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.

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.

Is familial papillary thyroid microcarcinoma more aggressive than sporadic form?

PURPOSE: With the increasing incidence of papillary thyroid microcarcinoma (PTMC), familial papillary thyroid microcarcinoma (FPTMC) is now recognized more frequently. However, the biological behavior of FPTMC is poorly understood. The aim of this study was to investigate the prevalence of FPTMC and its biological aggressiveness. METHODS: Between March 2006 and July 2010, 2,414 patients underwent primary surgical therapy for PTMC and 149 (6.2%) were further classified as FPTMC. To determine the biological aggressiveness of FPTMC, we compared the clinicopathological features and prognosis between FPTMC and sporadic PTMC (SPTMC). RESULTS: The male-to-female ratio was higher in FPTMC than in sporadic papillary thyroid microcarcinoma (SPTMC: 1:4.5 vs. 1:7.2, P = 0.041). The central lymph node (LN) metastasis rate was significantly higher in FPTMC than in SPTMC (36.2% vs. 24.2%, P = 0.002). The local recurrence rate was also higher in FPTMC than in SPTMC (4.5% vs. 0.6%, P < 0.001). We identified familial occurrence in 6.2% of cases of PTMC. FPTMC is associated with a high rate of central LN metastasis and local recurrence. CONCLUSION: These findings suggest that close follow-up can be beneficial in FPTMC patients to detect local recurrence.

Primary Squamous Cell Carcinoma of the Remnant Stomach after Subtotal Gastrectomy

Primary squamous cell carcinoma (SCC) of the stomach is a very rare disease. However, the pathogenesis, clinical characteristics, and prognosis of gastric SCC are controversial and remain to be elucidated. Herein, we report a case of primary gastric SCC of the remnant stomach after subtotal gastrectomy. A 65-year-old man was admitted to our hospital due to epigastric discomfort and dizziness. He had undergone subtotal gastrectomy 40 years previously for gastric ulcer perforation. Endoscopy revealed a normal esophagus and a large mass in the remnant stomach. Abdominal computed tomography revealed enhanced wall thickening of the anastomotic site and suspected metachronous gastric cancer. Endoscopic biopsy revealed SCC. Total gastrectomy was performed with Roux-en-Y esophagojejunostomy. A 10-cm tumor was located at the remnant stomach just proximal to the previous area of anastomosis. Pathologic examination showed well-differentiated SCC extended into the subserosa without lymph node involvement (T3N0M0). The patient received adjuvant systemic chemotherapy with 6 cycles of 5-FU and cisplatin regimen, and he is still alive at the 54-month follow-up. According to the treatment principles of gastric cancer, early detection and radical surgical resection can improve the prognosis.

Differentiated Thyroid Carcinoma of Children and Adolescents: 27-Year Experience in the Yonsei University Health System

Thyroid carcinomas are uncommon in childhood and adolescence. The aim of this study was to analyze clinical features and clinical outcomes of thyroid cancer in the pediatric population treated in the Yonsei University Health System. From September 1982 to June 2009, 90 patients (75 females, 15 males; female:male ratio of 5:1) with differentiated thyroid carcinoma were identified in our institute. The mean age at diagnosis was 15.8 yr old (range 4.8-19.9 yr). Cervical masses were most common clinical manifestations at diagnosis in 65 patients (72.2%). Forty-two patients underwent less than total thyroidectomy and 18 patients underwent total thyroidectomy. Thirty patients (33.3%) had lateral neck lymph node metastasis and seven patients (7.8%) had lung metastasis at the time of surgery. Among the 90 patients, recurrence occurred in 14 patients (15.5%). Mean follow-up period for patients with differentiated thyroid carcinoma was 81.6 months (13-324 months). No patients died of differentiated thyroid carcinoma. Patients with differentiated thyroid carcinoma who were < 20-yr-of-age were present with aggressive local disease and a high frequency of lymph node and distant metastasis. It is recommended that pediatric thyroid cancer should be managed mostly using proper surgical approach with thyroidectomy and lymph node dissection when indicated.

Coexistence of Chronic Lymphocytic Thyroiditis with Papillary Thyroid Carcinoma: Clinical Manifestation and Prognostic Outcome

The study aimed to identify the clinical characteristics of coexisting chronic lymphocytic thyroiditis (CLT) in papillary thyroid carcinoma (PTC) and to evaluate the influence on prognosis. A total of 1,357 patients who underwent thyroid surgery for PTC were included. The clinicopathological characteristics were identified. Patients who underwent total thyroidectomy (n = 597) were studied to evaluate the influence of coexistent CLT on prognosis. Among the total 1,357 patients, 359 (26.5%) had coexistent CLT. In the CLT group, the prevalence of females was higher than in the control group without CLT (P < 0.001). Mean tumor size and mean age in the patients with CLT were smaller than without CLT (P = 0.040, P = 0.047, respectively). Extrathyroidal extension in the patients with CLT was significantly lower than without CLT (P = 0.016). Among the subset of 597 patients, disease-free survival rate in the patients with CLT was significantly higher than without CLT (P = 0.042). However, the multivariate analysis did not reveal a negative association between CLT coexistence and recurrence. Patients with CLT display a greater female preponderance, smaller size, younger and lower extrathyroidal extension. CLT is not a significant independent negative predictive factor for recurrence, although presence of CLT indicates a reduced risk of recurrence.

