Timing of Admission to the Surgical Intensive Care Unit is Associated with in-Hospital Mortality

Purpose@#The relationship between the timing of admission (work-hours or after-hours) to the intensive care unit (ICU) and mortality among surgical ICU (SICU) patients is unclear. This study aimed to investigate whether admission to SICU during after-hours was associated with in-hospital mortality. @*Methods@#This retrospective cohort study was conducted in a tertiary academic hospital. The data of 571 patients who were admitted to the SICU and whose complete medical records were available were analyzed. Work-hours were defined as 07:00 to 19:00 Monday to Friday, during which the ICU was staffed with intensivists. After-hours were defined as any other time during which the SICU was not staffed with intensivists. The primary outcome measure was in-hospital mortality according to the time of admission (work-hours or after-hours) to the SICU. @*Results@#A total of 333 patients, were admitted to the SICU during work-hours, and 238 patients after-hours. Unplanned admissions (47.1% vs. 33.3%, p < 0.001), acute physiology and chronic health evaluation II score ≥ 25 (23.9% vs. 11.1%, p < 0.001), the need for ventilator support (34.0% vs. 17.4%, p < 0.001), and the use of vasopressors (50.0% vs. 33.3%, p < 0.001) were significantly higher in the after-hours group compared with the work-hours group. Multivariate analyses revealed that the timing of SICU admission was an independent predictor of in-hospital mortality (odds ratio, 2.526; 95% confidence interval, 1.010–6.320; p = 0.048). @*Conclusion@#This study showed that admission to the SICU during after-hours was associated with increased in-hospital mortality.

A surgical hospitalist system in Korea: a preliminary study of the effects on hospital costs and postoperative outcomes

Purpose@#The aim of this study is to investigate the effect of the surgical hospitalist system on postoperative outcomes and hospital costs for surgical patients. @*Methods@#We reviewed the medical records of 522 patients who were admitted to the divisions of colorectal and gastrointestinal surgery for operation from September to December 2017 at Severance Hospital, Yonsei University College of Medicine in Seoul, Korea. All patients were divided into 2 groups; one that was managed by surgical hospitalists group (HG) and another that was managed by non-hospitalist residents group (NHG) after elective surgery. Postoperative outcomes and hospital costs were analyzed for each group. @*Results@#Two hundred ninety-eight patients were managed by HG and 189 patients were managed by NHG after surgery. The length of hospital stay in the first group was shorter (9.6 ± 5.8 days vs. 12.2 ± 7.9 days, P < 0.001), the incidence of complications was lower (44.6% vs. 55.6%, P = 0.019), and the readmission rate was lower (3.0% vs. 6.9%, P = 0.046) in the HG than in the NHG. The difference in total hospital costs was not significant between the HG and the NHG (₩8,381,304 vs. ₩9,242,493, P = 0.559), but surgery-independent hospital costs were lower in the HG than in the NHG (₩3,020,873 vs.₩3,923,308, P = 0.001). @*Conclusion@#The surgical hospitalist system reduced the length of hospital stay, the incidence of postoperative complications, and the readmission rates of surgical patients. This led to the effect of a reduction in total hospital costs.

A surgical hospitalist system in Korea: a preliminary study of the effects on hospital costs and postoperative outcomes

Purpose@#The aim of this study is to investigate the effect of the surgical hospitalist system on postoperative outcomes and hospital costs for surgical patients. @*Methods@#We reviewed the medical records of 522 patients who were admitted to the divisions of colorectal and gastrointestinal surgery for operation from September to December 2017 at Severance Hospital, Yonsei University College of Medicine in Seoul, Korea. All patients were divided into 2 groups; one that was managed by surgical hospitalists group (HG) and another that was managed by non-hospitalist residents group (NHG) after elective surgery. Postoperative outcomes and hospital costs were analyzed for each group. @*Results@#Two hundred ninety-eight patients were managed by HG and 189 patients were managed by NHG after surgery. The length of hospital stay in the first group was shorter (9.6 ± 5.8 days vs. 12.2 ± 7.9 days, P < 0.001), the incidence of complications was lower (44.6% vs. 55.6%, P = 0.019), and the readmission rate was lower (3.0% vs. 6.9%, P = 0.046) in the HG than in the NHG. The difference in total hospital costs was not significant between the HG and the NHG (₩8,381,304 vs. ₩9,242,493, P = 0.559), but surgery-independent hospital costs were lower in the HG than in the NHG (₩3,020,873 vs.₩3,923,308, P = 0.001). @*Conclusion@#The surgical hospitalist system reduced the length of hospital stay, the incidence of postoperative complications, and the readmission rates of surgical patients. This led to the effect of a reduction in total hospital costs.

