Kyung Yul Hur

2014 clinical practice guidelines for overweight and obesity in Korea.

The dramatic increase in the prevalence of obesity and its accompanying comorbidities are major health concerns in Korea. Obesity is defined as a body mass index ≥25 kg/m2 in Korea. Current estimates are that 32.8% of adults are obese: 36.1% of men and 29.7% of women. The prevalence of being overweight and obese in national surveys is increasing steadily. Early detection and the proper management of obesity are urgently needed. Weight loss of 5% to 10% is the standard goal. In obese patients, control of cardiovascular risk factors deserves the same emphasis as weight-loss therapy. Since obesity is multifactorial, proper care of obesity requires a coordinated multidisciplinary treatment team, as a single intervention is unlikely to modify the incidence or natural history of obesity.

Predicting success of metabolic surgery: age, body mass index, C-peptide, and duration score.

BACKGROUND Surgery is the most effective treatment of morbid obesity and leads to dramatic improvements in type 2 diabetes mellitus (T2DM). Gastrointestinal metabolic surgery has been proposed as a treatment option for T2DM. However, a grading system to categorize and predict the outcome of metabolic surgery is lacking. The study setting was a tertiary referral hospital (Taoyuan City, Taoyuan County, Taiwan). METHODS We first evaluated 63 patients and identified 4 factors that predicted the success of T2DM remission after bariatric surgery in this cohort: body mass index, C-peptide level, T2DM duration, and patient age. We used these variables to construct the Diabetes Surgery Score, a multidimensional 10-point scale along which greater scores indicate a better chance of T2DM remission. We then validated the index in a prospective collected cohort of 176 patients, using remission of T2DM at 1 year after surgery as the outcome variable. RESULTS A total of 48 T2DM remissions occurred among the 63 patients and 115 remissions (65.3%) in the validation cohort. Patients with T2DM remission after surgery had a greater Diabetes Surgery Score than those without (8 ± 4 versus 4 ± 4, P < .05). Patients with a greater Diabetes Surgery Score also had a greater rate of success with T2DM remission (from 33% at score 0 to 100% at score 10); A 1-point increase in the Diabetes Surgery Score translated to an absolute 6.7% in the success rate. CONCLUSION The Diabetes Surgery Score is a simple multidimensional grading system that can predict the success of T2DM treatment using bariatric surgery among patients with inadequately controlled T2DM.

Learning curve for laparoscopic totally extraperitoneal repair of inguinal hernia

BACKGROUND Laparoscopic totally extraperitoneal (TEP) repair has been accepted as a popular procedure for inguinal hernia repair, but surgeons still encounter technical difficulties owing to unfamiliar pelvic anatomy and limited working space. We sought to estimate the learning curve for laparoscopic TEP repair without supervision. METHODS We retrospectively analyzed the medical records of patients scheduled for laparoscopic TEP repair of an inguinal hernia from December 2000 to October 2007. RESULTS We reviewed medical records for 700 patients. The cases were divided into 8 groups: 20 patients each in groups I-V and 200 patients each in groups VI-VIII. No significant difference in demographic characteristics was identified among the groups. The mean duration of surgery significantly decreased (p < 0.001) in relation to experience; it reached a plateau of less than 30 minutes (mean 28 min) after 60 cases. The mean length of stay in hospital was 0.97 days, reaching a plateau after 20 cases. Six patients were converted to other techniques: 1 patient each in groups III and VIII and 4 patients in group VII. Three recurrences were detected; however, 2 were excluded because the patient had bilateral inguinal hernias. CONCLUSION We estimate the learning curve for laparoscopic TEP repair is 60 cases for a beginner surgeon. The presence of an experienced supervisor during the first 60 cases can help prevent unnecessary complications and shorten the duration of surgery.

