Effect after Change of Evaluation Method in Surgical Clerkship Program / 한국의학교육

PURPOSE: Since 2002, Department of Surgery, Yonsei University Wonju College of Medicine attempted to revise the evaluation method of surgical clerkship program. The purpose of this study was to analyze the effect after change of evaluation method. METHODS: Major changes in current revisions were summarized as follows; (1) multiple evaluator, (2) student's attitude evaluated by rating scale method, (3) attendance and procedure evaluation were measured in numbers according to the fixed criteria, (4) addition of clinic-based items such as problem-solving items in the final written examination. We compared the measurement of revised evaluation at 2002 with those at 1999. And the correlation or simple linear regression analysis between score of clerkship and student academic grade score were taken. RESULTS: The clerkship score of students at 2002 showed more powerful discrimination between high performance group and poor group than that of 1999's. Even though the subject score of clerkship was significantly correlated with grade score regardless of evaluation method of clerkship, the subject score of clerkship at 2002 was more closely correlated with a grade score than 1999's. The score of knowledge-based items from final written examination is not correlated with clerkship score, but on the other hands, there was significant correlation between score of clinic-based items and clerkship score. CONCLUSION: In conclusion, variable measurements under the exact guideline and principle are more reliable method in evaluation of surgical clerkship.

Proper Treatment for Megacolon after Various Anoplasties for Anorectal Malformation

PURPOSE: The megacolon after repairing an anorectal malformation is not a rare complication, and there is much controversiy on the causes, the treatment of choice and the results after a longterm follow-up. We present 5 cases of a megacolon after the repair of an anorectal malformation, which were controlled with either a surgical resection or conservative treatment. METHODS: Five patients with a megacolon after the repair of an anorectal malformation were studied. A retrospective chart review was done and fecal continence was evaluated with an individual interview. RESULTS: All five patients initially underwent conservative treatment with laxatives and/or enemas. One Patient responded well to conservative treatment and the diameter of the bowel reduced to normal size. Another patient responded to conservative treatment after correcting the location of the anus. Three patients needed a surgical resection and one of those needed a further procedure to correct the anal location. After the surgical resection of the megacolon and/or correction of the anus (one out of the three patients), they soon reported an almost normal bowel habit. CONCLUSION: The first step in treating a megacolon after repairing an anorectal malformation was conservative treatment. However patients without an adequate response to conservative treatment are best managed with a surgical resection. The cause of the megacolon is now under investigation and the lack of adequate management after repair is one of the subjects.

Morphometric Evaluation of PGP9.5 and NCAM Expressing Nerve Fibers in Colonic Muscle of Patients with Hirschsprung's Disease

A quantitative assessment of the density of the protein gene product 9.5 (PGP9.5), the neural cell adhesion molecule (NCAM), and the low-affinity nerve growth factor receptor (NGFR) expressing nerve fibers in the circular muscle layer in the colon was carried out by morphometric analyses from 13 patients with Hirschsprung's disease (HD). The difference in the nerve fiber density between the ganglionic and aganglionic segments was compared by calculating the ratio of the sum of the areas occupied by positively stained nerve fibers per unit area of the muscle after immunohistochemical staining on paraffin embedded tissue sections using computer software. There was an obvious difference in the density of the PGP9.5 stained nerve fibers between the ganglionic (0.0380 +/- 0.0171) and aganglionic segments (0.0143 +/- 0.01661). The NCAM-positive nerve fibers were fewer in number than those of both the PGP9.5-positive fibers and NCAM-positive fibers, which were also markedly lower in number in the aganglionic segment (0.0066 +/- 0.0076) than in the ganglionic segment (0.0230 +/- 0.0195). Immunostaining for low-affinity NGFR revealed much fainter staining in the ganglionic and aganglionic segment without a statistically significant difference in their density. Considering the fact that PGP9.5 is a very sensitive marker for nerve fibers, the results of this study reaffirm the innervation failure of the proper muscle in HD. The decreased NCAM expression level in the aganglionic segment appears to be caused not by the selective down-regulation of NCAM expression among the nerve fibers but by a markedly reduced number of nerve fibers.

The Results of Surgical Treatment for Suppurative Cervical Lymphadenitis in Children

PURPOSE: The results of surgical treatment for acute suppurative cervical lymphadenitis in children were evaluated with literature reviews. METHODS: Children under 15-year old who required operative management for acute suppurative cervical lymphadenitis between January 1996 and December 2000 were evaluated with retrospective manner. The clinical characteristics, pathologic results and microbiologic studies were reviewed. RESULTS: 37 patients were treated with surgical methods. 36 patients recovered fully after surgical intervention without any recurrence and one patient expired of sepsis. CONCLUSION: The classical treatment, incision and drainage, is one of the treatment of choice for the recovery from suppurative cervical lymphadenitis in children.

Succesful Treatment of Multiseptated Liver Abscess by Percutaneous Drainage with Urokinase

Liver abscess is a rare disease but shows a high mortality rate. The standard treatment is complete drainage of the abscess through surgery or insertion of a percutaneous catheter and proper antibiotic treatment. However, successful percutaneous drainage in a multiseptated abscess has several drawbacks, such as the necessity for inserting more than one catheter for proper drainage, a necessity for repetitive cathterization and moreover, the ultimate failure of effective drainage causing surgery to become inevitable. The authors used 80,000 IU urokinase three times per day over 5 days to lyse the fibrous septum in a 9-year-old child with multiseptated liver abscess. Catheter drainage with urokinase under radiologic intervention yielded successful a outcome in the treatment of a multiseptated liver abscess.

Experimental Congenital Diaphragmatic Hernia in a Fetal Lamb Model (I)

PURPOSE: The purpose of this study was to construct a fetal animal model of congenital diaphragmatic hernia in a lamb under domestic environments. METHODS: Left-sided diaphragmatic hernias were created in seven fetal lambs at about 85 days' gestation (experimental group). Three other fetal lambs did not receive any surgical procedure and served as control group. Four of these lambs (3 in the experimental group and 1 in the control group) were delivered after a sufficient intrauterine period. The morphological changes of lung development were compared between the two groups. RESULTS: Creation of diaphragmatic hernia resulted in marked hypoplasia in fetal lung development. In this experiment, the maternal mortality was 33.3%, and the fetal mortality was 60% which are relatively high as compared with previous reports. CONCLUSION: From this data, the authors concluded that experimental fetal diaphragmatic hernia can be established although the technique for the measurement of gestational age, anesthesia and postoperative care should be improved to overcome domestic inexperience in using the lamb as an experimental animal.