Comparison of Clinical and Radiologic Findings Between Perforated and Non-Perforated Choledochal Cysts in Children

Objective@#To compare the clinical and radiologic findings between perforated and non-perforated choledochal cysts in children. @*Materials and Methods@#Fourteen patients (mean age ± standard deviation, 1.7 ± 1.2 years) with perforated choledochal cysts (perforated group) and 204 patients (3.6 ± 3.8 years) with non-perforated choledochal cysts (non-perforated group) were included between 2000 and 2019. All patients underwent choledochal cyst excision after ultrasound, CT, or MR cholangiopancreatography. Relevant data including demographics, clinical symptoms, laboratory findings, imaging findings, and outcomes were analyzed. Statistical differences were compared using the Mann-Whitney U test and Fisher’s exact test. @*Results@#Choledochal cyst perforation occurred only in children under the age of 4 years. Acute symptoms, including fever (p < 0.001), were more common in the perforated group than in the non-perforated group. High levels of white blood cells (p = 0.004), C-reactive protein (p < 0.001), and serum amylase (p = 0.002), and low levels of albumin (p < 0.001) were significantly associated with the perforated group. All 14 patients with perforated choledochal cysts had ascites, whereas only 16% (33/204) of patients in the non-perforated group had ascites (p < 0.001). In the subgroup of patients who had ascites, a large amount of ascites (p = 0.001), increase in the amount of ascites in a short time (p < 0.001), complex ascites (p < 0.001), and perihepatic pseudocysts (p < 0.001) were more common in the perforated group than in the non-perforated group. @*Conclusion@#Children with perforated choledochal cysts have characteristic clinical and radiologic findings compared to those with non-perforated choledochal cysts. In young children with choledochal cysts, perforation should be differentiated in cases with acute symptoms, laboratory abnormalities, and characteristic ascites findings.

Current status and directions of resident education

A resident is a preliminary specialist with a medical license. It is also the status of an employee at a training hospital who is trained by clinical faculty. This duality makes the role of a resident unique, because its interpretation differs dramatically depending on whether one focuses on a resident's status as a trainee or as an employee. Issues regarding patient safety have emerged as residents have come to emphasize their role as employees in discussions of how to balance their work duties with their learning responsibilities. The workload that was taken for granted is no longer considered natural. Two years have elapsed since the enactment of the resident law, which was passed to improve the training environment and working conditions of residents, and limits them to 80 hours of work per week. However, confusion persists in the field. In order to solve problems regarding resident education, new education program with hospitalists and the financial and administrative support from hospitals and the government are important.

Development of the role of teaching hospitalists in the education of residents

Resident law was enacted to improve the training environment and working conditions. However, the law caused confusion in the field and resulted in a medical vacuum in inpatient care. It also resulted in a lack of training time. A hospitalist system was introduced to improve the quality of patient care and to cover the shortage of residents. This study aimed to outline a development strategy for hospitalists participation in resident education in Korea. The result of pilot study of the hospitalists in Korea showed that patients, nurses, and residents were satisfied with hospitalists. Eighty-five percent of surgical residents were helped in postoperative patient care and 70.7% of residents were willing to work with a hospitalist. The competency of surgical hospitalists includes understanding surgery and the appropriate management of postoperative complications. In order to shift the paradigm of resident education, the Korean government must pay the expenses for resident training. Through hospitalists' participation in the resident training, it may be possible to provide residents with more comprehensive and continuous education for inpatient care.

Development of the role of teaching hospitalists in the education of residents

Resident law was enacted to improve the training environment and working conditions. However, the law caused confusion in the field and resulted in a medical vacuum in inpatient care. It also resulted in a lack of training time. A hospitalist system was introduced to improve the quality of patient care and to cover the shortage of residents. This study aimed to outline a development strategy for hospitalists participation in resident education in Korea. The result of pilot study of the hospitalists in Korea showed that patients, nurses, and residents were satisfied with hospitalists. Eighty-five percent of surgical residents were helped in postoperative patient care and 70.7% of residents were willing to work with a hospitalist. The competency of surgical hospitalists includes understanding surgery and the appropriate management of postoperative complications. In order to shift the paradigm of resident education, the Korean government must pay the expenses for resident training. Through hospitalists' participation in the resident training, it may be possible to provide residents with more comprehensive and continuous education for inpatient care.

