Meaningful standard of reference for appendiceal perforation: pathology, surgery, or both?

Kim, Hyuk Jung,Kim, Mi Sung,Park, Ji Hoon,Ahn, Soyeon,Ko, Yousun,Song, Soon-Young,Woo, Ji Young,Lee, Kyoung Ho The Korean Surgical Society 2017 Annals of Surgical Treatment and Research(ASRT) Vol.93 No.2

<P><B>Purpose</B></P><P>This retrospective study was aimed to determine if appendiceal perforation identified pathologically but not surgically is clinically meaningful.</P><P><B>Methods</B></P><P>The study consists of 2 parts. First, we reviewed 74 studies addressing appendiceal perforation published in 2012 and 2013. Second, in a cross-sectional study, we classified 1,438 adolescents and adults (mean age, 29.3 ± 8.4 years; 785 men) with confirmed appendicitis as “nonperforation” (n = 1,083, group 1), “pathologically-identified perforation” (n = 55, group 2), “surgically-identified perforation” (n = 202, group 3), or “pathologically- and surgically-identified perforation” (n = 98, group 4). The 4 groups were compared for the frequency of laparoscopic appendectomy and the length of hospital stay using multivariable logistic regression analyses.</P><P><B>Results</B></P><P> The reference standard for appendiceal perforation was frequently missing or inconsistent in the previous studies. Laparoscopic appendectomies were less frequent in groups 3 (52.5%, P = 0.001) and 4 (65%, P = 0.040) than in group 1 (70.7%), while group 2 (73%, P = 0.125) did not significantly differ from group 1. Median hospital stays were 2.9, 3.0, 5.1, and 6.0 days for groups 1–4, respectively. Prolonged hospital stay (≥3.7 days) was more frequent in groups 3 (77.7%, P < 0.001) and 4 (89%, P < 0.001) than in group 1 (23.4%), while group 2 (35%, P = 0.070) did not significantly differ from group 1.</P><P><B>Conclusion</B></P><P>We recommend using surgical rather than pathologic findings as the reference standard for the presence of appendiceal perforation in future investigations.</P>

Prognosis of early mucinous gastric carcinoma

Ryu, Seong Yeob,Kim, Ho Gun,Lee, Jae Hyuk,Kim, Dong Yi The Korean Surgical Society 2014 Annals of Surgical Treatment and Research(ASRT) Vol.87 No.1

<P><B>Purpose</B></P><P>Little is known about the clinicopathological features of early mucinous gastric carcinoma (MGC). The purpose of this study was to compare the clinicopathological features and prognosis between patients with early MGC and those with early nonmucinous gastric carcinoma (NMGC).</P><P><B>Methods</B></P><P>We reviewed the records of 2,732 patients diagnosed with gastric carcinoma who were treated surgically. There were 14 patients (0.5%) with early MGC and 958 with early NMGC.</P><P><B>Results</B></P><P>Early MGC patients had a higher prevalence of elevated type (71.4%) compared with early NMGC patients (29.5%). More early MGC patients had submucosal carcinoma, compared with early NMGC patients (78.6% <I>vs.</I> 64.1%). The overall 5-year survival of the patients with early MGC was 97.2% as compared with 92.7% for the patients with early NMGC (P < 0.01). The statistically significant prognostic parameters influencing the 5-year survival rate according to Cox's proportional hazard regression model were: age (risk ratio, 2.22; 95% confidence interval [CI], 1.62-3.04; P < 0.01); sex (risk ratio, 1.97; 95% CI, 1.42-2.73; P < 0.01); and lymph node metastases (risk ratio, 1.88; 95% CI, 1.28-2.77; P < 0.01).</P><P><B>Conclusion</B></P><P>Patients with early MGC had a better prognosis than those with early NMGC. Mucinous histology itself appears not to be an independent prognostic factor. Therefore, early detection is important for improving the prognosis for patients with gastric carcinoma regardless of tumor histology.</P>

Atypia of undetermined significance on thyroid fine needle aspiration: surgical outcome and risk factors for malignancy

Ryu, Young Jae,Jung, Youn Seung,Yoon, Hyun Chul,Hwang, Min Jung,Shin, Sun Hyoung,Cho, Jin Seong,Lee, Ji Shin,Kim, Hee Kyung,Kang, Ho Cheol,Lim, Hyo Soon,Yoon, Jung Han,Park, Min Ho The Korean Surgical Society 2014 Annals of Surgical Treatment and Research(ASRT) Vol.86 No.3

