담도폐쇄증에서 간문부-장 문합술의 성적

김인구,김대연,김성철,Kim, In-Koo,Kim, Dae-Yeon,Kim, Seong-Chul 대한소아외과학회 1999 소아외과 Vol.5 No.2

The results of hepatic portojejunostomy in 34 patients with biliary atresia operated upon by one surgeon between May 1989 and December 1997 were analyzed. Eleven (32.3 %) patients were 60 days or younger, 14 patient (41.2 %) were between 60 and 90 days, and 9 (26.5 %) were over 90 days of age. Jaundice cleared in 20 cases (58.8 %). Three patients died of liver insufficiency, 2 were anicteric but died from esophageal variceal bleeding. Three patients died as a result of sepsis, heart failure and left kidney agenesis. Five patients were lost to follow-up. The five-year survival rate was 73.8 %. Two patients over 90 days of age, survived more than 5 years. Survival rates were not significantly related to the age at operation. We conclude that hepatic portojejunostomy should be considered as a primary surgical modality for biliary atresia, even at age 90 days or more. Early detection of esophageal varices and sclerotherapy may be necessary. Liver transplantation is necessary if hepatic failure develops.

서론, 병인론 및 분류

김인구,Kim, In-Koo 대한소아외과학회 2003 소아외과 Vol.9 No.2

만삭아에 발생한 괴사성 장염

김대연,김성철,김경모,김애란,김기수,피수영,김인구,Kim, Dae-Yeon,Kim, Seong-Chul,Kim, Kyung-Mo,Kim, Ellen Ai-Rhan,Kim, Ki-Soo,Pi, Soo-Young,Kim, In-Koo 대한소아외과학회 2003 소아외과 Vol.9 No.1

Necrotizing Enterocolitis (NEC) is usually a disease of premature infants, but occasionally it affects the term neonate. Twenty-five infants with NEC were treated at Asan Medical Center between January 2000 and December 2002, and 13 of them were term infants. In each case, the diagnosis of NEC was established by a clinical illness fulfilling the Bell's stage II or III NEC as modified by Walsh or by surgical findings. There were six males and seven females. The birth weight was from 1,960 to 3,700 g. The age at diagnosis was from 1 to 40 days. Four patients had congenital heart disease: one of who had hypothyroidism and cleft palate. Abdominal distension was present in all, and bloody stools in four. One patient had history of hypoglycemia, three had Rota viral infection. Eight patients had leucopoenia (<$5.0{\times}10^9/L$), seven had thrombocytopenia (<$100{\times}10^9/L$), and three severe thrombocytopenia (<$50{\times}10^9/L$). Laparotomy was required in 10 of the 13 patients. Indications for operation in the acute phase were failure to respond to aggressive medical therapy in five, and perforation in three patients. There were two late phase operations for intestinal stricture and fistula. There were no operative complications. Ten of thirteen patients survived (76.9%). Two patients died of septic complication. There was a delayed death due to heart failure. There was a significant difference in survival according to platelet count ($50{\times}10^9/L$) (p<0.05). Congenital heart disease and Rota viral infection are associated with NEC in term infants and thrombocytopenia and leucopoenia may be surgical indications.

극소 저출생체중아에서의 소장천공

김대연,김성철,김애란,김기수,피수영,김인구,Kim, Dae-Yeon,Kim, Seong-Chul,Kim, Ai-Rhan,Kim, Ki-Soo,Pi, Soo-Young,Kim, In-Koo 대한소아외과학회 2001 소아외과 Vol.7 No.2