Current status and directions of resident education

A resident is a preliminary specialist with a medical license. It is also the status of an employee at a training hospital who is trained by clinical faculty. This duality makes the role of a resident unique, because its interpretation differs dramatically depending on whether one focuses on a resident's status as a trainee or as an employee. Issues regarding patient safety have emerged as residents have come to emphasize their role as employees in discussions of how to balance their work duties with their learning responsibilities. The workload that was taken for granted is no longer considered natural. Two years have elapsed since the enactment of the resident law, which was passed to improve the training environment and working conditions of residents, and limits them to 80 hours of work per week. However, confusion persists in the field. In order to solve problems regarding resident education, new education program with hospitalists and the financial and administrative support from hospitals and the government are important.

Antibiotic therapy for appendicitis treatment

Appendicitis is the most common diagnosis of acute abdominal pain that may require surgical treatment, and 8.6% for men and 6.9% for women are at risk for this illness over the course of their lives. During the past century, appendectomy was the standard treatment for acute appendicitis. However, laparoscopic appendectomy has been used as the first-line treatment choice for appendicitis since the introduction of laparoscopic surgery. In cases of perforation or abscess, interval appendectomy and percutaneous drainage are recommended. Treatment strategies have become more diverse. In recent years, in some European countries, non-surgical treatment has been used for simple appendicitis without complications, and nonoperative treatment of appendicitis has become increasingly common in adults and children. In this article, nonoperative treatment of appendicitis is introduced, and guidelines for the selection of antibiotics according to appendicitis classification are summarized.

Medical charges and the cold reality of surgeons of Korea

Surgery is a very hands-on area of medical care, in that surgeons identify problems in patients' bodies and directly change them through operations. Therefore, it is not only necessary for surgeons to have a high level of expertise, but also to take considerable responsibility for the outcomes of each operation. However, surgery, which was once an object of envy, has long been a process to avoid, due to various circumstances, such as abnormal medical expenses in the medical field and social phenomena that avoids difficult work. It is unfortunate that medical professionals do not receive sympathy from others within the same medical field because of the general difficulties of the profession. The fundamental problem in this situation is the abnormal profit structure of the Korean medical system. Efforts by various related organizations will be needed to objectively evaluate the problems of the current medical insurance system and to make reasonable adjustments considering the difficulty, frequency, and resource-intensiveness of medical care.

Clinical Significance of Non-Mass-Like Enhancement of Preoperative Magnetic Resonance Imaging in Breast Cancer Considering Breast-Conserving Surgery

PURPOSE: The purpose of this study was to investigate the significance of non-mass enhancement (NME) findings on preoperative breast magnetic resonance imaging (MRI) when invasive breast cancer patients with single lesions underwent breast-conserving surgery (BCS). METHODS: We reviewed the preoperative MRI findings of 252 patients who underwent BCS from January 2014 to September 2016. Based on the MRI findings, we divided the patients into two groups, those who did and did not have NME, and we retrospectively analyzed the clinical outcomes of the two groups. RESULTS: The NME group had 57 patients, and the no-NME group had 195 patients. The incidence of in situ lesions was higher in the NME group than in the no-NME group (p<0.001). Additionally, the positive resection margin rate on frozen biopsy was higher in the NME group than in the no-NME group (p=0.002). CONCLUSION: When preoperative MRI had NME findings, in situ lesions were more likely to accompany invasive breast cancer lesions, and the positive resection margin rate for frozen biopsy during BCS was high. Therefore, in these cases, the lesion should be excised more widely when BCS is performed, or frozen biopsy for resection margin during BCS should be performed if possible.

Antibiotic therapy for appendicitis treatment

Appendicitis is the most common diagnosis of acute abdominal pain that may require surgical treatment, and 8.6% for men and 6.9% for women are at risk for this illness over the course of their lives. During the past century, appendectomy was the standard treatment for acute appendicitis. However, laparoscopic appendectomy has been used as the first-line treatment choice for appendicitis since the introduction of laparoscopic surgery. In cases of perforation or abscess, interval appendectomy and percutaneous drainage are recommended. Treatment strategies have become more diverse. In recent years, in some European countries, non-surgical treatment has been used for simple appendicitis without complications, and nonoperative treatment of appendicitis has become increasingly common in adults and children. In this article, nonoperative treatment of appendicitis is introduced, and guidelines for the selection of antibiotics according to appendicitis classification are summarized.

