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Suk Bae Moon,1 Sang Beom Han21Department of Surgery, Kangwon National University Hospital, Kangwon National University Graduate School of Medicine, Chuncheon, Korea, 2Department of Ophthalmology, Kangwon National University Hospital, Kangwon National University Graduate School of Medicine, Chuncheon, KoreaWe read, with interest, the article by Sun et al1 entitled “Patient satisfaction with fixed-combination bimatoprost/timolol ophthalmic solution: a survey study in patients with glaucoma in China”. This observational multicenter study with excellent design was undoubtedly well conducted, and the authors successfully demonstrated that fixed-combination bimatoprost/timolol ophthalmic solution can provide the glaucoma patients with improved satisfaction.1View the original paper by Sun and colleagues.

Suk-Bae Moon Department of Surgery, Kangwon National University School of Medicine, Chuncheon, Republic of Korea Abstract: Annular pancreas (AP) is a rare cause of congenital duodenal obstruction that is usually discovered at the neonatal period, but clinical severities can vary over a wide range and definite diagnosis could be delayed until late childhood or adulthood. We report here a case of AP detected in an 11-year-old girl who had a long history of symptoms of partial duodenal obstruction. Upper gastrointestinal (UGI) study revealed narrowed second portion of duodenum by extrinsic compression, and computed tomography demonstrated complete ring of pancreatic tissue surrounding the second portion of the duodenum. Diamond-shaped duodenoduodenostomy successfully cured the patient, and the postoperative UGI study showed smooth passage through the bypass segment. Although rare, AP should be differentiated in children with unresolved symptoms of partial duodenal obstruction. Keywords: annular pancreas, children, duodenoduodenostomy&nbsp

Younglim Kim, Suk-Bae Moon Department of Surgery, Kangwon National University Hospital, Kangwon National University Graduate School of Medicine, Chuncheon, South Korea Purpose: Although abdominal computed tomography (ACT) has high sensitivity and specificity in helping to detect appendicitis in pediatric patients, diagnostic challenges still exist for some cases despite undergoing ACT, and negative appendectomies still persist. The aim of this study was to elucidate some ACT findings that support true appendicitis for patients who had inconclusive preoperative ACT findings. Patients and methods: For the 49 patients whose preoperative ACT diagnoses were inconclusive (ten negative appendicitis; 39 true appendicitis), the ACT findings were retrospectively measured for the following features: appendiceal enlargement, presence of appendicolith or hyperdense materials in the appendix, periappendiceal fat inflammation, periappendiceal fluid collection, appendiceal wall thickening, appendiceal gas, and right lower quadrant lymphadenopathy. These features were compared between true appendicitis and negative appendicitis cases. Results: The presence of an enlarged appendix of diameter >8 mm or periappendiceal fat inflammation strongly correlated with true appendicitis, while the absence of appendiceal wall thickening or mesenteric lymphadenopathy correlated with negative appendicitis. Conclusion: If the ACT findings were inconclusive for patients suspected of having appendicitis, factors such as periappendiceal fat inflammation, an enlarged appendix, appendiceal wall thickening, and mesenteric lymphadenopathy should be cautiously assessed to discriminate true appendicitis from negative appendicitis. Keywords: inconclusive abdominal CT, acute appendicitis, periappendiceal fat inflammation, appendiceal enlargement, wall thickening, lymphadenopathy

Suk-Bae MoonDepartment of Surgery, Kangwon National University Hospital, Kangwon National School of Medicine, Kangwon National University, Chuncheon, South KoreaAbstract: Neuroblastoma is the most common extracranial solid tumor in children. Mild hypertension is a frequent symptom, presumably an effect of catecholamines that tumors release. Reported herein is the rare occurrence of severe hypertension and subsequent heart failure attributable to adrenal gland neuroblastoma. A 3-year-old boy presented with anterior chest wall protrusion. Physical examination revealed severe hypertension, and left-sided cardiac failure was evident by echocardiography. Catecholamine metabolite (norepinephrine) levels were increased in serum (>2,000 pg/mL) and in urine (1,350.5 µg/day). Abdominal computed tomography scan showed a 7 cm solid mass arising from right adrenal gland. Oral phenoxybenzamine was given for hemodynamic stabilization, and right adrenalectomy was performed to remove an apparent pheochromocytoma. Ultimately, the pathologic diagnosis was ganglioneuroblastoma. Both hypertension and cardiac failure resolved postoperatively.Keywords: hypertension, heart failure, adrenal gland, pheochromocytoma

Suk-Bae MoonDepartment of Surgery, Kangwon National University Hospital, Kangwon National School of Medicine, Kangwon National University, Chuncheon, South KoreaPurpose: As an alternative to the existing fee-for-service (FFS) system, a diagnosis-related group (DRG)-based payment system has been suggested. The aim of this study was to investigate the early results of pediatric appendicitis treatment under the DRG system, focusing on health care expenditure and quality of health care services.Patients and methods: The medical records of 60 patients, 30 patients before (FFS group), and 30 patients after adoption of the DRG system (DRG), were reviewed retrospectively.Results: Mean hospital stay was shortened, but the complication and readmission rates did not worsen in the DRG. Overall health care expenditure and self-payment decreased from Korean Won (KRW) 2,499,935 and KRW 985,540, respectively, in the FFS group to KRW 2,386,552 and KRW 492,920, respectively, in the DRG. The insurer’s payment increased from KRW 1,514,395 in the FFS group to KRW 1,893,632 in the DRG. For patients in the DRG, calculation by the DRG system yielded greater overall expenditure (KRW 2,020,209 vs KRW 2,386,552) but lower self-payment (KRW 577,803 vs KRW 492,920) than calculation by the FFS system.Conclusion: The DRG system worked well in pediatric patients with acute appendicitis in terms of cost-effectiveness over the short term. The gradual burden on the national health insurance fund should be taken into consideration.Keywords: appendicitis, child, fee-for-service plans, diagnosis-related groups, quality of health care, health care expenditures

Younglim Kim, Suk-Bae MoonDepartment of Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South KoreaAbstract: Solid pseudopapillary neoplasm (SPN) is a rare tumor of the pancreas that tends to grow silently in patients at a young age, to a large size and mass. We report here a case of a small-sized SPN detected incidentally in a 12-year-old girl following a traffic accident. The tumor was 3.5 cm in maximal diameter and was found to have hemorrhagic necrosis without a solid component. Laparoscopic spleen-preserving distal pancreatectomy was performed which cured the patient. SPN is generally accepted to be a low grade malignant tumor, but its clinical behavior is sometimes unpredictable. Tumor size and the proportion of solid portion of the tumor have both recently been identified as predictors of malignancy. Although the initial presentation in this case was that of the traffic accident, the subsequent detection of a small, totally cystic SPN, and then the complete eradication of the lesion, led to a favorable outcome for the patient. Long-term monitoring should prevent any chance of recurrence.Keywords: pancreatic neoplasm, children, distal pancreatectomy