Acute Care Surgery: Implementation in Korea

The concept of acute care surgery (ACS) incorporates trauma, surgical critical care, and emergency general surgery. It was designed in the early 2000s by the United States as a solution to the looming crisis of trauma care and non-trauma emergency surgery. Reduced surgical opportunities for trauma surgeons resulted in a decreased interest in trauma surgery. Surgical sub-specialization further accelerated an indifference towards trauma and emergency general surgery. Started in 2008, the trauma center project in Korea is still in its infancy. Although the need for ACS was presented since the inception of the trauma center project, there was a lack of implementation at trauma centers due to government regulations. However, ACS has been initiated at several non-trauma center hospitals and is mainly operated by surgical intensivists. Studies demonstrate that adding emergency surgery to a trauma service does not compromise the care of the injured patients, despite an increase in trauma volume. Positive impacts of ACS are reported by numerous researches. We believe that the development and advancement of trauma centers will necessitate a discussion for the implementation of the ACS model at trauma centers in Korea.

Stab Wound Extension for the Eviscerated Small Bowel with Severe Ischemic Changes

An abdominal stab wound with evisceration is an indication of an emergency laparotomy. We encountered a case of a very severe ischemic change in the eviscerated small bowel as a result of stabbing. The patient was considered to have a high possibility of progressing to strangulation of the small bowel. Therefore, a stab wound extension was performed as a decompression in the emergency department before definite surgery in the operating room. Most of the small bowel could be saved except for the segment with the damage caused by the stab injury. The patient was discharged without complications.

Iatrogenic Delayed Aortic Injury Following a Surgical Stabilization of Flail Chest

Most of aortic injuries after blunt chest trauma usually occur at the aortic isthmus and are identified in the emergency department soon after arrival. Delayed aortic injures by fractured posterior ribs, however, are relatively rare and have been reported only a few times. We recently experienced an iatrogenic descending aortic injury sustained as a result of a direct puncture by a sharp rib end after surgical stabilization of rib fractures.

Near-Road Exposure and Impact of Air Pollution on Allergic Diseases in Elementary School Children: A Cross-Sectional Study

PURPOSE: The study aims to classify schools based on traffic pollutants and their complex sources, to assess the environment, to determine the state of allergic diseases among students using the International Study of Asthma and Allergies in children (ISAAC) questionnaire, and to assess their connection to air pollutants. MATERIALS AND METHODS: A total of seven schools were divided into three categories according to the characteristics of their surrounding environments: three schools in traffic-related zones, two schools in complex source zones I (urban), and two schools in complex source zones II (industrial complex). ISAAC questionnaires were administered and the 4404 completed questionnaires were analyzed. RESULTS: The frequency of asthma treatment during the past 12 months showed a significant increase (p<0.05) with exposure to NO2 [1.67, 95% confidence intervals (CIs) 1.03-2.71] in the complex source zones. The frequency of allergic rhinitis treatment during the past 12 months increased significantly with exposure to Black Carbon (1.60, 95% CIs 1.36-1.90) (p<0.001), SO2 (1.09, 95% CIs 1.01-1.17) (p<0.05), NO2 (1.18, 95% CIs 1.07-1.30) (p<0.01) for all subjects. CONCLUSION: In terms of supporting children's health, care, and prevention related to major spaces for children, such as school zones, spaces used in coming to and leaving school, playgrounds, and classrooms are essential to ensuring not only the safety of children from traffic accidents but also their protection from local traffic pollutants and various hazardous environmental factors.

House-plant placement for indoor air purification and health benefits on asthmatics

OBJECTIVES: Some plants were placed in indoor locations frequented by asthmatics in order to evaluate the quality of indoor air and examine the health benefits to asthmatics. METHODS: The present study classified the participants into two groups: households of continuation and households of withdrawal by a quasi-experimental design. The households of continuation spent the two observation terms with indoor plants, whereas the households of withdrawal passed the former observation terms with indoor plants and went through the latter observation term without any indoor plants. RESULTS: The household of continuation showed a continual decrease in the indoor concentrations of volatile organic compounds (VOCs) during the entire observation period, but the household of withdrawal performed an increase in the indoor concentrations of VOCs, except formaldehyde and toluene during the latter observation term after the decrease during the former observation term. Peak expiratory flow rate (PEFR) increased in the households of continuation with the value of 13.9 L/min in the morning and 20.6 L/ min in the evening, but decreased in the households of withdrawal with the value of -24.7 L/min in the morning and -30.2 L/min in the evening in the first experimental season. All of the households exhibited a decrease in the value of PEFR in the second experimental season. CONCLUSIONS: Limitations to the generalizability of findings regarding the presence of plants indoors can be seen as a more general expression of such a benefit of human-environment relations.