Medical charges and the cold reality of surgeons of Korea

Surgery is a very hands-on area of medical care, in that surgeons identify problems in patients' bodies and directly change them through operations. Therefore, it is not only necessary for surgeons to have a high level of expertise, but also to take considerable responsibility for the outcomes of each operation. However, surgery, which was once an object of envy, has long been a process to avoid, due to various circumstances, such as abnormal medical expenses in the medical field and social phenomena that avoids difficult work. It is unfortunate that medical professionals do not receive sympathy from others within the same medical field because of the general difficulties of the profession. The fundamental problem in this situation is the abnormal profit structure of the Korean medical system. Efforts by various related organizations will be needed to objectively evaluate the problems of the current medical insurance system and to make reasonable adjustments considering the difficulty, frequency, and resource-intensiveness of medical care.

RNA-Seq for Gene Expression Profiling of Human Necrotizing Enterocolitis: a Pilot Study

Necrotizing enterocolitis (NEC) characterized by inflammatory intestinal necrosis is a major cause of mortality and morbidity in newborns. Deep RNA sequencing (RNA-Seq) has recently emerged as a powerful technology enabling better quantification of gene expression than microarrays with a lower background signal. A total of 10 transcriptomes from 5 pairs of NEC lesions and adjacent normal tissues obtained from preterm infants with NEC were analyzed. As a result, a total of 65 genes (57 down-regulated and 8 up-regulated) revealed significantly different expression levels in the NEC lesion compared to the adjacent normal region, based on a significance at fold change ≥ 1.5 and P ≤ 0.05. The most significant gene, DPF3 (P < 0.001), has recently been reported to have differential expressions in colon segments. Our gene ontology analysis between NEC lesion and adjacent normal tissues showed that down-regulated genes were included in nervous system development with the most significance (P = 9.3 × 10⁻⁷; P(corr) = 0.0003). In further pathway analysis using Pathway Express based on the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, genes involved in thyroid cancer and axon guidance were predicted to be associated with different expression (P(corr) = 0.008 and 0.020, respectively). Although further replications using a larger sample size and functional evaluations are needed, our results suggest that altered gene expression and the genes' involved functional pathways and categories may provide insight into NEC development and aid in future research.

Selective B-RAF V600E Inhibitor PLX4032 Inhibits the Growth of Breast Cancer Cell Lines through Cell Cycle Arrest

PURPOSE: Breast cancer is the most common invasive cancer and the second common cause of death among women worldwide. Many researchers have focused on the effective treatment of advanced breast cancer using new drugs. Herein, we analyzed whether PLX4032, a B-RAF V600E inhibitor, could be used as a novel treatment for advanced breast cancer. METHODS: Two breast cancer cell lines, MCF7 and MDA-MB-231, were treated with the selective B-Raf inhibitor PLX4032 under adherent culture conditions and the effects of PLX4032 on cell growth, cell cycle duration, apoptosis and cell cycle related genes expression were evaluated. RESULTS: We found that PLX4032 dose-dependently inhibited cell growth in both cell lines through cell cycle arrest at phase G0/G1. However, PLX4032 treatment did not have a significant effect on cell apoptosis. In addition, CCNA2 gene expression was significantly decreased in the MCF7 cells in a dose-dependent manner. CONCLUSION: Our data demonstrated that treatment of breast cancer with PLX4032 could inhibit proliferation through cell cycle arrest. Therefore, PLX4032 might be a novel anticancer drug that can be used in the treatment of advanced breast cancer.

