Surgery in Korea FREE

The first and second years of kindergarten are optional. Obligatory education begins with primary school (grades 1 through 6) for 6 years, middle school (grades 7 through 9) for 3 years, high school (grades 10 through 12) for 3 years, and college for 4 years, except for medical college which lasts 6 years (for an MD degree) including 2 years in premedical school. Postgraduate education consists of 2 possible programs. The first option consists of 2 or more years of study for a masters' degree (suksa) and the second option requires 2 to 3 years of study for a PhD degree in medical science (baksa).

The candidate must complete 1 year of a rotating internship and 4 years of residency training to be eligible to take the surgery board examination. The successful candidate must complete a 1- to 2-year fellowship to be eligible to take the subspecialty board examinations.¹

In 1885, there were several Western medical hospitals, including Kwang Hye Won Hospital (later renamed Severance Hospital) and Jae Joong Won National Hospital, where medical physicians were educated. During the Japanese occupation (1910-1945), there were 7 medical schools. Since independence in 1945, the number of medical schools has been gradually increasing.² In 2002 there were a total of 41 medical schools. The total number of medical graduates from these 41 medical schools was 2696 in 2001 (including 628 female graduates). The total number of medical students was 14 707 (10 732 male and 3975 female students) as of 2001. The total number of hospitals and clinics is 40 276, including 268 general hospitals, 599 other types of private hospitals, and 20 819 clinics. The total number of inpatient care beds is 288 952, including 1 081 224 general hospital beds, 63 813 beds in other types of private hospitals, and 76 976 beds in clinics.³

The history of the modern residency program in general surgery in South Korea began with the importation of the training system from the United States in 1951. Before then, there were only a few hospitals in which surgery was performed and only 372 physicians regarded themselves as surgeons. Nowadays, there are 93 training hospitals nationwide, which produce almost 200 Board of General Surgery–certified surgeons annually. These training hospitals are evaluated biannually by the Board Committee of the Korean Surgical Society for their facilities, clinical materials, and the content of their training programs, including academic activities. The residency program in general surgery is based on 4 years of formal training in accord with the Korean Board of Surgery requirements. All residency programs have to be approved by the Korean Medical Association and the Korean Board of Surgery.

Although the individual program of surgical training differs among hospitals, all hospitals offering resident training should satisfy the basic requirements of the Korean Surgical Society. An effective surgical resident training program must satisfy the following requirements: There should be a mission statement for the purpose of the program along with having (1) adequate facilities; (2) adequate clinical materials; (3) an organization with a chairman who is a member of the faculty staff; (4) a number of residents; (5) a resident rotation schedule; (6) residents and attendings who attend and conduct surgical grand rounds, surgical service meetings, tumor clinics, surgicoradiological conferences, surgicopathological conferences, journal clubs, and clinicopathologic conferences held weekly and other meetings as scheduled in the hospital education program; (7) the conduction of ward rounds and general surgical conferences, daily ward rounds with staff members, chief's weekly ward rounds, case presentation, service meetings (morbidity and mortality); and oncology rounds; (8) residents who are responsibile for patient care and the keeping of clinical records; (9) residents who conduct research; and (10) residents who take the board-certified qualification examination to fulfill resident program requirements.¹

According to the annual health report of the Korean government, in 2001 there were 75 295 (61 744 male and 13 551 female) licensed physicians, 12 794 licensed herbal medicine physicians, and 51 872 licensed pharmacists. Among the 49 044 qualified medical specialists, there were 4850 general surgeons, 3403 orthopedic surgeons, 1534 neurosurgeons, 821 chest surgeons, and 1020 plastic surgeons. The passing rates for the national licensing examination were 85.7% for physicians (MD) and 89.6% for general surgery specialists.³

The National Insurance Policy was launched in 1977 by the Korean government. Up until 2002, there were 2 different types of insurance. One was the regional insurance policy for noncompany (institute) workers who had to pay the premium themselves; the other was the company (institute) workers' policy for which part of the premium was deducted from the employee's salary and part was paid by the company.

The company workers' insurance policy was functioning well; however, it was difficult to maintain financial balance for the regional insurance policy. Therefore, in 2003 these 2 insurance policies were merged into 1 unique policy.