Prospects for the Korean model of the surgical hospitalist system

To meet the increasing social demand for improved patient safety and quality medical care in Korea, a pilot project of the hospitalist system in the field of internal medicine and surgery was initiated in 2016. Since the hospitalist system in the field of surgery in Korea should be based on the specific Korean medical environment, it is difficult to adopt a precedent model from other countries, and therefore a uniquely Korean operational model is necessary. Surgical hospitalists (surgeons working only within wards) in Korea are in charge of advanced primary care, perioperative care, and medical system care. Surgical hospitalists are able to care for older adult patients who have undergone a major operation to treat a highly severe condition. For inpatient care, the axis will need to shift from a trainee-centered structure to a surgical hospitalist-centered structure. This change will make possible the improvement of patient safety and quality medical care. The role of surgical hospitalists will extend not only to medical care, but also to education, academic activities, research, and related administrative aspects. To build a more stable and sustainable system, it is necessary to create a systemic operational foundation for proceeding with this new surgical hospitalist system.

Present and future of surgicalist system in Korea

As the need for medical services increases, interest in the quality improvement of healthcare and patient safety is also increasing. This study aimed to propose a surgical hospitalist or surgicalist system in Korea. Specifically, it has been suggested that the essential capacities of the surgicalist, including their understanding of surgery, wound management, emergency management, surgical nutrition, and education, may be useful in improving the quality of healthcare and patient safety. The key characteristic of the surgicalist system is that surgeons are “readily available” in the hospital ward to provide primary care for hospitalized patients. Surgicalists provide both perioperative and advanced primary care. As the population ages, the number of high-risk patients who are undergoing major operations increases. The surgicalist system, which is responsible for the perioperative management and advanced primary care of inpatients, is expected to expand rapidly. The shift from the vertical surgeon-resident-centered system to the horizontal surgeon-surgicalist-centered system can help provide high-quality care for patients, and a systematic training system for residents. In addition, it is necessary to define the essential capacities of the surgicalist, and to determine the research and education that can promote them.

Present and future of surgicalist system in Korea

As the need for medical services increases, interest in the quality improvement of healthcare and patient safety is also increasing. This study aimed to propose a surgical hospitalist or surgicalist system in Korea. Specifically, it has been suggested that the essential capacities of the surgicalist, including their understanding of surgery, wound management, emergency management, surgical nutrition, and education, may be useful in improving the quality of healthcare and patient safety. The key characteristic of the surgicalist system is that surgeons are “readily available” in the hospital ward to provide primary care for hospitalized patients. Surgicalists provide both perioperative and advanced primary care. As the population ages, the number of high-risk patients who are undergoing major operations increases. The surgicalist system, which is responsible for the perioperative management and advanced primary care of inpatients, is expected to expand rapidly. The shift from the vertical surgeon-resident-centered system to the horizontal surgeon-surgicalist-centered system can help provide high-quality care for patients, and a systematic training system for residents. In addition, it is necessary to define the essential capacities of the surgicalist, and to determine the research and education that can promote them.

