enhanced anticancer effects of CDDP, which activity was additive but not synergistic. AIMs suppressed Akt activity of the cancer cells activated by CDDP. AIMs also suppressed in XIAP an anti-apoptotic protein. CONCLUSIONS: This study suggests that the anthocyanins isolated from fruits of Vitis coignetiae Pulliat enhanced anti-cancer effects of CDDP by inhibiting Akt activity activated by CDDP.

Delayed hepatic rupture after radiofrequency ablation for colorectal hepatic metastasis: management with transcatheter arterial embolization

Intraperitoneal bleeding after radiofrequency ablation (RFA) is the most common major vascular complication due to direct needle injury to a vessel or liver capsule. However, intraperitoneal bleeding as a result of a delayed hepatic rupture after RFA for liver tumors is an extremely rare complication. The present report describes a case of intraperitoneal hemorrhage caused by delayed hepatic rupture resulting from arterioportal fistula after RFA for hepatic metastasis from colorectal cancer and successful management using transcatheter embolization.

Outcomes of Early Liver Transplantation in a Hospital That Is Starting to Perform Liver Transplantation / 대한이식학회지

BACKGROUND: In Korea, the number of liver transplantation (LT) center is still changing. Many more centers are performing liver transplantations than that during the past decades. But several centers have stopped liver transplantation, while some centers have newly started performing liver transplantation. We present our initial experience in a newly built center as an example for any center that is considering performing LT. METHODS: A total of 33 consecutive adult LTs that were performed from June 2006 to October 2009 were analyzed by comparing the first 11 living donor liver transplants (LDLTs) performed with the help of an outside experienced team (group 2) with the second 11 LDLTs (group 3) and the 11 deceased donor liver transplantations (DDLTs) cases (group 1) that were independently performed in our center. RESULTS: There was no operative mortality for the donors and there were two operative mortalities for the recipients. During a mean follow-up of 27.1 months (range: 2 days~61 months), there were two cases of late mortality for the recipients. There were no re-operations and no major complications for the donors. The warm ischemic time was significantly longer in group 1 than that in groups 2 and 3. Otherwise, there was no significant difference in the operative outcomes among the three groups. CONCLUSIONS: Thorough preparation and the valuable assistance of an experienced liver transplantation team at the beginning can facilitate a more rapid learning curve and bring about good outcomes even in a small, newly established institution.

Early Results of Endovenous Ablation with a 980-nm Diode Laser for an Incompetent Vein of Giacomini

OBJECTIVE: We wanted to evaluate the effectiveness of endovenous ablation of the incompetent vein of Giacomini using a 980-nm diode laser. MATERIALS AND METHODS: A total of 18 patients (18 limbs, 4%) had the incompetent vein of Giacomini. Retrograde reflux originating from the great saphenous vein was noted in sixteen limbs and paradoxical diastolic anterograde reflux from the saphenopopliteal junction was observed in two limbs. After tumescent anesthesia, laser ablation using a 980-nm wavelength laser fiber was performed under ultrasound and/or fluoroscopic guidance. Patients were evaluated clinically and with duplex ultrasound at one week and at one, three, six and twelve months after laser ablation for the technical and clinical success. RESULTS: In the 18 limbs, the technical success rate was 100%. Continued closure of the vein of Giacomini was seen in 18 of 18 limbs after one month, in 12 of 12 limbs after three and six months and in six of six limbs after twelve months. No recanalization of the vein and no major complications occurred. CONCLUSION: Endovenous laser ablation with a 980-nm wavelength is an effective and safe procedure for treating an incompetent vein of Giacomini.