With the advances in neonatal intensive care, pediatric surgeons experience very low birth weight infants, weighing <1,500 g, more frequently. We report our 14 cases of very low birth weight infants with intestinal perforations without congenital causes, at the Asan Medical Center during the 11-year period from 1989 to 2000. The average birth weight was 919 g(563-1,490), and average gestational age was 206 days(161-286). There were nine males and five females, Operation was performed at an average age of 14.0 days(3-38). Ten neonates with symptomatic PDA were given indomethacin in an attempt to close the ductus. Bowel perforation involved the jejunum in two and ileum in twelve. At laparotomy, there were seven focal intestinal perforations, five typical NEC, one intussusception, and an unknown cause, Four neonates underwent resection and anastomosis of the bowel, and nine underwent exteriorization. One underwent resection and anastomosis after peritoneal drainage. Four patients had postoperative complications; two leakage of anastomosis, one stoma necrosis, and one internal herniation. Seven of fourteen patients survived(50.0 %). Seven patients died of septic complication. There was a significant difference in the birth weight and gestational age in survivors compared with those who died(p<0.05). There was an increased risk of bowel perforation in indomethacin treatment for PDA. Careful clinical observation and keen judgment are essential for this particular group of infants.

소아에 발생한 갑상선 악성 종양

이승주,김대연,김성철,김인구,Lee, Seung-Joo,Kim, Dae-Yeon,Kim, Seong-Chul,Kim, In-Koo 대한소아외과학회 2000 소아외과 Vol.6 No.2

Thyroid carcinoma is relatively rare in children. Eight cases of thyroid carcinoma were among 18 patients operated upon for thyroid tumors at Pediatric Surgery, Asan Medical Center in 11 years' period between 1989 and 2000. Five patients were boys and three were girls. The age distribution ranged from 10 to 14 years with a median age of 11.6 years. We studied clinical presentations, diagnostic workup, pathology, treatment, and follow-up (recurrence, mortality, and survival). All patients presented with anterior neck mass but one with multiple cervical lymph nodes enlargement. Familial history of thyroid cancer was seen in one case. All patients had a cold nodule by 1-131 thyroid scan. Fine needle aspiration (FNA) biopsy was performed in all patients. The right lobe was involved in four patients and the left lobe in two. Two had both lobes involvement. Pathologically, six cases were papillary carcinoma, one was follicular carcinoma, and one insular carcinoma. Four patients underwent unilateral lobectomy and isthmectomy. Total thyroidectomy was performed in three patients. The insular carcinoma case was preoperatively diagnosed as follicular neoplasm by FNA. After confirmation of the pathology by initial right thyroid lobectomy, total thyroidectomy was subsequently done. Cervical lymph node metastases were presented in three cases (37.5%), and lung metastasis in two cases (25%). Three patients received postoperative I-131 ablation. After a median follow-up of 53 months, all patients were alive without evidence of recurrence. In conclusion, thyroid carcinoma in children is frequently associated with lymph nodes involvement and distant metastasis, however, the prognosis is relatively good.

소아에서의 복강경 비장 절제술

정은영,김대연,김성철,김인구,Jung, Eun-Young,Kim, Dae-Yeon,Kim, Seong-Chul,Kim, In-Koo 대한소아외과학회 2004 소아외과 Vol.10 No.1

The laparoscopic splenectomy (LS) became popular over the last 10 years. The advantage of LS over open splenectomy (OS) includes short hospital stay, improved cosmesis, less development of postoperative intestinal ileus, and less analgesics required. The purpose of this study is to evaluate the outcome of LS at Asan Medical Center from January 1999 to January 2003. The records of 14 consequent children who underwent splenectomy were reviewed retrospectively. Patients characteristics, morbidity, mortality, operative time, blood loss, and hospital stay were analyzed., Seven patients age 5 to 15 years underwent LS under the indications: idiopathic thrombocytic purpura (ITP, n=3), hereditary spherocytosis (n=3), and myelodysplastic syndrome (n=l). Seven patients, age 7 to 16 years, underwent OS during the same period for ITP (n=7). Median operative time was 120 mInutes (80 to 170 mins.) in OS, and 270 minutes (110 to 480 mins,) in LS (p<0.05). Median length of hospital stay was 6 days (3 to 8) in OS, and 4 days (3 to 6) in LS (p>0.05). Median splenic length was 12.0cm (9.2 to 18.0) in OS, 14.0 cm (10.0 to 19.5) (p>0.05). Accessory spleens were identified in 3 of 7 LS and 1 of 7 OS cases. In the LS group, there was no conversion to open surgery. Two patients in LS required blood transfusion postoperatively. LS in children can be performed as effectively and safely as OS.