Brain metastasis from colorectal cancer: a single center experience

PURPOSE: The detection rate of brain metastasis (BM) from colorectal cancer (CRC) is increasing. This study was designed to analyze the clinical features of BM and prognosis according to the therapeutic modalities. METHODS: A total of 19 cases were collected in this study between November 2008 and December 2015. We reviewed the patients' demographic data and the clinical features of BM retrospectively and investigated their prognostic significance. RESULTS: Nineteen patients included 8 male and 11 female patients. The median age at diagnosis of BM was 62.4 years (range, 32–83 years). The median interval between diagnosis of CRC and BM was 39 months (range, 0–98 months). Eighteen patients (94.7%) had extracranial metastasis at the diagnosis of BM. Lung was the most common site of extracranial metastasis in 14 patients (73.7%). Synchronous BMs were found at the diagnosis of primary CRC in 2 patients (10.5%). The location of primary CRC was the colon in 6 patients (31.6%) and the rectum in 13 patients (68.4%). At the diagnosis of BM, 10 patients (52.6%) had a solitary BM. The common neurologic symptoms were headache in 8 cases (42.1%) and ataxia in 6 cases (31.6%). The median survival after the diagnosis of BM was 3 months (range, 1–10 months). The patients who underwent surgery plus stereotactic radiosurgery (SRS) had an improved survival (range, 3–10 months) than the other patients (range, 1–6 months) (P = 0.016). CONCLUSION: In patients with BM from CRC, surgical resection plus SRS might improve survival.

Clinical Significance of Preoperative Virtual Colonoscopy for Evaluation of the Proximal Colon in Patient With Obstructive Colorectal Cancer

PURPOSE: Virtual colonoscopy is the most recently developed tool for detecting colorectal cancers and polyps, but its effectiveness is limited. In our study, we compared the result of preoperative virtual colonoscopy to result of preoperative and postoperative colonoscopy. We evaluated also the accuracy of preoperative virtual colonoscopy in patients who had obstructive colorectal cancer that did not allow passage of a colonoscope. METHODS: A total of 164 patients who had undergone preoperative virtual colonoscopy and curative surgery after the diagnosis of a colorectal adenocarcinoma between November 2008 and August 2013 were pooled. We compared the result of conventional colonoscopy with that of virtual colonoscopy in the nonobstructive group and the results of preoperative virtual colonoscopy with that of postoperative colonoscopy performed at 6 months after surgery in the obstructive group. RESULTS: Of the 164 patients, 108 were male and 56 were female patients. The mean age was 62.7 years. The average sensitivity, specificity, and accuracy of virtual colonoscopy for all patients were 31.0%, 67.2%, and 43.8%, respectively. In the nonobstructive group, the average sensitivity, specificity, and accuracy were 36.6%, 66.2%, and 48.0%, respectively, whereas in the obstructive group, they were 2%, 72.4%, and 25.4%. Synchronous cancer was detected via virtual colonoscopy in 4 of the 164 patients. CONCLUSION: Virtual colonoscopy may not be an effective method for the detection of proximal colon polyps, but it can be helpful in determining the therapeutic plan when its results are correlated with the results of other studies.

A Comparative Study of USA and Europe Guidelines of Rate and Rhythm Control Pharmacotherapy in Atrial Fibrillation

OBJECTIVE: Atrial fibrillation (AF) guidelines have been published in the USA and Europe. Recently, the USA and Europe have updated their guidelines, respectively. These new AF guidelines help in addressing key management issues in clinical situations. This study, therefore, systematically compared guidelines for rate and rhythm control pharmacotherapy of patients with AF between the USA (American College of Cardiology and American Heart Association, ACC/AHA) and Europe (European Society of Cardiology, ESC). METHODS: This study investigated and compared American guidelines (2014) and European guidelines (2010 and 2012). RESULTS: Generally, there are four meaningful differences between ACC/AHA and ESC guidelines. Important differences are treatment classification system, level of recommendation, drug list, and dosage. In addition, ACC/AHA described pharmacokinetic drug interactions for antiarrhythmic drugs. ESC emphasized ECG and atrioventricular nodal slowing as feature of antiarrhythmic drugs. CONCLUSION: This research addresses important use of anti-arrhythmic drugs and movement to accept recent recommendations in Korea. For the successful application of the guidelines, a role of pharmacists is crucial in clinical situation.