The Primary Patency and Fracture Rates of Self-Expandable Nitinol Stents Placed in the Popliteal Arteries, Especially in the P2 and P3 Segments, in Korean Patients

OBJECTIVE: We wanted to evaluate the status of self-expandable nitinol stents implanted in the P2 and P3 segments of the popliteal artery in Korean patients. MATERIALS AND METHODS: We retrospectively analyzed 189 consecutive patients who underwent endovascular treatment for stenoocclusive lesions in the femoropopliteal artery from July 2003 to March 2009, and 18 patients who underwent stent placement in popliteal arterial P2 and P3 segments were finally enrolled. Lesion patency was evaluated by ultrasound or CT angiography, and stent fracture was assessed by plain X-rays at 1, 3, 6 and 12 months and annually thereafter. RESULTS: At the 1-month follow-up, stent fracture (Type 2) was seen in one limb (up to P3, 1 of 18, 6%) and it was identified in seven limbs at the 3-month follow-up (Type 2, Type 3, Type 4) (n = 1: up to P2; n = 6: P3). At the 6-month follow-up, one more fracture (Type 1) (up to P3) was noted. At the 1-year follow-up, there were no additional stent fractures. Just four limbs (up to P2) at the 2-year follow-up did not have stent fracture. The primary patency was 94%, 61% and 44% at 1, 3 and 6 months, respectively, and the group with stent implantation up to P3 had a higher fracture rate than that of the group that underwent stenting up to P2 (p < 0.05). CONCLUSION: We suggest that stent placement up to the popliteal arterial P3 segment and over P2 in an Asian population can worsen the stent patency owing to stent fracture. It may be necessary to develop a stent design and structure for the Asian population that can resist the bending force in the knee joint.

A comparison of postoperative pain in patients undergoing liver transplantation, donor hepatectomy, and a major hepatectomy for a tumor

BACKGROUND: Because liver transplantation (LT) essentially accompanies the deterioration, total absence, and recovery of hepatic function, and donor hepatectomy (DH) is performed in otherwise healthy individuals, we planned to compare the postoperative pain in patients undergoing LT, DH, and a major hepatectomy (MH) for a tumor. METHODS: Postoperatively, all patients were permitted to administer patient-controlled fentanyl with a standard dosing regimen. Breakthrough pain was treated with a 25microgram fentanyl bolus. Verbal rating scale (VRS) pain scores at rest (static) and during coughing (dynamic), total fentanyl consumption, and side effects were assessed at 2, 4, 6, 12, 24, and 48 h postoperatively. RESULTS: Thirty patients (11, 10, and 9 in the MH, DH, and LT groups, respectively) were included in the study. The LT group showed a lower static pain VRS score 2, 4, 6, and 12 h postoperatively, and a lower dynamic pain VRS score 12, 24, and 48 h postoperatively than the MH group. Total fentanyl consumption was significantly less in the LT group than the other two groups throughout the study period. Postoperative nausea and vomiting were reduced significantly in the LT group than in the other two groups. No significant differences in postoperative fentanyl requirement, or static and dynamic pain, existed between the MH and DH groups. CONCLUSIONS: LT patients experienced less static pain during the early postoperative period and less dynamic pain during the late postoperative period than MH patients. DH patients had similar pain intensity and postoperative fentanyl requirements to the MH patients.

Hypoglycemia due to Focal Nesidioblastosis in a Patient with Type 2 Diabetes Mellitus / 당뇨병

We report a 45-year-old man with type 2 diabetes who presented with recurrent hypoglycemia. Biochemical and imagingstudies did not show any mass-like lesion in the pancreas, so prednisolone and diazoxide were administered for the treatment of hypoglycemia. However, the hypoglycemia persisted during and after the medical treatment. A selective arterial calcium stimulation test was performed and revealed a suspicious lesion at the head of the pancreas. The patient underwent enucleation of the pancreas head lesion. The lesion was confirmed histologically to be focal nesidioblastosis and surgical resection was successfully performed. The patient showed no hypoglycemic symptoms postoperatively.

An Experience of ABO-incompatible Kidney Transplantation Using Plasmapheresis and Anti-CD20 Monoclonal Antibody / 대한진단검사의학회지

Due to an extreme shortage of cadaveric kidneys, many centers in Japan successfully performed ABO-incompatible kidney transplantations using plasmapheresis, splenectomy and immunosuppression. Recently, a protocol including anti-CD20 monoclonal antibody (rituximab) and antigen-selective immunoadsorption has been used for ABO-incompatible transplantation in Europe. In Korea, ABO-incompatible kidney transplantation has been rarely performed. We report an experience of successful ABO-incompatible kidney transplantation using plasmapheresis and rituximab. The patient was a 32-yr-old female suffering from chronic renal failure, and her blood type was O, Rh+. The donor was her husband, and his blood type was B, Rh+. A combination therapy including 5 times of plasmapheresis starting from 10 days before transplantation with 2-day interval, intravenous gammaglobulin, rituximab at 2 weeks before transplantation and potent immunosuppression successfully decreased the titers of anti-A and anti-B antibodies to 1:2 and 1:1, respectively. The kidney transplantation was successful without any sign of hyperacute or acute rejection.