Risk Factors for Surgical Procedure on Ileo-Colic Intussusception in Children / 소아외과

PURPOSE: The aim of this study was to analyze of the risk factors for surgical procedure on ileo-colic intussusception without leading point in children. METHODS: We retrospectively reviewed medical records of patient treated for ileo-colic intussusception between January 2003 and December 2014. We exclude the patients who had leading point. Because of the large difference on patient's numbers between non-operative group (cases of ileo-colic intussusceptions successfully reduced by air reduction) and operative group (cases underwent operation due to failed air reduction), we compared the data of operative group of patients without leading point between 2003 and 2014 with the data of non-operative group as control group from 2013 to 2014. Clinical features such as gender, age, body temperature, body weight in diagnosis, growth curves for age-gender-body weight, and laboratory data of blood test were compared. RESULTS: In non-operative group, total 94 patients who were treated successfully by the non-operative air reduction. In operative group, total 21 patients treated by surgical procedure. The age under 12 months, weight over upper 75 percentile group, increased segment neutrophil count, decreased hemoglobin level and lymphocyte count were significantly associated with a requirement for surgical procedure. CONCLUSION: We conclude that younger age, higher weight percentile group, increased segment neutrophil, decreased hemoglobin and lymphocyte are the independent risk factors related to operative treatment for ileo-colic intussusception in children. If primary air reduction is failed in patients with such risk factors, operative treatment over ultrasonography or secondary reduction can prevent unnecessary effort and complications, thus emphasizing the consideration of operative treatment when selecting treatment methods.

Two Cases of Congenital Diaphragmatic Hernia Manifestated with Atypical Symptoms in Newborn Infants / 대한주산의학회잡지

Most of the congenital diaphragmatic hernia (CDH) cases are diagnosed at prenatal period or immediately after birth with severe respiratory symptom. The classic triad, which is respiratory distress, apparent dextrocardia and a scaphoid abdomen, is usually seen in this period. Several case reports have described older infants and children with a wide spectrum of symptoms of CDH, whereas extremely few cases were reported in neonatal period except classic triad such as straungulation of the bowel. These atypical manifestations can lead physician to delayed diagnosis. We report two cases of CDH newborns. First case was diagnosed with pneumoperitoneum following tension pneumothorax, transient diaphragm eventration on 5 days after birth. The other case was diagnosed with failure to thrive and mediastinal mass on 30 days after birth. These cases suggest physicians to consider CDH in late newborn period with pneumoperitoneum following tension pneumothorax, transient diaphragm eventration, failure to thrive, and mediastinal mass.

Comparison between Laparoscopic and Open Nissen Fundoplication in Pediatric Patients

Fundoplication is a common surgical procedure for gastroesophageal reflux Disease (GERD). Recently the procedure has been performed with increased frequency laparoscopically. The aim of this study is to compare laparoscopic Nissen fundoplication (LNF) and open Nissen fundoplication (ONF) for GERD in children. We studied retrospectively the 88 pediatric patients who underwent the Nissen fundoplication for GERD as primary antireflux surgery from 1994 and 2009. ONF was performed in 34 cases and LNF was in 54 cases. 58 patients have neurologic impairment. Time to initial food intake after the surgery were reduced in the LNF group (p = 0.032).Recurrent GERD symptom occurred in one patient in LNF group and four patients in ONF group within 1 year after the surgery (p = 0.012). There were no statistically significant differences in post operative morbidity and mortality between both groups. In conclusion, our practice of Nissen fundoplication indicates that LNF takes priority in most pediatric patients.

Comparison of the Laparoscopic and Open Peritoneal Dialysis Catheter Insertion in Children

The aim of this study was to compare peritoneal dialysis catheter insertion by the open method to the laparoscopic method. Twenty four laparoscopic and 10 open peritoneal dialysis catheter placements were performed in children between 2001 and 2008. Patient characteristics, operation related data, procedural complications and clinical outcome were compared. Although there were no cases of catheter obstruction, exit site infection or bleeding in the laparoscopic group, compared to the open method, there was no statistically significant difference between the two groups. Catheter removal rate due to complication was high in the open group and catheter survival rate was high in the laparoscopic group. We concluded that laparoscopic peritoneal dialysis catheter placement is feasible in children of all age groups with at least equivalent functional results compared to the open method. An advantage of laparoscopic catheter insertion is removal of the great omentum and easy fixation of the catheter to the abdominal wall.