<P><B>Purpose</B></P><P>This study was performed to analyze the surgical pathology results of the 'atypia of undetermined significance' (AUS) category from thyroid fine needle aspiration (FNA) and to describe the characteristics to distinguish a malignant from a benign nodule.</P><P><B>Methods</B></P><P>A retrospective analysis was done on 116 patients who underwent thyroid surgery from December 2008 to December 2012, following a diagnosis of AUS from preoperative thyroid FNA. We investigated the age, gender, size and site of the nodules, ultrasonographic criteria, cytological features, the number of atypia results after repeated FNAs, surgical method, and final pathologic results.</P><P><B>Results</B></P><P>Sixty-five out of 116 patients underwent total thyroidectomy and the rest had partial thyroidectomy. The final pathologic results were 41 malignancies (35.3%) and 75 benign diseases (64.7%). AUS was divided into group 1: 'cannot rule out malignancy' or group 2: 'cannot rule out follicular neoplasm'. After surgery, group 1 revealed papillary thyroid cancer in most cases and group 2 revealed follicular adenoma in most cases. Age over 40 years, ultrasonographic findings suggestive of malignancy, more than 2 results of atypia from repeated FNAs and nodules less than 2 centimeters were risk factors for malignancy on univariate analysis. Multivariate analysis showed that ultrasonographic findings suggestive of malignancy was a significant risk factor for malignancy.</P><P><B>Conclusion</B></P><P>For proper evaluation of the risk for malignancy in thyroid AUS patients, the ultrasonographic criteria should be considered along with other clinicopathological findings such as age, nodule size, number of atypia, cytologic features.</P>

Comparison of surgical outcomes of intracorporeal hepaticojejunostomy in the excision of choledochal cysts using laparoscopic versus robot techniques

Lee, Hongeun,Kwon, Wooil,Han, Youngmin,Kim, Jae Ri,Kim, Sun-Whe,Jang, Jin-Young The Korean Surgical Society 2018 Annals of Surgical Treatment and Research(ASRT) Vol.94 No.4

<P><B>Purpose</B></P><P>Increasing surgical expertise in minimally invasive surgery has allowed laparoscopic surgery to be performed in many abdominal surgeries. Laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy are challenging and sophisticated surgeries because of the difficult anastomosis. Recent advances in robotic surgery have enabled more delicate and precise movements, and Endowrist instruments allow for securing sutures during anastomosis. This study aimed to compare surgical outcomes of laparoscopic and robotic hepaticojejunostomy in choledochal cyst excision.</P><P><B>Methods</B></P><P>Sixty-seven patients who underwent laparoscopic or robotic-hybrid choledochal cyst excision from 2004 to 2016 were retrospectively analyzed and compared. In robotic surgery, dissection was performed laparoscopically, and hepaticojejunostomy was performed using a robotic platform.</P><P><B>Results</B></P><P>The mean operative time was significantly longer in robotic surgery than in laparoscopic surgery (247.94 ± 54.14 minutes <I>vs</I>. 181.31 ± 43.06 minutes, P < 0.05). The mean estimated blood loss (108.71 ± 15.53 mL <I>vs</I>. 172.78 ± 117.46 mL, respectively, P = 0.097) and postoperative hospital stay (7.33 ± 2.96 days <I>vs</I>. 6.22 ± 1.06 days, P = 0.128) were comparable between procedures. Compared to the laparoscopic approaches, robotic surgery had significantly less short-term complications (22.4% <I>vs</I>. 0%, P = 0.029). There were more biliary leakage (n = 7, 14.3%) observed during the first 30 days after surgery in laparoscopy while none were observed in the robotic method.</P><P><B>Conclusion</B></P><P>Robotic surgery allow for more precise and secure sutures during anastomosis thereby reducing biliary complications. With expanding knowledge and expertise, robotic surgery may offer more advantages over laparoscopy in the era of minimally invasive surgery.</P>

Cost comparison between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors

Nam, Myung Jin,Sohn, Dae Kyung,Hong, Chang Won,Han, Kyung Su,Kim, Byung Chang,Chang, Hee Jin,Park, Sung Chan,Oh, Jae Hwan The Korean Surgical Society 2015 Annals of Surgical Treatment and Research(ASRT) Vol.89 No.4

