Analysis of Pediatric Surgery Using the National Healthcare Insurance Service Database in Korea: How Many Pediatric Surgeons Do We Need in Korea?

Oh Chaeyoun,이상훈,장혜경,Ahn Soo Min,Chae Kyunghee,Kim Sujeong,Kim Sukil,Seo Jeong-Meen 대한의학회 2021 Journal of Korean medical science Vol.36 No.18

Background: In the past, general surgeons (GSs) without a pediatric surgical subspecialty often performed surgery on children and, even now, GSs are performing many pediatric surgeries. We aimed to investigate the involvement of pediatric surgeons (PSs) and GSs in pediatric surgery, compare the outcomes of surgery in the neonatal intensive care unit (NICU), and estimate the appropriate PS workforce in Korea. Methods: We used surgical data from the National Health Insurance Service database that was collected from patients under the age of 19 years in hospitals nationwide from January 2002 to December 2017. In this database, we found 37 hospitals where PSs worked by using the index operation (congenital diaphragmatic hernia, esophageal atresia, hypertrophic pyloric stenosis, Hirschsprung's disease, abdominal wall defect, jejunoileal atresia, malrotation, anorectal malformation, and biliary atresia). It was assumed that the surgery in the 37 hospitals was performed by PS and that the surgery in other hospitals was performed by GS. Mortality was analyzed to compare the outcomes of acute abdominal surgery in the NICU. We estimated the number of PS currently needed in Korea for each situation under the assumption that PS would perform all operations for the index operation, main pediatric diseases (index operation + gastroesophageal reflux disease, choledochal cyst, inguinal hernia, and appendicitis), acute abdominal surgery in the NICU, and all pediatric surgeries. Additionally, we estimated the appropriate number of PS required for more advanced pediatric surgery in the future. Results: The number of pediatric surgeries from 2002 to 2017 increased by 124%. Approximately 10.25% of the total pediatric surgeries were performed by PSs, and the percentage of the surgery performed by PSs increased from 8.32% in 2002 to 15.92% in 2017. The percentage of index operations performed by PSs annually was 62.44% in average. It was only 47.81% in 2002, and increased to 88.79% in 2017. During the last 5 years of the study period, the average annual number of surgeries for main pediatric diseases was approximately 33,228. The ratio of the number of surgeries performed by PS vs. GS steadily increased in main pediatric diseases, however, the ratio of the number of surgery performed by PS for inguinal hernia and appendicitis remained low in the most recent years. The percentage of the number of acute abdominal surgery performed by PS in the NICU was 44% in 2002, but it had recently risen to 89.7%. After 30 days of birth, mortality was significantly lower in all groups that were operated on by PS, rather than GS, during the last 5 years. In 2019, 49 PSs who were under the age of 65 years were actively working in Korea. Assuming that all pediatric surgeries of the patients under the age of 19 years should be performed by PS, the minimum number of PS currently required was about 63 if they perform all of the index operations, the main pediatric surgery was about 209, the NICU operation was about 63, and the all pediatric surgeries was about 366. Additionally, it was determined that approximately 165 to 206 PS will be appropriate for Korea to implement more advanced pediatric surgery in the future. Conclusion: The proportion of the pediatric surgery performed by PS rather than GS is increasing in Korea, but it is still widely performed by GS. PSs have better operative outcomes for acute abdominal surgery in the NICU than GSs. We believe that at least the index operation or the NICU operation should be performed by PS for better outcome, and that a minimum of 63 PSs are needed in Korea to do so. In addition, approximately 200 PSs will be required in Korea in order to manage main pediatric diseases and to achieve more advanced pediatric surgery in the future.