Pancreatic Resection Guided by Preoperative Intraductal Ultrasonography for Intraductal Papillary Mucinous Neoplasm

OBJECTIVES:Successful treatment requires reliable preoperative assessment of the highly variable extension of intraductal papillary mucinous neoplasms (IPMNs). We aimed to determine the role of intraductal ultrasonography (IDUS) in predicting the extension of IPMN, and in selecting the method of pancreatic resection and the long-term outcome after surgery.METHODS:Randomized prospective study. Forty consecutive patients who underwent IPMN resection were included in the study. Patients were randomly assigned to an IDUS group or control group, in which IDUS was not performed.RESULTS:Preoperative assessment by IDUS had an 85% (17 of 20) diagnostic accuracy for tumor extension of IPMN compared with 50% (10 of 20) in cases assessed by other imaging methods without IDUS (P=0.018). In 9 of 15 patients with invasive carcinoma, the tumor was located in the pancreatic head, and 11 had a main duct-type tumor. Recurrent disease was identified in 5 of 15 (33%) patients with invasive IPMN at a mean follow-up of 50 months; of them, 1 underwent preoperative IDUS and 4 were assessed by other imaging methods. None of the 25 patients with noninvasive IPMN had recurrent disease at follow-up. The overall cumulative 3-year survival rate was 79%.CONCLUSIONS:Preoperative IDUS was useful in determining the type of surgery and the extent of resection, especially in main-duct IPMN.

Gallbladder pseudolithiasis caused by ceftriaxone in young adult

Ceftriaxone is a commonly used antibiotic due to some of its advantages. Reversible gallbladder (GB) sludge or stone has been reported after ceftriaxone therapy. Most of these patients have no symptom, but the GB sludge or stone can sometimes cause cholecystitis. We experienced two patients who had newly developed GB stones after ceftriaxone therapy for diverticulitis and pneumonia, and this resolved spontaneously 1 month after discontinuation of the drug. Awareness of this complication could help to prevent unnecessary cholecystectomy.

Current Status of Laparoscopic Liver Resection in Korea

Since laparoscopic liver resection was first introduced in 2001, Korean surgeons have chosen a laparoscopic procedure as one of the treatment options for benign or malignant liver disease. We distributed and analyzed a nationwide questionnaire to members of the Korean Laparoscopic Liver Surgery Study Group (KLLSG) in order to evaluate the current status of laparoscopic liver resection in Korea. Questionnaires were sent to 24 centers of KLLSG. The questionnaire consisted of operative procedure, histological diagnosis of liver lesions, indications for resection, causes of conversion to open surgery, and postoperative outcomes. A laparoscopic liver resection was performed in 416 patients from 2001 to 2008. Of 416 patients, 59.6% had malignant tumors, and 40.4% had benign diseases. A total laparoscopic approach was performed in 88.7%. Anatomical laparoscopic liver resection was more commonly performed than non-anatomical resection (59.9% vs 40.1%). The anatomical laparoscopic liver resection procedures consisted of a left lateral sectionectomy (29.3%), left hemihepatectomy (19.2%), right hemihepatectomy (6%), right posterior sectionectomy (4.3%), central bisectionectomy (0.5%), and caudate lobectomy (0.5%). Laparoscopy-related serious complications occurred in 12 (2.8%) patients. The present study findings provide data in terms of indication, type and method of liver resection, and current status of laparoscopic liver resection in Korea.

Prediction of post-operative pancreatic fistula in pancreaticoduodenectomy patients using pre-operative MRI: a pilot study.

BACKGROUND Post-operative pancreatic fistula (POPF) is one of the most fearful complications which may occur after pancreaticoduodenectomy (PD). The methods used to predict POPF pre-operatively have not been studied in great detail. We analyzed correlation between various parameters related to PD including pre-operative magnetic resonance imaging (MRI) signal intensity (SI), pathology of pancreatic fibrosis and occurrence rates of POPF, and verified that MRI SI results could be the determining values for pre-operative prediction of POPF. METHODS From January 2005 to August 2006, we retrospectively examined 43 cases of PDs by reviewing abdominal MRI findings, degree of fibrosis of remnant pancreatic stump, and other surgery-related parameters. RESULTS POPF encountered in PD were 11 cases (25.6%). Operation time and degree of fibrosis of remnant pancreatic cut surface were related to POPF (P= 0.030, P= 0.010). The pancreas-liver SI ratio (PLSI) between fistula group and no fistula group was -0.0009 +/- 0.2 and -0.1297 +/- 0.2, respectively (P= 0.0004). The pancreas-spleen SI ratio (PSSI) in each group was 0.423 +/- 0.25 and 0.288 +/- 0.32, respectively (P= 0.014). Using quantitative analysis, the SI ratios were 1.27 and 0.66 in each group (P= 0.013). CONCLUSIONS When analyzing the results of POPF in 43 patients who underwent PD, PLSI, PSSI and qualitative analysis, fistula group differed significantly from no fistula group. Using these results, it will be helpful for us to predict the occurrence of POPF pre-operatively using MRI in PD patients.