소아에 시행한 복강경 담낭 절제술

김희성,남소현,김대연,김성철,김인구,Kim, Hee-Seong,Nam, So-Hyun,Kim, Dae-Yeon,Kim, Seong-Chul,Kim, In-Koo 대한소아외과학회 2006 소아외과 Vol.12 No.2

Laparoscopic cholecystectomy has been increasingly used because of several advantages, less pain, better expectation for cosmesis (requires small incisions), and more rapid recovery compared with open cholecystectomy. Oral intake is tolerated on the day of operation or on the next. In this study, we evaluated the effectiveness and safety of laparoscopic cholecystectomy in children. Nine cases of laparoscopic cholecystectomy for acute and chronic cholecystitis in children were performed at Asan Medical Center between April 2002 and April 2004. Laparoscopic cholecystectomy was performed on a total of 10 patients, but one of them was excluded because of the simultaneous splenectomy for sickle cell anemia. Clinical presentation, operative findings, operation time, length of hospital stay, and postoperative complications were analyzed. Mean age was 10.4 (4.15) years, and only 3 of patients were less than 10 years. One patient was female. In 8 the diagnosis was calculous cholecystitis. Mild adhesions were found in 3 cases and intraoperative bile leakage in 2. There was no conversion to open surgery and there were no vascular, bowel, or bile duct injuries. Mean operation time was 82.2 (20.160) minutes; mean length of hospital stay was 2.1 (1.3) day. There was no postoperative complication. Laparoscopic cholecystectomy in children was remarkably free of side effects and complications and had a short recovery time. Laparoscopic cholecystectomy for cholecystitis is considered to be a standard procedure in children.

신경모세포종 -15년간 한 병원에서의 임상적 경험-

김대연,김성철,김인구,Kim, Dae-Yeon,Kim, Seong-Chul,Kim, In-Koo 대한소아외과학회 2005 소아외과 Vol.11 No.2

Neuroblastoma treatment remains challenging, but treatment has become more effective due to the establishment of clinical and biological variables that determine prognostic risks. Initially, stage and age were the prime determinants of survival used in clinical practice. Risk-based therapy currently is the hallmark of neuroblastoma treatment. This study reviews one center's experience with the management of neuroblastoma. Sixty-three patients with neuroblastoma were treated from 1989 to 2003. All patients were graded according to the International Neuroblastoma Staging System (INSS) at diagnosis. There were 37 boys and 26 girls. The median age was 2.14 years (range, 33 days-10.2years). The primary site was the adrenal gland in 47, dumbbell shape extending into spinal canal in 6, retroperitoneum in 5, mediastinum in 3, and other sites in 2. The probability of 5-year overall survival (OS) and event free survival (EFS) were 46.7 % and 44.2 % by Kaplan-Meier method. According to INSS, there were stage 1 in 2 cases, stage 2 in 5, stage 3 in 12, stage 4 in 42, and stage 4s in 2. There were statistically significant differences in the survival rates between patients with stage1, 2 and stage 3, 4(P<0.05). For the stage 3 and 4, the extents of surgical resection, determined from the operative records and pathologies, were complete resection in 17 cases, minimal residual in 15, and partial resection 11, and the 5-year OS rate was 57.8, 51.4, and 13.6 %, respectively. There is a trend toward higher OS with more complete resection (P<0.05). We conclude that age and stage at diagnosis are prognostic factors, and complete excision of the primary tumor can provide better prognosis for patients with stage 3 and 4 neuroblastoma.