Proteomic analysis of novel targets associated with the enhancement of TrkA-induced SK-N-MC cancer cell death caused by NGF

Nerve growth factor (NGF) is known to regulate both cancer cell survival and death signaling, depending on the cellular circumstances, in various cell types. In this study, we showed that NGF strongly upregulated the protein level of tropomyosin-related kinase A (TrkA) in TrkA-inducible SK-N-MC cancer cells, resulting in increases in various TrkA-dependent cellular processes, including the phosphorylation of c-Jun N-terminal kinase (JNK) and caspase-8 cleavage. In addition, NGF enhanced TrkA-induced morphological changes and cell death, and this effect was significantly suppressed by the JNK inhibitor SP600125, but not by the phosphatidylinositol 3-kinase (PI3K) inhibitor wortmannin. To investigate novel targets associated with the enhancement of TrkA-induced SK-N-MC cell death caused by NGF, we performed Coomassie Brilliant Blue staining and two-dimensional (2D) proteomic analysis in TrkA-inducible SK-N-MC cells. We identified 31 protein spots that were either greatly upregulated or downregulated by TrkA during NGF treatment using matrix-associated laser desorption/ionization time of flight/time of flight mass spectrometry, and we analyzed the effects of SP600125 and wortmannin on the spots. Interestingly, 11 protein spots, including heterogeneous nuclear ribonucleoprotein K (hnRNP K), lamin B1 and TAR DNA-binding protein (TDP43), were significantly influenced by SP600125, but not by wortmannin. Moreover, the NGF/TrkA-dependent inhibition of cell viability was significantly enhanced by knockdown of hnRNP K using small interfering RNA, demonstrating that hnRNP K is a novel target associated with the regulation of TrkA-dependent SK-N-MC cancer cell death enhanced by NGF.

Insertion of Totally Implantable Central Venous Access Devices by Surgeons

PURPOSE: The aim of this study is to evaluate the results for the insertion of totally implantable central venous access devices (TICVADs) by surgeons. METHODS: Total 397 patients, in whom TICVADs had been inserted for intravenous chemotherapy between September 2008 and June 2014, were pooled. This procedure was performed under local anesthesia in an operation room. The insertion site for the TICVAD was mainly in the right-side subclavian vein. In the case of breast cancer patients, the subclavian vein opposite the surgical site was used for insertion. RESULTS: The 397 patients included 73 males and 324 females. Primary malignant tumors were mainly colorectal and breast cancer. The mean operation time was 54 minutes (18-276 minutes). Operation-related complications occurred in 33 cases (8.3%). Early complications developed in 15 cases with catheter malposition and puncture failure. Late complications, which developed after 24 hours, included inflammation in 6 cases, skin necrosis in 6 cases, hematoma in 3 cases, port malfunction in 1 case, port migration in 1 case, and intractable pain at the port site in 1 case. CONCLUSION: Insertion of a TICVAD under local anesthesia by a surgeon is a relatively safe procedure. Meticulous undermining of the skin and carefully managing the TICVAD could minimize complications.

Reply on "What Is the Role of Surgeons When Implanting a Totally Implantable Venous Access Device to Prevent Immediate Complications?"

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A Comparative Study the USA, Europe and Korea Guidelines of Antiplatelet Therapy for Patients with Acute Coronary Syndrome

OBJECTIVE: Patients with acute coronary syndrome (ACS) are typically managed with dual antiplatelet therapy of acetylsalicylic acid (aspirin) and P2Y12 receptor inhibitor. In this study, we discussed current and previous antiplatelet therapy guidelines and compared with guidelines of the USA (ACC/AHA), Europe (ESC) and Korea (KSC). METHOD: This study investigated from ACC/AHA Joint Guidelines (the USA), ESC Clinical Practice Guidelines (Europe) and Korea Society of Interventional Cardiology (Korea) web site, respectively. RESULTS: It is significant that difference between the current and the previous guidelines was integration of terminology from clopidogrel to P2Y12 receptor inhibitors since prasugrel and ticagrelor, new antiplatelet drugs, has been added. The other difference was all three guidelines has differences in dose of aspirin. The most notable difference was class of recommendation (COR) in P2Y12 receptor inhibitors. ACC/AHA and Korean guidelines recommend clopidogrel, prasugrel, and ticagrelor with COR IB; whereas, ESC recommend prasugrel and ticagrelor with IB which is higher than clopidogrel with IC. CONCLUSION: This research addresses important movement to revise the Korean existing guideline recommendations. New Korean antiplatelet therapy guideline should be avoiding obvious differences in ACC/AHA and ESC guidelines and harmonizing international guidelines.

