Although the subspecialization of surgical practice and fellowship training have progressed well in most of the university hospitals in Korea, no apparent supervision system has yet been activated. There have recently been active debates and discussions between society members on the issue of a certification for fellowship training, which ultimately prompted the Korean Surgical Society to prepare appropriate measures. In order to facilitate the process of establishing ideal measures, in our unique circumstance of surgical practice, I can suggest some of my personal opinions. First of all, I recommend that the Korean Surgical Society and its all member to strive against government interference and achieve an attending system for surgical practice and to obtain reasonable insurance reimbursement for surgeons' work, which are all prerequisites for both general and subspecialty surgical practices. Rigorous criteria for approval and credentialing of a fellowship training program should be established, whether certification will be given or not. Certification should be offered only when there is agreement between all the members of subspecialty boards and the association of practicing surgeons. All measures should be taken so as not to compromise surgical residency training by subspecialty fellowship. As subspecialization progresses, the specialty of general surgery also needs to be redefined. A discreet long-range plan of the surgical work force should be done to keep the proper number of both generalist- general surgeons and subspecialist-general surgeons. In order to take the initiative for the moderation of the interests between different subspecialty boards, and to establish a structured fellowship training program, the Korean Surgical Society should reinforce its administrative functions.
Certification ; Credentialing ; Education ; Fellowships and Scholarships* ; Hospitals, University ; Humans ; Insurance ; Internship and Residency ; Korea ; Organization and Administration

PURPOSE: Bilateral breast cancer is categorized as synchronous or metachronous. The aim of this study was to evaluate the characteristics of synchronous and metachronous breast cancers. METHODS: Between 1989 and 2003, 1111 patients were treated for breast cancer at Yeung-Nam University Hospital. We retrospectively analyzed 27 women with bilateral breast cancer. RESULTS: Among the 27 cases (2.4% of the patients) of bilateral cancers, 7 (0.6%) were synchronous and 20 (1.8%) were metachronous. The mean age of the patient with synchronous and metachronous cancer was 46.9 and 41.1 years, respectively. Eighty percent (16/20) of the metachronous cases were under the age of 50. For the metachronous cancers, 65% of the cases (13/20) were down-staged, and 20% and 15% of the patients were up-staged and at same stage, respectively, compared to the primary cancer. The ER, PR, C-erbB2 and p53 positivity was 20% (4/20), 15%, 21.1% and 52.9% in metachronous cancers, respectively, compared to 65%, 60%, 31.6% and 41.2% in the primary cancers, respectively. During the mean follow up of 74.3 months, the recurrence rate and mortality rate was 42.9% and 28.6%, respectively, for the synchronous cancers, and 5% and 5%, respectively, for the metachronous cancers. CONCLUSION: The stage of the metachronous cancer was lower than that of the primary cancer, and this was probably due to careful follow-up. The lower proportion of ER and/or PR positive tumor in metachronous cancer might be associated with the effect of tamoxifen treatment. The prognosis was less favorable for the synchronous cases than for the metachronous second breast cancers in this study.
Breast Neoplasms* ; Breast* ; Female ; Follow-Up Studies ; Humans ; Mortality ; Prognosis ; Recurrence ; Retrospective Studies ; Tamoxifen

PURPOSE: Buerger's disease (Thromboangiitis obliterans, TAO) is characterized by non- atheromatous inflammatory disease, and segmental inflammatory thrombotic occlusions of the small & middle-sized arteries and veins of the upper or lower extremities. Any epidemiological study of Buerger's disease in Korea has not been carried out until now. This study was undertaken to investigate the incidence of Buerger's disease in Korea among the patients suffering with arterial disease. METHODS: We collected and analyzed the data on 11,128 patients who were admitted to or visited the participating 22 hospitals for chronic arterial diseases throughout the major region of the South Korea from January 1986 to December 2003. The clinical diagnostic inclusion criteria for Buerger's disease were the followings: (1) a history of smoking or tobacco abuse; (2) an age of onset less than 50 years; (3) infrapopliteal, segmental arterial occlusions with sparing of the proximal vasculature; (4) frequent distal upper extremity arterial involvement (Raynaud's syndrome or digital ulceration) or-superficial phlebitis; and (5) the absence of arteriosclerotic risk factors other than smoking. RESULTS: The incidence rate of Buerger's disease among the arterial disease (11,128 patients) was 93 patients (0.83%) when the strict criteria of Shionoya was applied. 699 male-patients (6.55%) and 30 female patients (4.12%) who met the less strict criteria (the extended clinical diagnostic criteria group) were also reviewed. The 4th and 5th decades were the most common ages with-249 patients (34.2%) and 222 patients (30.5%) respectively, being found at these ages. The mean age was 40.4+/-1.6 years (age range: 16~83 years) and this was similar in both the strict criteria group and the less strict criteria group. CONCLUSIONS: This study suggests there was a low incidence of Buerger's disease in Korea among the patients who visited the participating hospitals when the strict diagnostic criteria were used. The incidence was lower than expected even when the less strict criteria were used. The more accurate incidence of Buerger's disease among the general population can be obtained by performing careful prospective study that is participated in by not only vascular surgeons, but also the other medical specialists with utilizing the strict diagnostic criteria.
Age of Onset ; Arteries ; Epidemiologic Studies ; Female ; Humans ; Incidence ; Korea* ; Lower Extremity ; Phlebitis ; Risk Factors ; Smoke ; Smoking ; Specialization ; Thromboangiitis Obliterans* ; Tobacco ; Upper Extremity ; Veins