소아외과 지표질환 유병률의 변화: 단일 국립어린이병원의 사례분석

김수홍,조용훈,김해영 대한의사협회 2021 대한의사협회지 Vol.64 No.3

Pusan National University Children’s Hospital (PNUCH) opened in November 2008 as the second National Children’s Hospital in Korea and celebrated its 10th anniversary in 2018. In the last decade, birth rates and pediatric populations have been declining sharply and has been more serious in Busan, Ulsan, and Gyeongsangnam-do where the PNUCH is located, affecting the prevalence of index diseases. The number of the index diseases was investigated by year according to changes in the population. Patients who underwent surgery at PNUCH for 10 years were included. Changes in pediatric population and the number of live births were analyzed using the data from Statistics Korea. The number of the index diseases was analyzed retrospectively through the review of electronic medical records. Statistical analysis was performed through Poisson regression. The number of live births and pediatric population decreased from 69,528 to 48,600 (30.1%) and 1,880,284 to 1,444,961 (23.2%), respectively. Operations of pediatric surgery decreased by 32.3% compared to that during the peak season, but the prevalence rate ratio of the pediatric population increased to 1.03 (P<0.001). The number of emergency operation increased due to the largest surge in acute appendicitis operations. Both esophageal atresia and Hirschsprung disease decreased, while hypertrophic pyloric stenosis significantly increased. The absolute number of pediatric surgery cases decreased. However, considering the changes in pediatric population and the number of live births, the relative number of pediatric surgery cases does not changed. The decrease in the number of each disease would be related to the decrease in pediatric population and the number of live births. We should consider the increase of emergency operations such as acute appendicitis.

Clinical Comparison of Low-dose and High-dose Steroid in Pediatric Cardiac Surgery with Cardiopulmonary Bypass

Choi Seok-Cheol,Kim Song-Myung,Kim Yang-Weon 대한의생명과학회 2006 Biomedical Science Letters Vol.12 No.3

Cardiopulmonary bypass (CPB) for cardiac surgery triggers the production and release of numerous chemotactic substances and cytokines, ensuing systemic inflammatory response that leads to postoperative major organ dysfunction. Traditionally, corticosteroids (steroid) have been administered to patients undergoing cardiac surgery to ward off these detrimental physiologic alterations. However, the majority of the studies have been performed on adult patients with high-dose steroid. We carried out a randomized, prospective, double-blind study to compare the efficacy of low-dose steroid with that of high-dose steroid and to determine the adequate dose of pretreated-steroid for prophylactic effects in pediatric cardiac surgery. Thirty pediatric patients scheduled for elective cardiac surgery were randomly assigned to two groups; fifteen patients received low-dose methylprednisolone (10mg/kg intravenously, n=15, low-dose group) and the others received high-dose methylprednisolone (30mg/kg intravenously, n=15, high-dose group) 1 hour prior to CPB. Arterial blood samples were taken before CPB (Pre-CPB), 10 minutes after start of CPB (CPB-10), and immediately after CPB-end (CPB-OFF) for measuring total leukocyte counts (T-WBC) and diff-counts, platelet counts, interleukin-6 (IL-6), myeloperoxidase (MPO), total antioxidant (TAO), neuron-specific enolase (NSE), troponin I (TNI), aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine, and blood urea nitrogen (BUN) levels. Other parameters such as volumes of urine output, pulmonary index $(PI,\;PaO_2/FiO_2)$, mechanical ventilating period, intensive care unit (ICU)-staying period, postoperative complications (fever, wound problem), postoperative 24 hrs and total volumes in blood loss, and hospitalized days were also assessed. All parameters were compared between two groups. There were no significant differences in T-WBC counts, monocyte fraction, platelet counts, TA levels, NSE levels, creatinine levels, BUN levels, the volumes of total urine output, PI, the incidences of fever and wound problem, postoperative 24hrs- and total-blood loss volumes and ICU-staying period between two groups (P>0.05). At CPB-OFF, neutrophil fraction, MPO level, TNI level, and AST level were higher in the high-dose group than in the low-dose group (P<0.05). IL-6 level at CPB-10 was higher in the high dose-group than in the low-dose group (P<0.05). Furthermore, mechanical ventilating periods and hospitalized days of the high-dose group were significantly longer than those of low-dose group (P<0.05). The high-dose group had significantly low lymphocyte fi-action at CPB-OFF compared with the low-dose group (P<0.001). These findings suggest that pretreatment of high-dose steroid is not superior to that of low-dose steroid regrading its potential benefits in pediatric cardiac surgery. Therefore, the conventional strategy of steroid treatment, high-dose pretreatment, should be modified in the cardiac surgery with CPB. However, further studies must be performed on the larger number of patients in as much as small number of patients in this study.