체외막 산소화 요법을 적용한 선천성 횡격막탈장 치료의 초기 경험

김태훈,조민정,박정준,김대연,김성철,김인구,Kim, Tae-Hoon,Cho, Min-Jeng,Park, Jeong-Jun,Kim, Dae-Yeon,Kim, Seong-Chul,Kim, In-Koo 대한소아외과학회 2011 소아외과 Vol.17 No.2

Extracorporeal membrane oxygenation (ECMO) has been utilized in congenital diaphragmatic hernia (CDH) patients with severe respiratory failure unresponsive to conventional medical treatment. We retrospectively reviewed 12 CDH patients who were treated using ECMO in our center between April 2008 and February 2011. The pre ECMO and on ECMO variables analyzed included gestational age, sex, birth weight, age at the time of ECMO cannulation, arterial blood gas analysis results, CDH location, timing of CDH repair operation, complications and survival. There were 9 boys and 3 girls. All patients were prenatally diagnosed. Mean gestational age was $38.8{\pm}1.7$ weeks and mean birth weight was $3031{\pm}499$ gram. Mean age at the time of ECMO cannulation was $29.9{\pm}28.9$ hours. There were 4 patients who survived. Survivors showed higher 5 min Apgar scores ($8.25{\pm}0.96$ vs. $7.00{\pm}1.20$, p=0.109), higher pre ECMO mean pH ($7.258 {\pm}0.830$ vs. $7.159{\pm}0.986$, p=0.073) and lower pre ECMO $PaCO_2$ ($48.2{\pm}7.9$ vs. $64.8{\pm}16.1$, p=0.109) without statistical significance. The hernia was located on the left side in 10 patients and the right side in 2 patients. The time interval from ECMO placement to operative repair was about 3~4 days in 5 early cases and around 24 in the remaining cases. There were 3 cases of post operative bleeding requiring re operation and 2 cases of abdominal compartment syndrome requiring abdominal fascia reopening. ECMO catheter reposition was required in 4 cases. Three cases of arterial or venous thrombosis were detected and improved with follow up. Our data suggests that ECMO therapy could save the lives of some neonates with CDH who can not be maintained on other treatment modalities. Protocolized management and accumulation of case experience might be valuable in improving outcomes for neonates with CDH treated with ECMO.

히크만 카테터를 삽입한 소아 환자에서 발생한 합병증 분석

김태훈,김대연,조민정,김성철,김인구,Kim, Tae-Hoon,Kim, Dae-Yeon,Cho, Min-Jeong,Kim, Seong-Chul,Kim, In-Koo 대한소아외과학회 2010 소아외과 Vol.16 No.1

Hickman catheters are tunneled central venous catheters used for long-term venous access in children with malignancies. The appropriate management for various kinds of catheter related complications has become a major issue. We retrospectively analyzed the clinical, demographic, and surgical characteristics in 154 pediatric hemato-oncology patients who underwent Hickman catheter insertion between January 2005 and December 2009. There were 92 boys and 62 girls. The mean age at surgery was $7.6{\pm}5.1$ years old. The mean operation time was $67.4{\pm}21.3$ minutes and C-arm fluoroscopy was used in 47(30.5 %). The causes of Hickman catheter removal were termination of use in 82 (57.3 %), catheter related bloodstream infection in 44(30.8 %), mechanical malfunction in 11(7.7 %), and accidents in 6(4.2 %). Univariate and multivariate analysis for associated factors with catheter related bloodstream infection showed that there were no statistically significant associated factors with catheter related infection complications. All cases except two showed clinical improvement with catheter removal and relevant antibiotics treatment. The mean catheter maintenance period in patients of catheter removal without complications was $214.9{\pm}140.2$ days. And, The mean catheter maintenance period in patients of late catheter related bloodstream infection was $198.0{\pm}116.0$ days. These data suggest that it is important to remove Hickman catheter as soon as possible after the termination of use. When symptoms and signs of complications were noticed, prompt diagnostic approach and management can lead to clinical improvements.