PURPOSE: Iliac vein compression syndrome (IVCS), first characterized by Cockett and Thomas in 1965, is the development of iliofemoral deep venous thrombosis due to compression of the left common iliac vein against the spine and pelvic brim by the right common iliac artery. Thrombectomy treatment of the underlying compression is essential if significant long-term sequelae are to be avoided. Surgical treatment options include venous reconstruction or venous bypass, but treatment using endovascular techniques have recently been described. This study was conducted to evaluate the usability of endovascular treatment (esp. thrombolysis with stent insertion) in a venous outflow obstruction resulting from IVCS. METHOD: During a 2-year period, 20 patients (17 women, 3 men; mean age, 60 years) presented with clinical and imaging findings consistent with IVCS. All patients presented with leg edema or pain. The mean duration of symptom onset was 6.6+/-4.4 days, ranging from 1 to 15 days. All patients were evaluated using a Duplex scan, computerized tomography and venography. After the ascending venography had been performed, an infusion catheter system was placed, and urokinase infused locally into the thrombus burden. After near complete clot dissolution, the residual left common iliac vein stenosis was treated by means of angioplasty and the placement of a Wallstent. All patients continued to receive oral warfarin. Patients were followed-up by means of clinical visits, and the stent patency was assessed by means of a Duplex scan or computerized tomography. RESULT: The total dose of urokinase used and the duration of infusion were 2.28+/-0.93 million unit, ranging from 1.00 to 5.20 and 46.8+/-14.8 hours, ranging from 14 to 72 hours, respectively. Grade III (complete lysis) thrombolysis was achieved in 17 patients. All 17 patients successfully received a Wallstent. The initial clinical success was 100%, with complete resolution of symptoms in all patients. One patient, with combined ovarian cancer, had a recurrent symptomatic deep vein thrombosis and complete occlusion of the stent due to thrombosis 2 months after treatment. However, no other patients showed evidence of deep vein thrombosis after treatment. The overall patency rate of the stenting at 18 months was 94.1%. There were no deaths, pulmonary embolism, cerebral hemorrhage or major bleeding complications. CONCLUSION: These results suggested that the treatment of iliac vein compression syndrome, using catheter directed thrombolytic therapy and venous stent insertion, was a safe and effective method at the mid term evaluation. These patients will continue to be followed up with screening tests to further define the long-term patency.
Angioplasty ; Catheters ; Cerebral Hemorrhage ; Constriction, Pathologic ; Edema ; Endovascular Procedures ; Female ; Hemorrhage ; Humans ; Iliac Artery ; Iliac Vein* ; Leg ; Male ; Mass Screening ; May-Thurner Syndrome* ; Ovarian Neoplasms ; Phlebography ; Pulmonary Embolism ; Spine ; Stents ; Thrombectomy ; Thrombolytic Therapy ; Thrombosis ; Urokinase-Type Plasminogen Activator ; Venous Thrombosis ; Warfarin