케타민과 리도카인으로 시행한 소아 탈장 수술 2,230명

주종수,주현호,주인호,Joo, Jong Soo,Joo, Hyun Ho,Joo, In Ho 대한소아외과학회 2013 소아외과 Vol.19 No.2

Ketamine is a safe and effective drug for pediatric anesthesia, sedation and analgesia. We hoped to identify that surgeons could operate a pediatric hernia with the ketamine anesthesia without general anesthesia. The study was a consecutive case series of 2230 inguinal hernia patients aged 1 months to 17 years in a Joo's day-surgical clinic during 11-year period. The patients had pediatric inguinal hernia surgery without general anesthesia under the day-surgery system. We retrospectively analyzed the medical record of patients who were registered with the Diagnosis Related Group (DRG) system. All patients received ketamine (5mg/kg) and atropine (0.01mg/kg) intramuscularly before surgery. After anesthesia, we injected 1~2% lidocaine (Less than 5ml) subcutaneously at the site of incision and started operation. The surgical method was the high ligation method of the hernia sac.) In total 2230 patients, male were 1756 and female were 474. 2076 patients were a unilateral inguinal hernia at the time of surgery and 154 were bilateral hernia patients. Less than three months, depending on the age of the patients was 391, and less than 12 months the patient was 592 people (26.5%). After surgery, there were no accidents or long term complications associated with ketamine anesthesia. We think the surgeon can safely do the pediatric inguinal hernia surgery using ketamine and lidocaine without anesthesiologist through 11 years of our surgical experiences.

소아 비부비동염 환자에서 비내시경 수술의 장기 추적 결과

모지훈,김상협,정영준 대한비과학회 2019 Journal of rhinology Vol.26 No.1

Background and Objectives: Chronic pediatric sinusitis continues to be a challenging problem to otolaryngologists and hasbeen reported to show worse prognosis than that of adults. However, most studies were performed with short-term follow-up. Inthis study, we aimed to assess the clinical outcome of pediatric endoscopic sinus surgery (ESS) with a longer follow-up and todetermine the effect of age on postoperative outcome. Subjects and Method: A retrospective analysis was performed on pediatric patients than 15 years with ESS younger from2005 to 2014 in a tertiary referral hospital. All patients completed a questionnaire regarding symptoms before to from 1 to 9 yearsafter surgery. Telephone survey was performed to evaluate symptoms including nasal obstruction, nasal discharge, PND, andheadache at 1 to 9 years after surgery. Results: Seventy-one pediatric patients with bilateral chronic sinusitis were treated with ESS. They showed gradual symptomimprovement from 5 year after surgery for the following: nasal obstruction (p=0.032), PND (p=0.005), and headache (p=0.048). However, there was improvement in rhinorrhea after 9 years (p=0.042). In addition, when analyzed in terms of age, the outcomewas poor in children younger than 13 years (p=0.003) compared with the older age group. Multivariate analysis showed that preoperativenasal obstruction was dependent on AR, and postoperative symptoms were dependent on presence of AR and involuntarysmoking. Nasal discharge was dependent on presence of AR and involuntary smoking preoperatively and postoperatively. These suggest the importance of AR and involuntary smoking as risk factors for prognosis. Conclusion: Chronic pediatric sinusitis showed gradual improvement after ESS and should be more carefully monitored on along-term basis. We should keep in mind that long-term follow-up is needed for pediatric ESS cases.

소아 환자의 당일 수술 경험

남소현,김대연,김성철,곽미정,이동명,김인구,Nam, So-Hyun,Kim, Dae-Yeon,Kim, Seong-Chul,Gwak, Mi-Jeung,Lee, Dong-Myung,Kim, In-Koo 대한소아외과학회 2006 소아외과 Vol.12 No.2