<P><B>Purpose</B></P><P>To compare medical costs of endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal tumors.</P><P><B>Methods</B></P><P>The records of 80 patients who underwent ESD and 32 who underwent TEM for the treatment of rectal tumors were collected. Factors compared in the two groups included patient age, sex and clinical characteristics, as well as hospital stay, procedure time, instrument use, medications, postoperative complications, and imaging and laboratory findings. Costs were analyzed based on medical insurance fees, as set publicly by the Ministry of Health & Welfare, Korea. Medical costs were also divided into patient copayments and National Health Insurance (NHI) Corporation charges.</P><P><B>Results</B></P><P>Patient characteristics, including age, sex, and comorbidities, were similar in the two groups, as were procedure time, histologic diagnosis, tumor size and distance from the anal verge, hospital stay, and complication rates. Median total hospital costs were significantly lower in the ESD than in the TEM group (1,214 United State dollars [USD] vs. 1,686 USD, P < 0.001). The costs for consumables, drugs and laboratory as well as operation fee were also significantly lower in the ESD than in the TEM group. However, patient copayments in the ESD group were significantly higher than in the TEM group (928 USD vs. 496 USD, P < 0.001), because ESD procedure for rectal tumors is not yet covered by the Korean NHI.</P><P><B>Conclusion</B></P><P>Overall direct medical costs were significantly lower for ESD than for TEM in the treatment of rectal tumors.</P>

Body size and thyroid nodules in healthy Korean population

Kim, Ju-Yeon,Jung, Eun-Jung,Park, Soon-Tae,Jeong, Sang-Ho,Jeong, Chi-Young,Ju, Young-Tae,Lee, Young-Joon,Hong, Soon-Chan,Choi, Sang-Kyeong,Ha, Woo-Song The Korean Surgical Society 2012 Annals of Surgical Treatment and Research Vol.82 No.1

<P><B>Purpose</B></P><P>Excess weight and obesity have been associated with numerous diseases including thyroid cancer, but the relationship has been weak. The objective of this study was to evaluate the relationship of body sizes on thyroid nodules in healthy Korean population.</P><P><B>Methods</B></P><P>A total of 7,763 persons who underwent a health examination in our health examination center were included in this study. The epidemiologic factors, body size and thyroid ultrasound results were reviewed. We investigated the effects of body size on the presence of thyroid nodules and malignancy.</P><P><B>Results</B></P><P>The incidence of thyroid nodules was 20.6%. In the group who were found to have thyroid nodules, mean height, weight and body surface area (BSA) were significantly smaller compared to the others. Especially, in the women, smaller height (less than 160 cm) and overweight (≥ 60 kg) were identified as independent risk factors for the presence of thyroid nodules. The patients with body mass index (BMI) subgroups of normal or overweight had a tendency to have thyroid nodules more frequently. The detection rate of thyroid cancer was 0.47%. The patients with thyroid cancer tended to be smaller in height and BSA than the others.</P><P><B>Conclusion</B></P><P>A higher frequency of thyroid nodules was associated with women and, older age. In women, there were significant correlations in height, weight and BMI subgroups to the presence of thyroid nodules.</P>

An online questionnaire survey on preferred timing for the diagnosis and management of thyroid carcinoma in general population in Korea

Park, Jin-Woo,Yoo, Jae-Soo,Yun, Jin-Kyung,Kim, Byoung-Hoon,Noh, Yeon-Woo,Kim, Dong-Ju The Korean Surgical Society 2016 Annals of Surgical Treatment and Research(ASRT) Vol.90 No.6

<P><B>Purpose</B></P><P>An optimal timing for diagnosis and management of papillary thyroid microcarcinoma (PTMC) has become the subject for much controversy. The aim of the present study is to analyze people's preference in Korea for timing of diagnosis and management of PTMC using an online questionnaire.</P><P><B>Methods</B></P><P>The questionnaire consists of 3 questions about preference for the diagnosis and management of PTMC and 3 additional questions about respondents' personal information. An online survey was conducted from March 3 to June 3 in 2015 using Google Survey (http://goo.gl/forms/b81yEjqNUA).</P><P><B>Results</B></P><P>A total 2,308 persons (1,246 males, 1,053 females) answered the questionnaire. Respondents' ages varied widely from teenagers to 70-year-olds. If there was a suspicious thyroid nodule from PTMC measuring less than 1 cm in diameter, 95.7% of respondents want to know a cytological diagnosis for it. If a thyroid nodule turned out to be a PTMC, 59.5% of respondents wanted it removed immediately. For surgical management of PTMC, 53.0% of respondents were worried more about recurrences than complications. In subgroup analyses, respondents younger than 40 years old more often want immediate surgery than others: 66.7% vs. 32.7% (P < 0.05). Respondents who underwent thyroid cancer surgery (n = 91) were worried more about recurrences than others: 69.2% vs. 52.4% (P < 0.05).</P><P><B>Conclusion</B></P><P>Almost all respondents in the present study wanted diagnosis of suspicious thyroid nodules immediately. However, there were opposing opinions about the preferred timing for surgical treatment and surgical extents. A patient's right to know their disease status and decision on treatments should be emphasized all the more.</P>