While endovascular aneurysm repair (EVAR) is prevailing for the treatment of abdominal aortic aneurysm (AAA) in modern vascular practice, PURPOSE: we conducted nationwide questionnaire survey to investigate the current status of AAA treatment and their results in Korea. METHOD: We reviewed the replies from 28 hospitals (33 departments) to the questionnaire inquiring annual number, clinical features, mode of treatment and results of AAA patients during the period from Jan. 2000 to Jul. 2004. Results: 980 AAA patients were reported including 292 ruptured AAA (29.8%) and 688 non-ruptured AAA (70.2%). For treatment of AAA, 834 (85.1%) surgical repairs (SRs) and 111 (11.3%) endovascualr aneurysm repairs (EVARs) were performed while 35 patients (3.6%) died of AAA rupture before operation. The locations of AAA were infrarenal in 889 (90.7%), juxtarenal in 62 (6.3%), and suprarenal in 29 patients (3.0%). Among 834 patients undergoing SR, 577 patients (69.2%) had non-ruptured AAAs and 257 patients (30.8%) had ruptured AAAs. Mean operative mortality rate was 4.1% after elective SRs, 30.7% after SR for ruptured AAAs, and 2.3% after EVARs. The reported brand name of stent graft devices were various including domestic custom-made in 56 (50.5%), imported brand in 18 (16.2%) while 37 (33.3%) stent grafts were not reported their brand name. The frequencies of type I and III endoleaks after EVAR were reported 5.8% and 5.8% respectively in 86 patients with an available data. CONCLUSION: SR has been used as a major treatment option in Korea for the treatment of AAA patients while EVAR is increasing. The mortality rate of SR of AAA was comparable to western multi-center trial reports but mortality or morbidity rates of EVAR were unable to know in this questionnaire survey.
Aneurysm ; Aortic Aneurysm ; Aortic Aneurysm, Abdominal* ; Blood Vessel Prosthesis ; Endoleak ; Humans ; Korea* ; Mortality ; Questionnaires* ; Rupture ; Treatment Outcome

PURPOSE: Thrombus formation enhances both neointima formation and clinical restenosis after vascular injury or angioplasty. Thrombotic occlusions and intimal hyperplasia limit the success of vascular reconstructive procedures. Thrombolysis is expected to improve the outcome for both restenosis and acute arterial occlusion after injury. Tissue-type plasminogen activator (tPA) is commonly used clinically, and it is thought to play a critical role in vascular remodeling by mediating intravascular clot lysis and modulating cell migration within the vessel wall. However, there is controversy about the late effects of tPA on the vascular lumen either for preventing or enhancing intima hyperplasia in vivo. Thus, this study was done to evaluate the impact of a clinical infusion of tPA on the neointima formation after a balloon injury. METHOD: Forty male Sprague- Dawley rats weighting of 250~300 gm each were underwent aortic intimal denuation with a 2F balloon catheter. The rats were divided into two groups: the control group (n=20: normal saline infusion), and the*ean IMAR on the 21st day was 1.14+/-0.16 in the control group and 1.10+/-0.11 in the experiment group. The mean IMAR was lower in the experiment group, but the result was not statistically significant. In comparison to the gelatinolytic activity of MMP-9 and, activated MMP-2, there was no significant difference between the two groups. CONCLUSION: These results suggest that the effect of tPA on intimal hyperplasia after balloon injury to rat aorta showed minimal significance.
Angioplasty ; Animals ; Aorta* ; Catheters ; Cell Movement ; Humans ; Hyperplasia* ; Male ; Negotiating ; Neointima ; Rats* ; Thrombosis ; Tissue Plasminogen Activator* ; Vascular System Injuries