One day surgery in children has been practiced for last 10 years in this institution. This study is to examine its safety and effectiveness for patients younger than 15 years old treated at the Department of Pediatric Surgery, Asan Medical Center, from September. 1996 to December, 2005. A total of 3,709 patients, 37 % of the total pediatric operations, are included in this retrospective study. The most prevalent ages were between 1 and 3 years olds (1,199 patients). Twenty patients were younger than 6 months, and they all had one day surgery safely. Operations were herniorrhaphy in 3,126 patients,followed by excisional biopsy, chemoport removal, and OK 432 injection. There were 12 cases (0.32 %) of unplanned admissions, 7 occurred within 6 months of one day surgery. Perioperative fever was the most common cause of admission in 4 cases. The related conditions of unplanned admission were bleeding in 2 cases and radical surgery in 2. One day surgery in this institution was easily accessible and safe. This is to the result of appropriate selection of patients, cooperation with anesthesiologists, adequate control of postoperative pain, and home care programs.

국내 소아청소년 환자에서의 혀유착증 진단과 설소대 수술 시행의 최근 경향

김태현,이대우,김재곤,양연미 대한소아치과학회 2023 大韓小兒齒科學會誌 Vol.50 No.2

The objective of this study was to investigate trends in ankyloglossia and its surgical treatment among pediatric patients in South Korea from 2011 to 2020. Data from Health Insurance Review and Assessment Service (HIRA)’s Healthcare Bigdata Hub were used for analysis of the ankyloglossia diagnosis rate and frenum surgery rate. Considering annual population change, crude rates per 100,000 were calculated and analyzed. To investigate other factors of frenum surgery incidence besides gender and age, pediatric patient sample data from HIRA were used. The diagnosis rate of ankyloglossia increased from 204.4 in 2011 to 356.6 per 100,000 people in 2020, while the frenum surgery rate increased from 26.8 to 34.3 per 100,000 people. Males were more likely to receive frenum surgery than females. Surgeries were more likely to be done at a hospital instead of a clinic or a general hospital. In the age group of 0 - 4 years, the largest number of frenum surgeries were performed in pediatrics, and in the age group of 5 - 9 years, the largest number of surgeries were conducted in pediatric dentistry. In the older age groups, the largest proportion of frenum surgeries were performed in the departments of conservative dentistry and oral and maxillofacial surgery. The diagnosis of ankyloglossia and the operation of frenum surgery among South Korean children increased during the last decade. Since the function of the tongue can affect maxillofacial development in many aspects, pediatric dentists should pay more attention to the functional management of intraoral soft tissue in growing children. 이 연구의 목적은 2011년부터 2020년까지 대한민국 소아 청소년 환자들의 혀유착증 진단과 그 수술적 치료의 동향을 조사하는 것이다. 건강보험심사평가원의 보건의료 빅데이터 개방시스템에서 제공하는 자료를 이용하여 혀유착증의 진단과 설소대 수술 시행의 연간 경향을 분석하였다. 설소대 수술 시행과 관련된 세부 요인을 조사하기 위해, 소아청소년 환자표본자료를 이용하였다. 혀유착증 진단의 경우 2011년 10만 명당 204.4명에서2020년 356.6명으로 증가하는 경향을 보였으며, 설소대 수술은 26.8명에서 34.3명까지 증가하였다. 설소대 수술에 대한 로지스틱 회귀분석 결과, 남자가 여자보다 수술을 진행할 확률이 높았고, 0 - 4세의 연령군에서 가장 높은 진료 확률을 보였으며 병원급 요양기관에서수술이 시행될 확률이 가장 높았다. 0 - 4세 연령군에서는 소아청소년과에서, 5 - 9세의 연령군에서는 소아치과에서 가장 많이 수술이 진행되었다. 그 이상의 연령에서는 보존과와구강악안면외과에서 가장 높은 비율로 수술을 시행하였다. 혀의 기능은 악안면의 성장에영향을 미칠 수 있는 만큼, 소아치과의사는 성장하는 어린이의 구강 연조직의 기능적 관리있어서도 면밀한 주의 및 관심을 기울여야 할 것으로 사료된다.