A Distribution Weighted Prognostic Scoring Model for Node Status in Advanced Rectal Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: There are various lymph node-based staging systems. Nevertheless, there is debate over the use of parameters such as the number of involved lymph nodes and the lymph node ratio. As a possible option, the distribution of metastatic lymph nodes may have a prognostic significance in rectal cancer. This study is designed to evaluate the impact of distribution-weighted nodal staging on oncologic outcome in rectal cancer. MATERIALS AND METHODS: From a prospectively maintained colorectal cancer database of our institution, a total of 435 patients who underwent a curative low anterior resection for mid and upper rectal cancer between 1995 and 2004 were enrolled. Patients were divided into 3 groups according to the location of apical metastatic nodes. A location-weighted prognostic score was calculated by a scoring model using a logistic regression test for location based-statistical weight to number of lymph nodes. All cases were categorized in quartiles from lymph node I to lymph node IV using this protocol. RESULTS: The location of lymph node metastasis was an independent factor that was associated with a poor prognostic outcome (p<0.001). Based on this result, the location-weighted-nodal prognostic scoring model did not show lesser significant results (p<0.0001) in both overall survival and cancer-free survival analyses. CONCLUSION: The location of apical nodes among the metastatic nodes does not have a lesser significant impact on oncologic result in patients with advanced rectal cancer. A location-weighted prognostic scoring model, which considered the numbers of involved lymph nodes as the rate of significance according to the location, may more precisely predict the survival outcome in patients with lymph node metastasis.

Transfusion-Related Acute Lung Injury after Stored Packed Red Blood Cell Transfusion: A Case Report / 대한구급학회지

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related mortalities. Each type of blood product is likely to cause TRALI. Patients with TRALI present with dyspnea/respiratory distress and fever. The symptoms, signs and chest radiological findings in TRALI are similar to transfusion associated circulatory overload. Therefore, it is difficult to distinguish such from circulatory overloads. We report a case of TRALI in a 49-year-old woman after stored packed red blood cell transfusion. The patient developed hypoxemia and pulmonary edema after packed red blood cell transfusion during postoperative period. The patient completely recovered after an oxygen support for 3 days.

Corrigendum: Health Risks Assessments in Children for Phthalates Exposure Associated with Childcare Facilities and Indoor Playgrounds

In Table 6, the unit concentration of phthalates was not correctly indicated.

Pancreatic hamartoma diagnosed after surgical resection / 대한외과학회지

A pancreatic hamartoma is a rare benign lesion that may be mistaken for malignancy. A pancreatic hamartoma can present with vague, non-specific symptoms, which can be difficult to diagnose despite modern diagnostic tools. We report here a pancreatic hamartoma diagnosed after surgical resection. A 52-year-old female presented with postprandial abdominal discomfort. Abdominal computed tomography and pancreatic magnetic resonance imaging revealed a 2.2 x 2.5-cm cystic mass in the pancreatic head. The patient underwent a pylorus-preserving pancreaticoduodenectomy. The histopathological and immunohistochemical studies helped make the diagnosis of pancreatic hamartoma. Here, we report a case of pancreatic hamartoma and review the relevant medical literature.

Peripheral eosinophilia - is it a predictable factor associated with eosinophilic cholecystitis?