Since the national insurance policy was started, the social needs of both hospital inpatients and outpatients have markedly increased and health care costs have escalated. Therefore, it is necessary to increase the number of hospitals and hospices designed for chronic convalescence to reduce the cost of health care. Nowadays, the percentage of people older than 65 years in the general population is growing, with the current figure being 8.7%.³

Before 1900, traditional, conventional herbal medicine was the only real treatment available for sick or injured persons or for persons with a tumor. Until the late 19th century, diseases were treated using herbal medicine which was a combination of herbal medicines and acupuncture.³

Before the advent of modern medicine, medical treatment consisted of a few injections and various drugs that were dispensed in the form of powders or tablets. Modern medical science and surgery came into being in 1884 when an injured high government official was sutured and treated by a US surgeon named Horace N. Allen, MD, founder of Kwang Hye Won Hospital. This was the first incidence of Western surgical methods being practiced in South Korea.³

Since the introduction of Western medicine and surgery in the late 19th century until 1945, surgery was limited to excisional surgery and consisted mainly of appendectomy for treating acute appendicitis, cholecystectomy for gallstones and acute or chronic cholecystitis, herniorrhapy, hemorrhoidectomy, fistulectomy, gastric resection or bypass surgery for peptic ulcer disease, lung resection or thoracoplasty for pulmonary tuberculosis, treatment of infections such as peritonitis, and nonradical tumorectomy for the resection of malignant tumors.²

After 1945 antibiotics, general anesthesia, blood typing and transfusion became available, and more radical curative surgical procedures for treating malignancy began to be performed, including radical gastrectomy, mastectomy, hepatectomy, pancreatectomy (pancreatoduodenectomy), colectomy, and Miles operation.

There were many cases of biliary ascariasis and intrahepatic stones, a relatively higher incidence of common bile duct stones compared with Western countries, and the incidence of typhoid perforation of the terminal ileum was also high. Nosocomial infections mainly involved Staphylococcus species, Escherichia coli, and other gram-negative bacteria.²

In 1995, more than 50 000 persons died in South Korea because of cancer and around 230 000 patients with cancer were receiving some kind of medical treatment. Patients with cancer accounted for 8.3% of all inpatients. The medical care expenditure for patients with cancer accounted for 15% to 18% of all expenditures for inpatients. The age-standardized annual incidence rate of all cancers in the period 1992-1995 was 290.8 per 100 000 in male patients and 173.4 per 100 000 in female patients. The cumulative rates for the age span 0 to 74 years were 35.8% in male patients and 20% in female patients. Four cancer sites (the stomach, liver, lung, and colorectum) constitute two thirds of all new cancers in male patients. For female patients, the major sites include the cervix of the uterus and breast, in addition to the aforementioned 4 cancer sites. The age-adjusted cancer death rate in 1995 was 179.0 in male patients and 73.5 in female patients, which accounted for 24.1% and 17.7% of all deaths in male and female patients, respectively. Some changing patterns of major cancer were observed, especially in the older-age group. Since 1992 early detection programs for specific cancer sites such as the stomach, liver, colorectum, breast, and cervix of the uterus have been adopted and conducted by several medical insurance companies. However, it was not until 1995 that the South Korean government considered the institution of a national cancer control program. In 1995, the 10-Year Plan for Cancer Control was formulated and the government adopted the plan as a national policy in 1996. The economic crisis in South Korea in 1997, however, hindered the carrying out of the plan.⁴

The incidence of surgical infections has decreased along with the development of new antibiotics and aseptic surgical techniques, but no improvement was noted in patients with malignant diseases or in patients receiving organ transplants. Moreover, resistance to antibiotics and mutations of bacteria represent substantial obstacles to the prevention of surgical infection.

To examine the chronological changes relating to surgical infection, the incidence of surgical infection, class of infectious diseases, and changes in infectious agents in 61 patients during the period from 1981 through 1983 were compared with those of 121 patients in 1991 who were operated on in the Department of Surgery, Seoul National University Hospital. The results were as follows: (1)The overall incidence of surgical infection in 1991(4.58%) was significantly decreased compared with the overall incidence of surgical infection in the time span of 1981-1983 (7.89%). (2) A decrease in the incidence of surgical infection was observed in the case of malignant pancreatobiliary. (3) Infectious complication was most frequent after kidney transplantation among the benign diseases, but the change in incidence was not statistically significant between the 2 periods. (4) Among the malignant diseases, Pseudomonas species (18.8%), Proteus species (15.9%), and E coli (13.6%) were the main infectious agents in the time span of 1981-1983. However, this order of infectious agents was different in 1991 with E coli (20.8%), coagulase-negative Streptococcus species (18.5%), Pseudomonas species (16.2%), and Proteus species decreasing and coagulase-negative Staphylococcus species increasing. (5) Among the benign diseases, Pseudomonas species (23.7%) and E coli (21.1%) were the main infectious agents in the time span of 1981-1983. Enterobacter species (30.5%) and coagulase-negative Staphylococcus species (18.6%) were the main infectious agents in 1991. Gram-positive agents and Enterobacter species significantly increased. (6) Methicillin-resistant Staphylococcus aureus strain represented 50% of the infections during the time span of 1981-1983, while this figure was 71.6% in 1991. But the difference was not statistically significant.