Detection of Polyps After Resection of Colorectal Cancer

PURPOSE: Because colonoscopy after colorectal cancer surgery is important for detecting synchronous or metachronous colorectal neoplasms, we designed this study to investigate, by using postoperative colonoscopy, the miss rate for and the location of polyps remaining after colorectal cancer surgery. METHODS: In a prospectively-collected patient database, 264 patients were shown to have undergone a colorectal cancer resection between May 2012 and June 2013. Of these, 116 who had received a complete colonoscopy preoperatively and postoperatively were included in this study. RESULTS: Of these 116 patients, 68 were males and 48 were females; their mean age was 63 years. The mean time after surgery at which postoperative colonoscopy was performed was 7.1 months (range, 3-15 months). On postoperative colonoscopy, a total of 125 polyps were detected. Of these, there were no cancerous lesions; 46 (36.8%) were neoplastic polyps, and 79 (63.2%) were nonneoplastic polyps. Fifty-nine polyps (47.2%) and 15 polyps (12%) were located in the proximal and the distal parts of the anastomosis, respectively. The miss rates for the total numbers of polyps and of neoplastic polyps remaining after surgery were 37.4% and 24.2%, respectively. The incidence of neoplastic polyps increased during postoperative colonoscopy as it had during preoperative colonoscopy (r = 0.164, P = 0.048). CONCLUSION: Colonoscopic surveillance after colorectal cancer resection results in the detection of pathologic polyps in one-fourth of the cases. During postoperative colonoscopy, careful examination of the proximal colon is necessary. Patients in whom multiple neoplastic polyps had been detected during preoperative colonoscopy require careful and thorough follow-up.

Is Microsatellite Instability Really a Good Prognostic Factor of Colorectal Cancer?

PURPOSE: The aim of this study was to investigate the clinicopathologic features of and the prognosis for colorectal cancers (CRCs) with microsatellite instabilities (MSIs). METHODS: Between 2006 and 2009, genotyping was performed on 245 patients with stage II/III CRCs to establish the MSI status. The clinicopathologic differences and the prognostic value of MSI were analyzed. The median follow-up period was 38 months (range, 7-68 months). RESULTS: Of the total 245 patients, 20 (8.2%) had MSI-high (H) and 225 (91.8%) had MSI-low (L) or stable (S) CRCs. Adjuvant chemotherapies were performed on 101 stage II (87.8%) and 107 stage III patients (82.3%). Patients with MSI-H CRCs more frequently had a family history of colon cancer (10% vs. 2.7%, P = 0.003), more frequently had a cancer located at the proximal colon (90.0% vs. 19.1%, P < 0.0001), and more often showed a mucinous phenotype or poor differentiation (35.0% vs. 7.1%, P = 0.001). Despite less frequent lymph node metastasis (25% vs. 55.6%, P = 0.01), the number of retrieved lymph nodes was higher (26.3 +/- 13.1 vs. 20.7 +/- 1.2, P = 0.04) in the MSI-H group. The overall survival and the disease-free survival (DFS) did not differ with respect to MSI status. However, in the stage II subgroup, the DFS for patients with MSI-H CRCs was significantly worse (72.2% vs. 90.7%, P = 0.03). The multivariate analysis performed on this subgroup revealed that MSI-H was an independent poor prognostic factor (adjusted hazard ratio, 4.0; 95% confidence interval, 1.0-15.6, P = 0.046). CONCLUSION: MSI-H CRCs had distinct clinicopathologic features, and MSI-H was an independent poor prognostic factor in stage II CRCs. Considering the majority of stage II patients were administrated adjuvant chemotherapy, the efficacy of adjuvant chemotherapy for treating MSI CRCs might be different from that for treating MSI-L/S tumors.

Metachronous schwannoma in the colon with vestibular schwannoma

We experienced a case of vestibular schwannoma and metachronous schwannoma in the colon. A 59-year-old female presented with a 1-month history of hematochezia. She had undergone suboccipital craniectomy resulting in radical subtotal resection, followed by gamma knife radiosurgery for a large left vestibular schwannoma 4 years prior to admission. On preoperative colonoscopy, a huge mass through which the colonoscope could not be passed was detected. CT scans showed colo-colonic intussusception with a 4.8-cm-sized mass in the descending colon. PET/CT revealed hypermetabolism of the descending colon tumor and pericolic lymph nodes. We performed left hemicolectomy under the preoperative impression of colon cancer with intussusception. A pathological diagnosis of benign schwannoma of the colon was made in this patient.