BACKGROUNDS/AIMS: The purpose of this study was to evaluate the role of peripheral eosinophilia as a predictable factor associated with Eosinophilic cholecystitis (EC) compared with other forms of cholecystitis in patients who underwent a cholecystectomy. METHODS: Between January 2001 and May 2011, the histopathologic features of 3,539 cholecystectomy specimens were reviewed retrospectively. EC was diagnosed in 30 specimens (0.84%). Data from 30 consecutive patients with EC (eosinophilic cholecystitis group [E-group]) were compared with a retrospective control group of 60 patients (other cholecystitis group [O-group]) during the same period. The two groups were matched for age, gender, and the presence of cholelithiasis. RESULTS: The median absolute eosinophil count 1 day post-operatively was 144 cells/mm3 (range: 9-801 cells/mm3) in the E-group and 93 cells/mm3 (range: 0-490 cells/mm3) in the O-group (p=0.036). Pre-operative peripheral eosinophilia was more common in the E-group than the O-group (20% vs. 3.3%, p=0.015). Multivariate analysis revealed that pre-operative peripheral eosinophilia was an independent significant predictable factor associated with EC (odds ratio=7.250, 1.365 <95% confidence interval<38.494, p=0.020). CONCLUSIONS: In the present study, pre-operative peripheral eosinophilia was shown to be an independent predictable factor associated with EC. Further researches seem to be necessary to confirm this finding.

Health Risk Assessment of Lead Ingestion Exposure by Particle Sizes in Crumb Rubber on Artificial Turf Considering Bioavailability

OBJECTIVES: The purpose of this study was to assess the risk of ingestion exposure of lead by particle sizes of crumb rubber in artificial turf filling material with consideration of bioavailability. METHODS: This study estimated the ingestion exposure by particle sizes (more than 250 um or less than 250 um) focusing on recyclable ethylene propylene diene monomer crumb rubber being used as artificial turf filling. Analysis on crumb rubber was conducted using body ingestion exposure estimate method in which total content test method, acid extraction method and digestion extraction method are reflected. Bioavailability which is a calibrating factor was reflected in ingestion exposure estimate method and applied in exposure assessment and risk assessment. Two methods using acid extraction and digestion extraction concentration were compared and evaluated. RESULTS: As a result of the ingestion exposure of crumb rubber material, the average lead exposure amount to the digestion extraction result among crumb rubber was calculated to be 1.56x10(-4) mg/kg-day for low grade elementary school students and 4.87x10(-5) mg/kg-day for middle and high school students in 250 um or less particle size, and that to the acid extraction result was higher than the digestion extraction result. Results of digestion extraction and acid extraction showed that the hazard quotient was estimated by about over 2 times more in particle size of lower than 250 um than in higher than 250 um. There was a case of an elementary school student in which the hazard quotient exceeded 0.1. CONCLUSIONS: Results of this study confirm that the exposure of lead ingestion and risk level increases as the particle size of crumb rubber gets smaller.

Association Between Body Mass Index and Asthma Symptoms Among Korean Children: A Nation-Wide Study

The purpose of this study was to investigate the association between body mass index (BMI) and the prevalence of wheeze using nation-wide cross-sectional study in Korean children. Total 50,200 children from 427 elementary schools were randomly selected according to residential areas (metropolitan, provincial, rural, and industrial areas) by the cluster sampling method. The International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires were used to measure the prevalence of wheeze. Among 31,026 respondents, 25,322 were analyzed. BMI was classified into quartiles based on BMI-for-age percentile. In all residential areas, pets at home and visible mold or moisture were associated with an increased prevalence of wheeze in both genders. However, other living environment factors were not consistently associated among residential areas and gender. Among girls, lowest BMI was negatively associated with prevalence of wheeze and highest BMI was positively associated in all residential areas. In multilevel logistic regression analysis, environmental tobacco smoking exposure, pets at home, visible mold or moisture, and being in the lowest and highest BMI quartile were significantly associated with the prevalence of wheeze in both genders. BMI has become an important risk factor for asthma symptoms among Korean children.

Primary leiomyosarcoma of the pancreas / 대한외과학회지

Primary sarcomas of the pancreas are extremely rare, accounting for 0.1% of malignant pancreatic (non-islet) neoplasms. Pancreatic leiomyosarcoma is a highly aggressive malignancy that spreads in a similar manner to gastric leiomyosarcoma, i.e., by adjacent organ invasion, hematogenous spread, and lymph node metastasis. These tumors are large at the time of diagnosis and are usually found at an advanced stage. We report a case of a 70-year-old female with intermittent right upper quadrant abdominal discomfort. Radiological, histopathological, and immunohistochemical studies revealed the tumor to be a primary leiomyosarcoma of the pancreas. Herein, we describe a patient with a primary leiomyosarcoma of the pancreas who presented with clinical and radiological findings indicative of a mass in the pancreatic head.

