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      • 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.

      • 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.

      • 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.

      • 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.

      • 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.

      • 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.

      • 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.

      • 치료 원칙 변화에 따른 신생아 Bochdalek 탈장의 예후

        서진영,남소현,김대연,김성철,김애란,김기수,피수영,김인구,Seo, Jin-Young,Nam, So-Hyun,Kim, Dae-Yeon,Kim, Seong-Chul,Kim, Ai-Rhan E.,Kim, Ki-Soo,Pi, Soo-Young,Kim, In-Koo 대한소아외과학회 2006 소아외과 Vol.12 No.2

        1989년 3월부터 2005년 5월까지 울산대학교 의과대학 서울아산병원 소아외과에서 치료받은 신생아 Bochdalek 탈장 67예를 대상으로 하였다. 1989년 3월부터 1999년 말까지 조기수술, 과호흡, 수술시 흉관의 삽입을 시행한 I기(33예)와, 2000년 1월부터 2005년 5월까지 지연 수술, 최소한의 호흡 요법과 고빈도 환기 요법, 일산화질소 흡입 요법을 병행하고, 수술시 흉관의 삽입을 제한한 II기(34예)로 나누어 생존율을 비교하였다. I기의 경우 33예 중 20예가 생존하여 60.6 %, II기의 경우 34예 중 25예가 생존하여 73.5 %의 신생아기 생존율을 보였으나 통계학적 유의성은 없었다. 하지만 II기에서 생존율이 향상된 경향을 보임으로, II기에 불필요한 수술은 피할 수 있었던 것으로 생각되며, 나쁜 예후 인자를 갖는 예에서 치료 원칙의 변화가 의미 있는 역할을 했을 것으로 생각된다. 지연수술, 호흡요법, 일산화질소 흡입요법 각각의 영향에 대한 조사를 할 수 없었던 것은 이번 연구의 한계이다. 그러나 수술 전에 충분하게 제반 상태가 안정된 후에 시행하는 지연 수술이 바람직하다고 생각되며, 수술시 흉관 삽입은 피하는 것이 좋겠다. 수술 전후의 고빈도 환기 요법과 에 대해서는 좀 더 연구가 필요할 것으로 보인다. There are considerable controversies in the management of congenital diaphragmatic hernia. By 1997, early operation, routine chest tube on the ipsilateral side and maintainingrespiratory alkalosis by hyperventilation were our principles (period I). With a transition period from 1998 to 1999, delayed operation with sufficient resuscitation, without routine chest tube, and permissive hypercapnia were adopted as our practice. High frequency oscillatory ventilation (HFOV) and nitric oxide (NO) were applied, if necessary, since year 2000(period II). Sixty-seven cases of neonatal Bochdalek hernia from 1989 to 2005 were reviewed retrospectively. There were 33 and 34 cases in period I and II, respectively. The neonatal survival rates were 60.6 % and 73.5 %, respectively, but the difference was not significant. In period I, prematurity, low birth weight, prenatal diagnosis, inborn, and associated anomalies were considered as the significant poor prognostic factors, all of which were converted to nonsignificant in period II. In summary, improved survival was not observed in later period. The factors considered to be significant for poor prognosis were converted to be nonsignificant after change of the management principle. Therefore, we recommend delayed operation after sufficient period of stabilization and the avoidance of the routine insertion of chest tube. The validity of NO and HFOV needs further investigation.

      • 소아에 발생한 악성 난소 종양

        신혜아,김대연,조민정,김태훈,김성철,김인구,Shin, Hye-Ah,Kim, Dae-Yeon,Cho, Min-Jeong,Kim, Tae-Hoon,Kim, Seong-Chul,Kim, In-Koo 대한소아외과학회 2010 소아외과 Vol.16 No.2

        Malignant ovarian tumors in children are very rare, and consist of about 1 % of all childhood malignant tumors. The purpose of this study is to examine the clinical characteristics, treatment, and prognosis for children with malignant ovarian tumors. We retrospectively reviewed the medical records of children under 15 years of age with malignant ovarian tumors who had been treated surgically at Asan Medical Center between 1989 and March 2009. There were 32 patients, ranged in age at surgery from 2 to 15 years (mean; 10.4 years). The median follow-up period was 64.7 months (from 1 month to 188 months). Pathologic diagnosis were; immature teratoma (n=10), mixed germ cell tumor (n=10), and dysgerminoma (n=6). Tumor stage was classified by the staging system of the International Federation of Gynecology and Obstetrics (FIGO). The number of patients in stage I, II, III, and IV were 24 (75 %), 2 (6.2 %), 4 (12.5 %), and 2 (6.1 %), respectively. The tumor recurred in 4 patients. Seven patients of group 1 did not receive postoperative adjuvant chemotherapy, and in three of them, the tumor recurred. Twenty-five patients (group 2) underwent postoperative adjuvant chemotherapy, and there was only one recurrence. One patient who did not receive postoperative adjuvant chemotherapy and expired 10 months after operation because of tumor recurrence and distant metastasis. The overall 5-year event free survival (EFS) was 84.2 %: group 1 in 44.4 %, and group 2 in 95.7 %. Tumor recurrence was related to the postoperative adjuvant chemotherapy (p=0.004). In conclusion, proper surgical procedures with relevant postoperative adjuvant chemotherapy might improve clinical results in children with malignant ovarian tumors.

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