Nevoid Basal Cell Carcinoma Syndrome: A Case Report and Review of Korean Cases / 대한악안면성형재건외과학회지

Nevoid basal cell carcinoma syndrome (NBCCS) is a rare autosomal genetic disease caused by a PTCH mutation. The disease is characterized by multiple basal cell carcinomas of the skin, multiple keratocystic odontogenic tumors (KCOTs) in the jaw, palmar and/or plantar pits, bifid ribs, ectopic calcification of the falx cerebri, and skeletal abnormalities. Early diagnosis is difficult in many cases because there may be a number of systemic symptoms. The purpose of this study is to report the case of a 12-year-old girl who was hospitalized with multiple KCOTs that occurred in the upper and lower jaws. Through characteristic clinical symptoms and radiologic findings, she was finally diagnosed as having NBCCS. This study also aims to organize the symptoms often observed in Korea using previously published case reports to provide useful information for the early diagnosis of NBCCS.

Decompression Device Using a Stainless Steel Tube and Wire for Treatment of Odontogenic Cystic Lesions: A Technical Report / 대한악안면성형재건외과학회지

Decompression is considered an effective treatment for odontogenic cystic lesions in the jaw. A variety of decompression devices are successfully used for the treatment of keratocystic odontogenic tumors, radicular cysts, dentigerous cysts, and ameloblastoma. The purpose of these devices is to keep an opening between the cystic lesion and the oral environment during treatment. The aim of this report is to describe an effective decompression tube using a stainless steel tube and wire for treatment of jaw cystic lesions.

Small bowel diverticulosis in patient with early gastric cancer

Jejunal and ileal diverticula are rare in adults. Duodenal diverticula are five times more prevalent than jejunoileal diverticula. Most patients are asymptomatic. However, chronic symptoms including intermittent abdominal pain, flatulence, diarrhea and constipation are seen in 10%-30% of patients. Gastric cancer is the second most common cancer in South Korea and here we report a case of early gastric cancer with multiple duodenal and jejunal diverticula. A 67-year-old woman was admitted to Konkuk University Medical Center with chronic diarrhea and weight loss of 19 kg over 2 months. Following gastroduodenoscopy, we identified adenocarcinoma of the lower body of the stomach. On abdominopelvic computed tomography, diverticula of duodenum and jejunum were found. Patient underwent distal gastrectomy and gastroduodenostomy with lymphadenectomy. She was discharged on the tenth postoperative day without complications.

Usefulness of Carcinoembryonic Antigen for Monitoring Tumor Progression during Palliative Chemotherapy in Metastatic Colorectal Cancer

PURPOSE: To evaluate the efficacy of carcinoembryonic antigen (CEA) measurement for monitoring tumor progression during palliative chemotherapy in metastatic colorectal cancer. MATERIALS AND METHODS: Forty-eight patients with initially unresectable metastatic colorectal cancer (n=26, 54.2%) or recurrent unresectable metastatic colorectal cancer (n=22, 45.8%) received FOLFOX-4 chemotherapy for palliation. Serum CEA levels and carbohydrate antigen 19-9 levels were measured and computed tomography (CT) studies were performed prior to chemotherapy and after 3 cycles of chemotherapy. From the CT images, tumor responses were evaluated according to the Response Evaluation Criteria in Solid Tumors criteria and categorized as complete response, partial response, stable disease, and progressive disease. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of tumor marker assessments for determining tumor response were calculated. RESULTS: The sensitivity, specificity and diagnostic accuracy of CEA assessment for prediction of disease progression were 50%, 77% and 69%, respectively. When the patients were dichotomized according to baseline CEA level, the initially elevated CEA group showed higher sensitivity and higher diagnostic accuracy compared to the initially normal CEA group (sensitivity=67% vs. 20%; diagnostic accuracy=71% vs. 62%). CONCLUSION: CEA assessment could be useful for monitoring tumor progression during palliative chemotherapy in only patients with initially elevated CEA level.