Liver resection for hepatocellular carcinoma: case-matched analysis of laparoscopic versus open resection / 대한외과학회지

PURPOSE: To analyze the outcomes of laparoscopic liver resection compared with open liver resection in patients with hepatocellular carcinoma (HCC). METHODS: Between July 2005 and December 2009, 26 consecutive patients with HCC underwent a pure laparoscopic liver resection, and data from this group (laparoscopic liver resection group, L-group) were compared with a retrospective control group of 29 patients who underwent open liver resection for HCC (open liver resection group, O-group) during the same period. The two groups were matched in terms of demographic data, tumor size, degree of liver cirrhosis, American Society of Anesthesiology score, type of resection, and tumor location. RESULTS: Median operation time and the amount of intraoperative packed red blood cell transfusion in the L-group were 147.5 minutes and 0.35 units, respectively. The L-group revealed a shorter operation time (147.5 vs. 220.0 minutes, P = 0.031) than the O-group. No difference in perioperative morbidity or mortality rates was observed (3.8, 0 vs. 24.1%, 0%; P = 0.054, non-specific, respectively); the L-group was associated with a shorter hospital stay than the O-group (11.08 vs. 16.07 days, P = 0.034). After a mean follow-up of 23.9 months (range, 0.7 to 59.4 months), the 1-year disease-free survival rate was 84.6% in the L-group and 82.8% in the O-group (P = 0.673). CONCLUSION: Laparoscopic liver resection for HCC is feasible and safe in selected patients and can produce good surgical results with a shorter postoperative hospital stay and similar outcomes in terms of perioperative morbidity, mortality, and disease-free survival than open resection.

Cystic lymphangioma of the pancreas mimicking pancreatic pseudocyst / 대한외과학회지

Lymphangiomas are rare congenital benign tumors arising from the lymphatic system, and are mostly encountered in the neck and axillary regions of pediatric patients (95%). Lymphangioma of the pancreas is extremely rare accounting for less than 1% of these tumors. We report here on a case of pancreatic cystic lymphangioma. A 54-year-old woman presented with intermittent postprandial abdominal discomfort and radiating back pain. Abdominal computed tomography scan revealed 8 x 6.5 cm hypodense cystic mass arising from the tail of the pancreas without septa or solid component. The initial impression was a pancreatic pseudocyst. The patient underwent distal pancreatectomy with splenectomy. The histopathologic and immunohistochemical study helped make the diagnosis of a pancreatic cystic lymphangioma. Herein, we report a case of pancreatic cystic lymphangioma mimicking pancreatic pseudocyst and review the relevant medical literature.

Prevalence of Allergic Diseases among Korean School-age Children: A Nationwide Cross-Sectional Questionnaire Study

The purpose of this study was to investigate the nationwide prevalence of childhood asthma, eczema and other allergic diseases in Korean school-age children (8-11 yr old) and to assess the difference between residential areas. Among 6,279 elementary schools, 427 schools were randomly selected according to residential area (metropolitan, provincial, rural, and industrial area) by the cluster sampling method. Parents of students completed a modified Korean version of a questionnaire formulated by the International Study of Asthma and Allergies in Childhood (ISAAC). Among 50,200 subjects, 31,026 (61.8%) responded, and 30,893 (99.6%) were analyzed. The 12-month prevalence of wheeze, flexural rash, and allergic rhinitis symptoms were 4.8%, 15.3%, and 32.9%, respectively. The prevalence of diagnosis of allergic diseases in boys was higher than that in girls, with the exception of eczema. In both boys and girls, the difference of the prevalence of allergic diseases among industrial, metropolitan and provincial areas was not statistically significant, but the differences between rural area and other areas were significant. Our results support the importance of contextual effect associated with residential area as causative agents of allergic diseases among Korean school-age children.

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells / 대한외과학회지

Undifferentiated carcinoma with osteoclast-like giant cells is a rare neoplasm of the exocrine pancreas. Some similar cases have been reported, but the histogenesis of these tumors varies and is controversial. We report here on a case of undifferentiated carcinoma of the pancreas with osteoclast-like giant cells. A 77-year old woman presented with abdominal pain and anorexia. Abdominal computed tomography and magnetic resonance imaging showed an approximately 10 x 5 cm highly attenuated mass arising from the tail of the pancreas and invading the spleen and adjacent bowel loop. The initial impression was a malignant endocrine tumor or solid-pseudopapillary tumor of the pancreas. The patient underwent a distal pancreatectomy with splenectomy and left hemicolectomy. The histopathology and immunohistochemistry helped make the diagnosis that of an undifferentiated carcinoma with osteoclast-like giant cells of the pancreas.