Initial Experience with Posterior Retroperitoneoscopic Adrenalectomy for the Adrenal Tumors / 대한내분비외과학회지

PURPOSE: Posterior retroperitoneoscopic adrenalectomy (PRA) for small adrenal tumors has recently been in the spotlight due to its several benefits. Compelling advantages for endoscopic surgeons include direct, safe, and fast approach to the adrenal gland without trespass to the intraperitoneal organ. This study reports our initial experiences of PRA for the management of adrenal tumors. METHODS: From December 2009 to August 2011, 63 patients underwent PRA for the management of adrenal tumor. Among these patients, laparoscopic adrenalectomy and robotic adrenalectomy were performed in 54 and nine patients, respectively. We retrospectively reviewed records of all surgical outcomes. RESULTS: Of the 54 patients, 22 were male and 32 were female, and mean age was 51.7±14.0 years. Mean body mass index was 24.6±3.6 kg/m² and mean dimension of the tumors was 2.66±1.36 cm. Six patients were diagnosed with Cushing's disease, 22 patients with primary aldosteronism, seven patients with pheochromocytoma, one patient with metastatic adrenal gland cancer, and 18 patients with nonfunctioning adrenal tumors. Mean operative time was 88.5±27.1 min, mean blood loss was 17.4±37.4 ml, and mean duration to first oral intake was 0.83±0.4 days. Mean number of postoperative analgesics used was 2.28±2.54, and mean postoperative hospital stay was 2.85±1.43 days. There was no open conversion during the operation and no post-operative complication. CONCLUSION: PRA is a safe and fast procedure. In experienced hands, PRA represents one of the ideal approaching methods in the adrenal gland surgery.

In Vitro Adenosine Triphosphate Based Chemotherapy Response Assay in Gastric Cancer

PURPOSE: The purpose of this study was to investigate the reliability and the clinical applicability of the adenosine-triphosphate-based chemotherapy response assay (ATP-CRA) as a method of determining in vitro chemosensitivity in patients with gastric cancer. MATERIALS AND METHODS: A total of 243 gastric cancer tissue samples were obtained from gastrectomies performed between February 2007 and January 2010. We evaluated the effectiveness of the ATP-CRA assay in determining the chemosensitivity of gastric cancer specimens using eleven chemotherapeutic agents - etoposide, doxorubicin, epirubicin, mytomicin, 5-fluorouracil, oxaliplatin, irinotecan, docetaxel, paclitaxel, methotraxate, and cisplatin - for chemosensitivity studies using ATP-CRA. We assessed the failure rate, the cell death rate, and the chemosensitivity index. RESULTS: The failure rate of ATP-CRA was 1.6% (4/243). The mean coefficient of variation for triplicate ATP measurements was 6.5%. Etoposide showed the highest cell death rate (35.9%) while methotrexate showed the lowest (16.6%). The most active chemotherapeutic agent was etoposide, which most frequently ranked highest in the chemosensitivity test: 31.9% (51/160). Oxaliplatin was more active against early gastric cancers than advanced gastric cancers, whereas docetaxel was more active against advanced cancers. The lymph node negative group showed a significantly higher cell death rate than the lymph node positive group when treated with doxorubicin, epirubicin, and mitomycin. CONCLUSIONS: ATP-CRA is a stable and clinically applicable in vitro chemosensitivity test with a low failure rate. The clinical usefulness of ATP-CRA should be evaluated by prospective studies comparing the regimen guided by ATP-CRA with an empirical regimen.

In Vitro Adenosine Triphosphate Based Chemotherapy Response Assay in Gastric Cancer

PURPOSE: The purpose of this study was to investigate the reliability and the clinical applicability of the adenosine-triphosphate-based chemotherapy response assay (ATP-CRA) as a method of determining in vitro chemosensitivity in patients with gastric cancer. MATERIALS AND METHODS: A total of 243 gastric cancer tissue samples were obtained from gastrectomies performed between February 2007 and January 2010. We evaluated the effectiveness of the ATP-CRA assay in determining the chemosensitivity of gastric cancer specimens using eleven chemotherapeutic agents - etoposide, doxorubicin, epirubicin, mytomicin, 5-fluorouracil, oxaliplatin, irinotecan, docetaxel, paclitaxel, methotraxate, and cisplatin - for chemosensitivity studies using ATP-CRA. We assessed the failure rate, the cell death rate, and the chemosensitivity index. RESULTS: The failure rate of ATP-CRA was 1.6% (4/243). The mean coefficient of variation for triplicate ATP measurements was 6.5%. Etoposide showed the highest cell death rate (35.9%) while methotrexate showed the lowest (16.6%). The most active chemotherapeutic agent was etoposide, which most frequently ranked highest in the chemosensitivity test: 31.9% (51/160). Oxaliplatin was more active against early gastric cancers than advanced gastric cancers, whereas docetaxel was more active against advanced cancers. The lymph node negative group showed a significantly higher cell death rate than the lymph node positive group when treated with doxorubicin, epirubicin, and mitomycin. CONCLUSIONS: ATP-CRA is a stable and clinically applicable in vitro chemosensitivity test with a low failure rate. The clinical usefulness of ATP-CRA should be evaluated by prospective studies comparing the regimen guided by ATP-CRA with an empirical regimen.