Comparison of Outcomes between Open and Laparoscopic Pyloromyotomy

Hypertrophic pyloric stenosis (HPS) is the most common infantile surgical condition and the standard treatment is open pyloromyotomy. Recently, laparoscopic techniques have rapidly advanced, and the laparoscopic approach has become widely adopted by pediatric surgeons. The aim of this study was to compare the clinical outcomes between open and laparoscopic pyloromyotomy. We retrospectively evaluated outcomes of pyloromyotomy for HPS by the open (OP) and the laparoscopic (LP) method. The procedures were performed at the Samsung Medical Center between September 2001 and March 2009. We analyzed patient age, sex, birth weight, length of hospital stay, postoperative length of stay (LOS), operating time, time to feeding commencement, postoperative vomiting frequency, the time to full feeding without vomiting, and surgical complications. A total of 54 patients were included in the study. There were 26 OP and 28 LP patients. There was no statistically significant difference in age, sex, birth weight, operating time, postoperative emesis. In contrast, postoperative LOS in the LP group was statistically significantly shorter than that in the OP group (2.0 vs. 3.3 days, p=0.0003) and time to full feeding was significantly shorter following LP. (p=0.018) There were no wound complications. Laparoscopic pyloromyotomy significantly reduced postoperative LOS and time to full feeding compared to open pyloromyotomy.

Comparison of the Clinical Characteristics of Intestinal Malrotation in Infants and Children

Malrotation is a congenital anomaly that becomes symptomatic more frequently during infancy. The indication for surgical treatment at that age is straightforward. In older children, the diagnosis may be more difficult because of chronic and vague complaint. The aim of this study is to compare the symptoms, rate of volvulus and surgical findings in children younger and older than one year. A retrospective study of 40 patients in a a single medical center diagnosed with malrotation from April 1996 to May 2010 was performed. There were 20 (50%) boys and 20 (50%) girls. At the time of operation, 27 (67.5%) patients were younger and 13 (32.5%) were older than 1 year. Vomiting was seen in 20 cases (74.1%) of the younger group compared to 2 cases (15.4%) of the older group. Abdominal sonography and upper gastrointestinal series showed a sensitivity of 100%. Operative findings: 12 (44.4%) of the younger group presented with volvulus compared to none of the older group. The Ladd's procedure was routinely performed with appendectomy in all cases and bowel resection was requires when volvulus included bowel necrosis or other anomalies were found. After definite procedures, surgical correction for adhesive obstruction was necessary in 5 menbers (18.5%) of the younger group and 1 patient (7.7%) in the older group. There was 1 death due to respiratory failure and pneumonia. Abdominal pain was more frequent symptom and bilious vomiting was less frequent. Volvulus did not occur in the older group. Malrotation should be diagnosed promptly in children over 1 year of age by upper gastrointestinal series and abdominal ultrasonography even though symptoms are not as clear cut as in infants.

Postoperative Change of Intrahepatic Bile Duct Dilatation in Choledochal Cyst

Choledochal cyst is a congenital dilatation of the bile duct. Intrahepatic bile duct dilatation of type IVa by Todani's classification at the time of diagnosis resolved spontaneously after cyst excision and hepaticojejunostomy in many cases. It should be distinguished from the true cystic dilatation of the intrahepatic ducts, which tends to persist, albeit after some regression. We therefore studied postoperative intrahepatic duct dilatation changes in choledochal cyst. A total of seventy-six choledochal cysts were managed at the Division of Pediatric Surgery, Department of Surgery, Samsung Medical Center from May 1995 to December 2005. The ratio of males to females was 1:2.8. Preoperative radiologic diagnosis by Todani's classification was Type I (n=52, 68.4 %), II (n=1, 1.3 %), IVa (n=23, 30.3 %). Among fifty-five patients with intrahepatic bile duct dilatation we were able to follow up forty-eight by ultrasonography. Twenty-two patients were type IVa, and twenty-six patients were type I and showed intrahepatic duct dilatation. Mean follow-up duration was 35.3 months (9~105 months). Complete regression of dilated intrahepatic duct was observed in fifteen patients of type IVa and twenty-four patients of type I. Incomplete regression of dilated intrahepatic duct was observed in six patients in type IVa and two patients in type I. Only one patient in type IVa showed no change in ductal dilatation during a follow-up period of 15 months. We conclude that true type IVa is much less frequent than what was diagnosed preoperatively by imaging study. Therefore in type IVa patients who are diagnosed preoperatively the decision to perform liver resection should be carefully considered. Postoperative long term follow up of choledochal cyst with intrahepatic bile duct dilation is needed.