In conclusion, the general trend of surgical infection is a decreasing one, but this trend is not observed in the case of patients receiving organ transplants and patients with malignant diseases. Furthermore, recently gram-positive organism became the most frequent infectious agent, which was not the case 10 years ago.⁵

Biliary ascariasis, intrahepatic stones, and typhoid ileal perforation have gradually disappeared. With the westernization of our dietary habits, leading to increased animal fat and meat consumption and reduced vegetable consumption, the incidence of breast cancer, colon cancer, lung cancer, and pancreatic cancer is increasing; whereas gastric cancer and hepatoma are gradually decreasing. Acute leukemia, both in children and adults, thought to be incurable in the past, has become curable with adequate chemotherapy.²

For the treatment of advanced cancer, multidisciplinary (multimodality) treatment has become more popular. For example, advanced (ie, more than stage III) gastric cancer can be successfully treated with radical curative surgery, followed by early postoperative chemoimmunotherapy (immunochemosurgery). The 5-year survival rate for curative surgery alone in the case of advanced (stage III) gastric cancer used to be less than 30%, but this figure has been raised to 48.6% because of immunochemosurgery. More extensive curative surgical procedures were used, such as total or extended total gastrectomy, extended right hepatectomy or trisegmentectomy, extended radical mastectomy, and regional pancreatectomy for selected advanced cancers until the late 1990s, when the issue of postoperative quality of life started to be an important consideration.⁶

Limited resection such as endoscopic mucosal resection for small early gastric cancer, hepatic segmentectomy, low anterior resection, or sphincter-saving colectomy, and breast tumorectomy combined with postoperative radiation therapy have begun to be used to a greater extent. However, among the 3 essential factors, radicality, safety, and the quality of life in curative surgery for cancer, radicality still remains the most important factor.⁶

I analyzed the clinicopathologic characteristics of 13 135 consecutive patients who underwent operations for gastric cancer from 1970 to 2001. I also evaluated the survival and prognostic factors for 9262 consecutive patients treated from 1981 to 1996. The prognostic significance of the treatment modality surgery alone; surgery and chemotherapy; surgery, immunotherapy, and chemotherapy (immunochemosurgery) were evaluated in the case of stage III gastric cancer. The overall 5-year survival rate of patients was 55.8%, and that of patients who received curative resection was 64.8%. The 5-year survival rates according to the TNM stage were 92.9% for Ia, 84.2% for Ib, 69.3% for II, 45.8% for IIIa, 29.6% for IIIb, and 9.2% for IV. Regarding adjuvant treatment modality, a significant survival difference was observed in the case of patients with stage III cancer. The 5-year survival rates were 45.8% for the immunochemosurgery group, 36.8% for the surgery and chemotherapy group, and 27.2% for the surgery alone group. Curative resection, depth of invasion, and lymph node metastasis were the most significant prognostic factors in gastric cancer. Consequently, early detection and curative resection with radical lymph node dissection, followed by immunochemotherapy, especially in patients with stage III gastric cancer, should be recommended as a standard treatment principle for patients with gastric cancer.^7- 8

Transplantation in South Korea began in 1969, when renal transplantation was successfully performed for the first time. The Korean Society for Transplantation was founded at this time. The number of founding members of the Korean Society for Transplantation was 345. The first successful organ transplantations listed by organ were performed as follows: kidney in 1969, pancreas in 1992, heart in 1992, lung in 1996, and heart and lung in 1997. In February 2002 the organ transplantation law was enacted and brain death was accepted. The Korean Network of Organ Sharing was organized to handle the distribution of organs and for the scientific registration of transplantation in 2001. Until the end of 2002, the total number of organ transplantations were kidney, 8458 (cadaveric donor,1416 (16.7%]); liver, 1397 (living donor, 1016 [72.7%]); pancreas, 56; heart, 209; and lung 12.