A Comparative Study about Complications of Laparoscopic Appendectomy in Children and Adults

PURPOSE: In recent studies, laparoscopic appendectomy has been widely performed for not only uncomplicated appendicitis but also perforated appendicitis. But, in children, the value of laparoscopic appendectomy for acute appendicitis is not yet established. Our retrospective study is to evaluate the safety of laparoscopic surgery for acute appendicitis in children. METHODS: We reviewed electronic medical records of a total of 595 patients (95 children and 500 adults), who had been operated upon for acute appendicitis, from August 2005 to February 2007. Those patients were divided into two groups; children and adults. Demographic data, duration of pain, diagnostic methods, length of stay, operative time, time under anesthetic, time to diet, perforation rate, and complication rates were analyzed. RESULTS: In eight adult patients, laparoscopic surgery was converted to open laparatomy. There was no significant difference in perforation rates (children 20.0% vs. adults 18.1%, P=0.714). However, postoperative complication rates were significantly higher in the children group (7.4%) compared to the adult group (2.2%). CONCLUSION: We noted that laparoscopic appendectomy should be applied cautiously, especially in pediatric groups due to the relatively high complication rate. However, we need to see more high-quality randomized trials.

Treatment with pegylated interferon and ribavirin in a patient with fibrosing cholestatic hepatitis due to recurrent hepatitis C after liver transplantation / 대한간학회지

Fibrosing cholestatic hepatitis (FCH) is the most devastating manifestation of recurrent hepatitis C in transplant recipients with hepatitis C virus (HCV), possibly leading to death or retransplantation. Although FCH was first described as a complication of hepatitis B, this manifestation has been well documented in association with HCV in the setting of liver transplantation, bone marrow transplantation, heart transplantation, and end-stage human immunodeficiency virus infection. We report the clinical course and antiviral response in a patient with FCH due to recurrent hepatitis C after cadaveric liver transplantation who was treated with pegylated interferon alpha-2a and ribavirin.

A Living Donor Liver Transplantation after Therapeutic Plasmapheresis in a Patient with Positive HLA Crossmatch / 대한수혈학회지

A positive HLA crossmatch in cadevaric liver transplantation is relatively acceptable, but in living donor liver transplantation (LDLT) using relatively small sized grafts, the rejection rates were higher in positive crossmatchcases than in negative cases, as described in several previous reports. We report a case of LDLT performed with therapeutic plasmapheresis, in a recipient with a positive HLA crossmatch to donor before transplantation. The patient was a 56-year-old male patient with liver cirrhosis (UNOS status IIA, MELD score 28) caused by chronic hepatitis B. The HLA crossmatch results were 1:2 and 1:8 positive for NIH-CDC (complement dependent cytotoxicity) and AHG-CDC, respectively. The flow cytometric crossmatch (FCXM) was also positive (T-MFI ratio 9.0 and B-MFI ratio 3.4). With 5 cycles of preoperative therapeutic plasmapheresis, the HLA crossmatch converted to negative and liver transplantation was performed. The liver function of the patient was well maintained for 5 months, without any sign of hyperacute or acute rejection. However, the patient eventually died from suddenly occurred infection-associated hemophagocytic syndrome at 5 months after surgery. Therapeutic plasmapheresis can be considered as one of therapeutic options for LDLT patients with a positive HLA crossmatch to donor.