The Surgical and Cognitive Outcomes of Focal Cortical Dysplasia

Choi, Sun Ah,Kim, Ki Joong The Korean Neurosurgical Society 2019 Journal of Korean neurosurgical society Vol.62 No.3

Focal cortical dysplasia (FCD) is the major cause of intractable focal epilepsy in childhood leading to epilepsy surgery. The overall seizure freedom after surgery ranges between 50-75% at 2 years after surgery and the long-term seizure freedom remain relatively stable. Seizure outcome after surgery depends on a various factors such as pathologic etiologies, extent of lesion, and types of surgery. Therefore, seizure outcome after surgery for FCD should be analyzed carefully considering cohorts' characteristics. Studies of pediatric epilepsy surgery emphasize the early surgical intervention for a better cognition. Early surgical intervention and cessation of seizure activity are important for children with intractable epilepsy. However, there are limited data on the cognitive outcome after surgery in pediatric FCD, requiring further investigation. This paper reviews the seizure and cognitive outcomes of epilepsy surgery for FCD in children. Several prognostic factors influencing seizure outcome after surgery will be discussed in detail.

소아 백내장 수술 후 입체시에 영향을 주는 인자

안정효,김완수,이수정,Jung Hyo Ahn,Wan Soo Kim Soo Jung Lee 대한안과학회 2008 대한안과학회지 Vol.49 No.3

`Purpose: To evaluate factors influencing stereoacuity outcomes after pediatric cataract surgery. Methods: We retrospectively reviewed 38 eyes of 22 patients who had undergone irrigation and aspiration of cataracts and primary posterior chamber intraocular lens implantation from February 1992 to July 2006. In all patients, stereoacuity was assessed with the Titmus stereo test. Patients were divided into two groups according to stereoacuity: group 1 (n=9) had a stereoacuity less than 100 sec/arc; group 2 (n=13) had a stereoacuity more than 100 sec/arc. Nine variables associated with stereoacuity were evaluated in each group. Results: Postoperative strabismus was the strongest factor influencing the stereoacuity level. Good postoperative mean visual acuity was related with good stereoacuity. Though mean visual acuity in two children with exodeviation over 30PD was 0.7 and 0.8, their stereoacuity was 400 sec/arc. Showing little difference in the spherical equivalent between the eyes was also related to good stereoacuity. Conclusions: Postoperative strabismus onset, postoperative mean visual acuity between the two eyes, and differences in the spherical equivalent were important factors influencing stereoacuity in patients after pediatric cataract surgery.`

임상연구 : 소아 사시수술 시 Remifentanil 마취의 혈역학적 반응과 회복 특징

정찬종 ( Chan Jong Chung ),김태균 ( Tae Gyun Kim ),이형창 ( Hyung Chang Lee ),이승철 ( Seung Cheol Lee ),진영준 ( Young Jhoon Chin ) 대한마취과학회 2006 Korean Journal of Anesthesiology Vol.51 No.2

Background: This study evaluated the hemodynamic response and recovery profile of remifentanil-N2O anesthesia, compared with secoflurane-N2O anesthesia in pediatric surgery. Methods: Fifty-seven healthy children aged 1-9 years undergoing strabismus surgery were randomly assigned to two groups, group R or group S. None of the children was premedicated with an anticholinergic agent. Anesthesia was induced with intravenous ketamine 1.0 mg/kg. A laryngeal mask airway (LMA) was placed with rocuronium 0.4 mg/kg. Anesthesia was maintained with sevoflurane 2.0-3.0 vol% and N2O 66% in group S, and with remifentanil 0.75㎍/kg over 1 min followed by remifentanil 0.5㎍/kg/min and N2O 66% in group R. At the end of surgery, the anesthetic agents were discontinued, and the early emergence, recovery, and side effects were assessed. Results: During anesthesia, the heart rate and blood pressure were lower in group R (P < 0.05). The incidence of an oculocardiac reflex was similar in both groups. The times to spontaneous ventilation and the removal of LMA were similar in the two groups. The times from eye opening to command, orientation and full recovery were faster in group R (P < 0.05). The incidence of postoperative nausea and vomiting was similar in both groups. The incidence of coughing was lower in group R (P < 0.05). Mild pruritus developed in 17.2% of patients in group R. Conclusions: In pediatric strabismus surgery, remifentanil provided similar hemodynamic stability, and an earlier and smoother recovery, compared with sevoflurane anesthesia. (Korean J Anesthesiol 2006; 51: 174~8)