PURPOSE: This study was designed to determine the clinical factors affecting the long-term graft patency of leg arterial bypass for the patients with chronic lower limb arterial occlusion. METHOD: The clinical data of 81 femoro-distal bypasses performed at Yeungnam University Hospital from January 1996 to December 2002 were included for this retrospective study. A Log-Rank test of Kaplan-Meier method and Cox proportional hazard analysis were performed to identify those main effects that were predictive of graft patency. The patients, 79 males and 2 females, ranged from 37 to 81 years of age, with a mean age of 64. The highest incidence occurred among those in their 60s and 70s. Associated diseases were hypertension in 42 cases (51.8%), diabetes mellitus in 15 (18.8%), cardiac disease in 26 (32.1%) and cerebrovascular disease in 6 (7.4%). A history of smoking was noted in 76.5% of the cases. As for the clinical grades of chronic limb ischemia according to SVS/ISCVS classification, 21 limbs (25.9%) were classified as grade I (category 3), 40 (49.4%) as grade II, and 20 (24.7%) as grade III. The site of distal anastomosis was above the knee popliteal artery in 53 limbs (65.4%), below the knee popliteal artery in 8 (9.9%) and tibial artery in 20 (24.7%). As bypass conduit, autologous vein graft was used in 67 limbs (82.7%) and polytetrafluoroethylene (PTFE) graft in 14 (17.3%). There were no hospital mortalities or major perioperative complications. RESULT: From the univariate analysis of 21 clinical variables (age, sex, smoking, hypertension, diabetes mellitus, coronary arterial disease, congestive heart failure, chronic pulmonary disease, cerebrovascular disease, malignancy, hypercholesterolemia, clinical grade of chronic limb ischemia by SVS/ISCVS, level of occlusion, preoperative ankle-brachial index, type of graft, site of distal anastomosis, operation time, status of inflow artery, postoperative ankle-brachial index, clinical outcome criteria by SVS/ISCVS, postoperative anticoagulation therapy), 5 factors were identified as being associated with long-term graft patency: preoperative clinical grade (P=0.03), preoperative ankle-brachial index (P=0.00), level of occlusion (P=0.03), type of graft (P=0.00) and clinical outcome criteria (P=0.00). In multivariate analysis, type of graft, PTFE graft (vs. autologous vein graft, P=0.002), and clinical outcome criteria, minimally improved (vs. moderately, and markedly improved, P=0.029), showed a lower graft patency rate. CONCLUSION: These results suggest that autogenous vein is more acceptable for leg arterial bypass and poor early clinical outcome predicts poor long term graft patency rate.
Ankle Brachial Index ; Arteries ; Classification ; Diabetes Mellitus ; Extremities ; Female ; Heart Diseases ; Heart Failure ; Hospital Mortality ; Humans ; Hypercholesterolemia ; Hypertension ; Incidence ; Ischemia ; Knee ; Leg ; Lower Extremity ; Lung Diseases ; Male ; Multivariate Analysis ; Polytetrafluoroethylene ; Popliteal Artery ; Retrospective Studies ; Risk Factors ; Smoke ; Smoking ; Tibial Arteries ; Transplants* ; Vascular Patency ; Veins

PURPOSE: There is growing evidence that thrombosis and inflammation are closely interrelated and that the inflammatory response may play a role in the development of the syndrome of post-thrombotic, chronic venous insufficiency. A thrombus contains biologically active factors that stimulate cellular and structural alterations and lead to post-thrombotic venous abnormalities. Prolonged exposure to thrombus may result in the development of more severe pathologic conditions. To assess the effect of prolonged thrombus exposure on the development of secondary venous wall changes, the level of D-dimer test and the microscopic findings of thrombosed vein were analyzed in a rat venous thrombosis model. METHOD: The left iliac vein of male Sprague-Dawley rats weighing of 250 to 300 gm were thrombosed by means of either proximal ligation or temporary 24-hour occlusion with a microvascular clamp. The rats were divided into three groups: control group (n=10), thrombosis model by proximal ligation of the iliac vein only; group A (n=10), thrombosis model by proximal ligation of the iliac vein with treatment of low molecular weight heparin (LMWH; Clexane(r) 0.5 mg/kg, s.c.b.i.d); and group B (n=10), thrombosis model by temporary 24-hours clamp of the iliac vein without treatment of LMWH. The vein located 2 cm below from the initial ligation was harvested at time intervals of 7 and 14 days after ligation or clamp. Thrombi were identified by gross findings and indirectly quantitated with D-dimer test. RESULT: The levels of D-dimer test on days 7 and 14 after ligation or occlusion were significantly higher in the control group than in groups A and B (P<0.05). However, gross findings of intraluminal thrombosis were not present only in group B. These findings suggest that injection of LMWH did not prevent the development of thrombi around the ligation area. The neutrophilic infiltration of the perivascular area was evaluated microscopically (Hematoxylin-Eosin stain, x100). Severe perivascular neutrophilic infiltration was found in the control group and group A, whereas in group B neutrophilic infiltration was decreased to a mild or moderate degree. The vein wall thickness was evaluated by counting cells on representative sections through the mid vein area and by direct measuring of the vein wall usinga scale bar. The rat vein walls on days 7 and 14 were significantly thicker in the control group and group A than in group B (P<0.05). CONCLUSION: These results suggest that prolonged exposure of thrombus plays a major role in the development of secondary venous wall changes. However, the injection of LMWH did not prevent the development of secondary venous wall changes during the prolonged exposure of thrombus.
Animals ; Heparin, Low-Molecular-Weight ; Humans ; Iliac Vein ; Inflammation ; Ligation ; Male ; Neutrophils ; Rats* ; Rats, Sprague-Dawley ; Thrombosis* ; Veins ; Venous Insufficiency ; Venous Thrombosis*