The effective distribution system for the concentration of patients to extra-large hospitals

Hong, Du Pyo,Song, Jaeki The Korean Surgical Society 2011 Annals of Surgical Treatment and Research Vol.80 No.6

<P><B>Purpose</B></P><P>In Korean society, extra-large hospitals are congested with the majority of patients. Because of the congestions, the urgent patients need to wait anywhere from as short as a month to around three months. These concentrations of the patients on the extra-large hospitals causes not only the economic problem in terms of loss of opportunity cost and resources of other medium and large hospitals but also the fear and the consequential stress of the patients and the families of the patients who are waiting for the surgeries. The phenomenon of the concentrations derived due to the insufficient information to the medical consumers. If the information on medical treatment services such as surgery schedule is provided before the selection of hospital, we expect that the selection of hospital for the patients and their family will differ, resulting in redistribution of concentration phenomenon. In this paper, we propose and verify the effective distribution system for the concentration on the extra-large hospitals.</P><P><B>Methods</B></P><P>Web simulation survey was conducted. A total 100 respondents were divided into 4 groups of 25 respondents and the different information was provided to each group.</P><P><B>Results</B></P><P>Through multiple comparisons among groups, only group which was provided with both information about 'the difference of surgical results' and 'the waiting time for surgery', had difference in significance.</P><P><B>Conclusion</B></P><P>By providing two sets of information to patients, reckless selection of extra-large hospitals can be spread to more appropriate hospitals and therefore achieve effective distribution of the population concentration on extra-large hospital.</P>

An exclusively dopamine secreting paraganglioma in the retroperitoneum: a first clinical case in Korea

Yi, Jin Wook,Oh, Eun Mee,Lee, Kyu Eun,Choi, June Young,Koo, Do Hoon,Kim, Kyung Joo,Jung, Kyeong-Cheon,Kim, Seong-Yeon,Youn, Yeo-Kyu The Korean Surgical Society 2012 Annals of Surgical Treatment and Research Vol.82 No.6

<P>Exclusively dopamine producing retroperitoneal paragangliomas are extremely rare. We have experienced the first Korean case managed successfully based on the proper evaluation. A 26-year-old female patient came to our attention after the accidental detection of an adrenal mass. She had no symptoms and denied any family history. Laboratory evaluations were normal but serum dopamine (425 ng/L) and 24-hour urine dopamine levels (1,565.3 µg/day) were elevated. She underwent laparoscopic right adrenalectomy. Histopathological diagnosis was a paraganglioma. After operation, dopamine levels in serum and 24-hour urine dropped to 0.09 ng/L and 388.4 µg/day. Dopamine producing paraganglioma elicit no clinical symptoms. Only the dopamine level is elevated in serum and 24-hour urine samples. Surgical resection without using preoperative alpha blockage is the treatment of choice. The prognosis for patients with this tumor tends to be poor because the diagnosis is usually delayed due to lack of symptoms.</P>

Comparison of the outcomes of robotic cholecystectomy and laparoscopic cholecystectomy

Lee, Eun Kyoung,Park, Eunyoung,Oh, Won-Oak,Shin, Nah-Mee The Korean Surgical Society 2017 Annals of Surgical Treatment and Research(ASRT) Vol.93 No.1

<P><B>Purpose</B></P><P>This study compared the effects of robotic single-port cholecystectomy (RC) and 3-port laparoscopic cholecystectomy (LC) on patients' surgical pain, postoperative complications, and satisfaction.</P><P><B>Methods</B></P><P>One hundred twenty patients with gallbladder disease scheduled for either LC or RC were recruited. Each patient was followed up for 1 week after hospital discharge.</P><P><B>Results</B></P><P>Time stayed in operating room was longer in patients with RC, however their hospital stay was shorter than those with LC (t = 3.01, P = 0.003). Since patients with RC received more analgesics during the surgery (t = 3.98, P < 0.001), all participants' surgical pain level were analyzed by using analysis of covariance. Patients who underwent RC reported less surgical pain consistently at 6 hours and first day after surgery and 2 days and 1 week later than patients in the LC. Repeated measure analysis of variance also demonstrated that the RC with single-port might cause less pain throughout the postoperative period (F = 25.68, P < 0.001). Participants' conditions appeared stable without complications such as infection or bleeding regardless of the surgical type however, overall satisfaction with RC showed significantly higher than those with LC except for one item, “the cost of surgery.”</P><P><B>Conclusion</B></P><P>These results suggested that the RC might be a better choice for people who concern about surgical pain and early hospital discharge. Since there were no differences in postoperative health status between the 2 groups, health care providers as an advocate can provide more reliable information to their patients.</P>