Terlipressin Effect of Portal Pressure Control on Liver Regeneration in 90% Hepatectomized Rats

PURPOSE: Liver regeneration is crucial following major liver resection or partial liver transplantation. The inhibition mechanism of regeneration is portal hypertension caused by excessive portal flow to the small liver. Portal hypertension can be controlled with terlipressin, an effective splanchnic vasoconstrictor. The purpose of this study was to investigate the effect of terlipressin on the portal pressure and liver regeneration in 90% hepatectomized rats. METHODS: Forty-eight male Sprague-Dawley (250 gm) rats were divided into three groups; Group N (n=16) underwent Sham operation, Group C (n=16) was injected with 0.1 mL saline after 90% hepatectomy, and Group T (n=16) was injected with 50microgram/kg terlipressin after 90% hepatectomy. To assess the liver regeneration response, the changes in proliferating cell nuclear antigen (PCNA) and tumor necrosis factor-alpha (TNFalpha) were monitored for 48 hours. RESULTS: The baseline portal pressures in Groups N, C, and T were 4.9, 12.4, and 14.1 mmHg (P<0.05). In Group T, the injection of terlipressin induced a significant reduction of the portal pressure (-30.2%, P<0.05). There was no difference in PCNA between Groups C and T. However, serum TNFalpha levels were significantly higher in Group T (248.4 pg/ mL) than Group C (52.3 pg/mL) 48 hours postoperatively (P<0.05). CONCLUSION: The control of portal pressure with the use of terlipressin was correlated with serum TNFalpha. These data provide evidence that the administration of terlipressin during the early postoperative period following major liver resection may have an attenuating effect on portal hypertension, which may also stimulate the initiation of the regenerative process.

Laparoscopy-assisted Hepatic Resection in a Patient with Eosinophilic Liver Abscess by Toxocaris Cani Involving Liver

The laparoscopy-assisted hepatic resection has been introduced for solitary benign or malignant hepatic tumors. We successfully had undergone left lateral sectionectomy with assistance of laparoscopy. Forty-three year old male patient was admitted for diagnosis of liver mass. Abdominal computed tomography showed a 2 cm sized single nodular tumor in segment 3 which was consistent with hepatoma. He underwent laparoscopy-assisted left lateral sectionectomy using Cavitron Ultrasonic Surgical Aspirator and Ultrasonic Shears. The patient discharged without any complications in the 8th postoperative day. The pathologic findings of nodule were consistent with the eosinophilic abscess of liver. Left lateral sectionectomy of liver can be conducted safely with assistance of laparoscopy.

The Educational Program of Surgery Using Tele-video System for Medical Students / 한국의학교육

PURPOSE: Observation of operations is believed to be a major part in the clinical clerkship of surgery, but it is very hard to be performed effectively due to the difficulty of providing an appropriate view of surgical field for many students. To overcome this problem, we have started to provide a tele-video system for clinical clerkship of surgery since 2001. The aim of this study was to evaluate the effectiveness of educational program of surgery using tele-video system. METHODS: We provided the tele-video system with camera systems in two operating rooms and 2 video projection systems in the teaching room to the third year medical students as a curriculum of clinical clerkship of surgery. Education using tele-video system was performed in the form of the interrogatory teaching between the teacher (operator) and students using microphone. The questionnaires about the program of clinical clerkship of surgery and the education with tele-video system were filled up by 190 students who had completed the 4 weeks clerkship schedule. After then, items in the questionnaires were analyzed in September and in December to evaluate the change of the students' response for the education with tele-video system. RESULTS: Eighty-eight percent of students had experienced the education with tele-video system. Most students (96%) recommended this system to their juniors, and 78% of students wanted this system to be also used in other departments' clinical clerkship. The advantages of tele-video system were revealed as the better view of surgical field, followed by clear explanation for the surgical procedure, interrogatory teaching between the operator and the students, and so on. The most effective teaching methods were revealed as direct participating in the operation (33%), followed by tele-video system (32%), reading of textbook (19%), and simple observation of the operation (15%). General satisfaction for tele-video system were scored with five (11%), four (48%), three (25%), two (7%), and one (1%) (5=excellent, 1=very poor). General satisfaction rate about tele-video system was markedly improved from September to December. CONCLUSIONS: The education with tele-video system in the clinical clerkship of surgery seems to be very effective method for teaching the medical students.