Health Risks Assessment in Children for Phthalate Exposure Associated with Childcare Facilities and Indoor Playgrounds

OBJECTIVES: This study assessed the health risks for children exposed to phthalate through several pathways including house dust, surface wipes and hand wipes in child facilities and indoor playgrounds. METHODS: The indoor samples were collected from various children's facilities (40 playrooms, 42 daycare centers, 44 kindergartens, and 42 indoor-playgrounds) in both summer (Jul-Sep, 2007) and winter (Jan-Feb, 2008). Hazard index (HI) was estimated for the non-carcinogens and the examined phthalates were diethylhexyl phthalate (DEHP), diethyl phthalate (DEP), dibutyl-n-butyl phthalate (DnBP), and butylbenzyl phthalate (BBzP). The present study examined these four kinds of samples, i.e., indoor dust, surface wipes of product and hand wipes. RESULTS: Among the phthalates, the detection rates of DEHP were 98% in dust samples, 100% in surface wipe samples, and 95% in hand wipe samples. In this study, phthalate levels obtained from floor dust, product surface and children's hand wipe samples were similar to or slightly less compared to previous studies. The 50th and 95th percentile value of child-sensitive materials did not exceed 1 (HI) for all subjects in all facilities. CONCLUSIONS: For DEHP, DnBP and BBzP their detection rates through multi-routes were high and their risk based on health risk assessment was also observed to be acceptable. This study suggested that ingestion and dermal exposure could be the most important pathway of phthalates besides digestion through food.

Hamartoma of the Spleen Diagnosed after Surgical Resection: Three Case Reports

Hamartoma of the spleen is a rare benign lesion and the pathogenesis of this is not completely understood. It is usually incidentally discovered during an operation or autopsy. Since the first report in 1861 by Rokitansky, less than 150 cases of splenic hamartoma have been documented in the literature to date. The majority of the patients with this tumor are asymptomatic. However, a few of these lesions are associated with clinical features such as hypersplenism, cirrhosis of the liver and spontaneous splenic rupture. Because there are no specific symptoms, tumor markers or radiologic results, it is usually difficult to make a diagnosis before surgery and the specimen pathology. We report here on three cases of splenic hamartoma (a 33-year-old man associated with thrombocytopenia, a 29-year-old woman with a 6-month history of left upper quadrant abdominal pain and a 43-year-old man with synchronous hepatocellular carcinoma) and we review the relevant literature.

Histopathologic Prognostic Factors for Recurrence and Survival after Surgical Resection of Middle and Distal Bile Duct Cancer

PURPOSE: Surgery remains the only curative option for patients with extrahepatic bile duct cancer (EHBD Ca). But, long-term survival is typically not good because of the advanced stage of disease at the time of diagnosis and frequent disease recurrence after surgical resection. The purpose of this study was to evaluate factors that influence survival and recurrence after surgical resection of EHBD Ca. METHODS: A retrospective analysis of 113 patients who had received surgical resection for EHBD Ca between 2004 and 2009 was done. We investigated histopathological features, and survival and recurrence rates, and evaluated prognostic factors affecting survival and disease recurrence after surgical resection. RESULTS: Overall survival rates for 1, 3 and 5 years were 73.2%, 42.8%, and 36.0% respectively. In univariate analysis, prognostic factors influencing survival were histologic differentiation, T stage, lymph node (LN) metastasis, TNM stage, perineural invasion (PNI), lymphovascular invasion (LVI) and resection margin state. Among them, LN metastasis, PNI and resection margin state were found to be independent prognostic factors for overall survival in multivariate analysis. Recurrence occurred in 44 patients (48.9%) and disease-free survival rates were 50.6% at 1 year and 38.3% at 3 year. Univariate analysis revealed that histologic differentiation, T stage, LN metastasis, TNM stage, PNI and LVI were significantly associated with recurrence. In multivariate analysis, only LN metastasis was found to be a significant independent predictor of recurrence. CONCLUSION: LN metastasis, PNI and positive resection margin were significant prognostic factors affecting survival. LN metastasis was found to be a significant independent predictor of recurrence in surgical resection of EHBD Ca.