Comparison of the outcomes between laparoscopic totally extraperitoneal repair and prolene hernia system for inguinal hernia; review of one surgeon’s experience

Purpose To compare the outcomes between laparoscopic total extraperitoneal (TEP) repair and prolene hernia system (PHS) repair for inguinal hernia. Methods A retrospective analysis of 237 patients scheduled for laparoscopic TEP or PHS repair of groin hernia from 2005 to 2009 was performed. Results The mean age was 52.3 years in TEP group and 55.7 years in PHS group. Of 119 TEP cases, 98 were indirect inguinal hernia, 15 direct type, 5 femoral hernia and 1 complex hernia; Of 118 PHS cases, 100 indirect, 18 direct type. All in TEP group were performed under general anesthesia and 64% of PHS group were performed under spinal or epidural anesthesia. Preoperatively, 10 cases of recurrent inguinal hernia were involved in our study (4 in TEP, 6 in PHS group). The mean operative time was similar in both groups (74.8 in TEP, 71.2 in PHS group), however mean hospital stay (1.6 days in TEP, 3.2 days in PHS group, P = 0.018) and mean usage of analgesics (0.54 times in TEP, 2.03 times in PHS group, P < 0.01), complications (36 cases in TEP, 6 cases in PHS group, P < 0.01) showed statistical differences. There is only 1 case of postoperative recurrence inguinal hernia in PHS group but it has no statistical significance (P = 0.314). Conclusion Compared to PHS repair, laparoscopic TEP repair has some advantages; shorter hospital stay, less frequent need of analgesics; as well as more postoperative complications such as hematoma, seroma, scrotal swelling.

Swelling After Laparoscopic Total Extraperitoneal Repair of Inguinal Hernias: Review of One Surgeon's Experience in 1,065 Cases

BackgroundIt is often difficult to assess the clinical significance of scrotal or operative site swelling after a laparoscopic total extraperitoneal (TEP) repair of an inguinal hernia. Specifically, surgeons are often faced with the dilemma of determining whether such a swelling is a recurrent hernia or just a swelling only.Materials and MethodsA total of 1,065 laparoscopic TEP inguinal hernia repairs were performed on 944 patients by a single surgeon between December 2000 and December 2008, and we reviewed these data.ResultsThe overall incidence of swelling formation was 6.5% (70 of 1,065 cases). Swellings were more frequent in males, and in association with the following diagnoses: indirect inguinal hernias, larger hernia defects, scrotal hernias, omental incarcerations, and the presence of residual distal sacs. Fifty-eight (83%) of 70 patients who had swelling after laparoscopic TEP did not need any intervention for swelling and the swelling resolved spontaneously.ConclusionsAlthough postoperative swellings are a common complication after laparoscopic TEP repairs of inguinal hernias, swellings are minor complications, are not associated with hernia recurrence, and generally subside spontaneously.

Laparoscopic total extraperitoneal repair for incarcerated inguinal hernia

Purpose We wanted to measure and compare the patient demographics and perioperative outcomes between patients with incarcerated and patients with non-incarcerated inguinal hernia. Methods We conducted a retrospective analysis of 945 patients who were scheduled for laparoscopic total extraperitoreal (TEP) repair of inguinal hernia from May 2002 to May 2010. There were 66 patients who had incarcerated hernia and 879 patients who had non-incarcerated hernia. Results The mean age was younger in the incarcerated hernia group than in the non-incarcerated hernia group (41.67 vs. 48.50 years, P < 0.01), and all the incarcerated inguinal hernias patients were male. Most of the incarcerated hernias (63 out of 66 cases, 95%) were indirect hernias. The mean hospital stay showed no difference between the two groups (1.03 vs. 0.93 days, P = 0.142) but the operation time was longer for the incarcerated group than that for the non-incarcerated group (33.36 vs. 24.59 minutes, P < 0.01). Postoperative swelling (including seroma) was more frequent in the incarcerated group (14 out of 66 cases, 21%, P < 0.01), but postoperative pain was similar in both groups (3.0 vs. 8.9%, P = 0.095). There was one recurrence in the non-incarcerated group, but this had no statistical significance. Conclusion Laparoscopic TEP repair for the patients with chronic incarcerated inguinal hernias was safe and feasible. However, a well-designed study is needed to confirm if it is suitable for acute incarcerated inguinal hernias.