PURPOSE: Migration and proliferation of vascular smooth muscle cells (VSMCs) are important for neointimal formation after arterial injury. Migration of VSMCs requires the degradation of basement membrane and extracellular matrix surrounding the cell. There is increasing evidence that VSMCs produce extracellular matrix-degradating proteinases, such as matrix metalloproteinases (MMPs) after arterial injury. METHOD: To assess the effect of gabexate mesylate, an MMP inhibitor, in VSMCs proliferation, migration and intimal thickening, the gelatinolytic activity of MMPs and the expression of VSMC alpha-actin mRNA were analyzed in the balloon-injured rat aorta model. Forty male Sprague-Dawley rats, weighing of 250 to 300 g, underwent aortic intimal denudation with a 2 F balloon catheter. The rats were divided into two groups: the control group (n=20: no medication), and the treatment group (n=20: daily intraperitoneal injection of gabexate mesylate (5.0 mg/kg)). The aorta was harvested at various time intervals, 1, 5, 7, and 21 days after the injury. MMP expression was analyzed by using gelatin zymography, the VSMC alpha-actin mRNA expression was analyzed by RT-PCR, and the intima to media area ratio (IMAR) were evaluated microscopically. RESULT: The treatment group showed significant suppression of intimal hyperplasia compared to the control group on day 21 (P<0.05). Mean IMAR on day 21 were 1.18+/-0.2 in the control group and 0.61+/-0.06 in the treatment group. The gelatinolytic activity of MMP-9 on day 1 after injury was significantly lower in the treatment group compared to the control group (P<0.05). The gelatinolytic activity of activated MMP-2 on days 5, 7, and 21 after injury, decreased significantly in the treatment group compared to the control group (P<0.05). The expression of VSMC alpha-actin mRNA increased on days 7 and 21 after injury. Although the expression of VSMC alpha-actin mRNA was lower in the treatment group, it was not statistically significant. CONCLUSION: These results suggest that gabexate mesylate suppresses intimal hyperplasia formation after arterial injury by decreasing activation of MMP.
Actins ; Animals ; Aorta ; Basement Membrane ; Catheters ; Extracellular Matrix ; Gabexate* ; Gelatin ; Humans ; Hyperplasia* ; Injections, Intraperitoneal ; Male ; Matrix Metalloproteinases ; Muscle, Smooth* ; Muscle, Smooth, Vascular ; Myocytes, Smooth Muscle* ; Peptide Hydrolases ; Rats ; Rats, Sprague-Dawley ; RNA, Messenger

PURPOSE: A sentinel lymph node mapping with blue dye has been well accepted as a common procedure in breast cancer surgery. However, it is well known that blue dye absorbed into the circulation may interfere pulse oximetery reading. The aim of this study was to evaluate the change of pulse oximetery reading by isosulfan blue dye injection during sentinel lymph node mapping. METHODS: Thirteen breast cancer patients with normal preoperative cardiopulmonary functions were studied. Four ml of isosulfan blue dye was injected subdermally when the patient became stable after induction of general anesthesia. The pulse oximetery was monitored continuously. Multiple arterial blood gas analyses (ABGA) were performed before dye injection and 10, 30, 40 minutes after dye injection. The results of oxygen saturturation by oximetery (SpO2) and the results of arterial oxygen tension (SaO2) and arterial oxygen saturation (SaO2) by ABGA were compared. RESULTS: The value of both SaO2 and PaO2 measured by ABGA has not been altered by isosulfan dye injection. However SpO2 decreased by isosulfan dye injection. SpO2 decrease started 8.2+/-1.5 (2~0) minutes after dye injection and returned to preinjection level by 85.7+/-5.6 (60~126) minutes after injection. The lowest vaule of SpO2 was 95.6+/-1.2% (93~97). Mean duration of SpO2 decrease was 77.5+/-6.2 (40~117) minutes. The duration of SpO2 decrease was longer in the aged patients, but it was not statistically significant (p=0.3). There was no siginificant difference in duration of SpO2 decrease according to injection site, operation method, and body mass index (BMI). CONCLUSION: .Isosulfan dye injection using for sentinel lymph node mapping causes no change in true ABGA results but causes a mild reversible decrease in SpO2, It is important to look for other causes when SpO2 decrease is significant and persistent.
Anesthesia, General ; Blood Gas Analysis ; Body Mass Index ; Breast Neoplasms ; Humans ; Lymph Nodes ; Oxygen ; Reading*