The Korean Surgical Society was established on May 10, 1947; the president is elected to a 1-year term. The presidents (term of office) of the Korean Surgical Society from 1947 to 2002 were as follows: In-Je Paik, MD (1947-1950); Gu-Chung Chung, MD (1951-1952); Byun-Gan Ko, MD (1953-1954); Sang-Chae Choe, MD (1955); Myung-hak Kim, MD (1956); Kun-Won Park, MD (1957); Soung-Jin Kim , MD (1958); Byung-Ho Chin, MD (1959); Kwang-Sik Min MD (1960 and 1972); Kir-Yu Chang, MD (1961); Woong-ku Kim , MD (1962); Hi-kyu Kim MD (1963 and 1974); Yong-Won Park, MD (1964); Chan-Berm Lee, MD (1965); Phil-Whoon Hong, MD (1966); Don-Sang Mok, MD (1967 and 1976); Ja-Hoon Kim, MD (1968); Duk-Sun Yoon, MD (1969); Chang-Kun Kim, MD (1970); Young-Kyun Lee, MD (1971); Kil-Soo Park, MD (1973); Tae-yoon Paik, MD (1975); Kyu-chol Whang, MD (1977); Hak-Yoon Kim, MD (1978); Yong-gak Lee, MD (1979); Do-Hun Ra, MD (1980); Yong-Woo Lee, MD (1981); Byung-Chol Min, MD (1982); Yong-Chul Park, MD (1983); Nak-Whan Paik, MD (1984); Chun-Kyu Kim, MD (1985); Hyung-Jin Lee, MD (1986); Sun-Taek Chang, MD (1987); Sun-Hee Hong, MD (1988); Kwang-Yun Kim, MD (1989); Soo-Tae Kim, MD (1990); Jin-Pok Kim, MD (1991); Kyoung-Bal Hur, MD (1992); Young-Kook Cho, MD (1993); Ki-Sob Son, MD (1994); Il-Woo Whang, MD (1995); Chi-Kyu Won, MD (1996); Sang-Eun Moon, MD (1997); Kyoung-Sik Lee, MD (1998); Hung-Jae Joo, MD (1998); Hyuk-Sang Lee, MD (2000); Jin-Sik Min, MD (2001); In-Chol Kim, MD (2002); and Kuk-Jin Choe (2003).

Before 1958, because there were not enough clinical and basic research funds at individual institutes, the Korean Surgical Society provide research funds to select the most diligent, able, feasible, and outstanding surgeons to perform collective review and research. The successful candidate was obliged to present a 1-hour lecture at the annual congress of the Korean Surgical Society. The year, the presenter, location, and titles of these lectures were as follows: 1958: Byong-Ho Chin, MD, PhD, Seoul National University (SNU), "Tissue Inhibition Factors"; 1959: Kwang-Sik Min, MD, PhD, Yonsei University (YU), "Thyroid Surgery"; 1960: Ki-Ryu Chang, MD, PhD, Busan National University (BNU), Busan, "Hepatobiliary Surgery"; 1961: Phil-Hoon Hong, MD, PhD, FACS, Seoul (YU), "Cardiac Surgery"; Sung-Heng Lee, MD, Kyungbuk National University (KNU), Daegu, "Hypothermia"; Young-Kyun Lee, MD, PhD, Seoul (SNU), "Extracorporeal Cardiac Surgery"; 1962: Hak-Yun Kim, MD, PhD, Chonnam University (CNU), Kwangju, "Peritoneal Absorption"; Hur Tak, MD, Daegu (KNU), "Terminal, Ileal Perforated Peritonitis"; Tae-Yun Paik, MD, PhD, Busan (BNU), "Ileal Perforation"; 1963: Sung-Wha Yoo, MD, PhD, Ewha University (EU), Seoul, "Surgery of Intractable Pulmonary Tuberculosis"; 1964: Duk-Sun Yoon, MD, Catholic University (CU), Seoul, "Hospital Infection"; 1965: Don-Sang Mok, MD, PhD, WooSuk University (WSU), Seoul, "Surgical Technic of Gastric Surgery"; 1966: Do-Hun Ra, MD, PhD, National Medical Center (NMC), Seoul, "Surgery of Peptic Ulcer"; 1967: Chong-Ho Kim, MD, PhD, Military Hospital, "Vietnam War Surgery"; 1968: Ja-Hoon Kim, MD, PhD, Seoul (SNU), "Intestinal Absorption in Gastrointestinal Disease"; 1969: Yong-Kak Lee, MD, PhD, FACS, Seoul (CU), "Artery Surgery"; 1970: David Seal, MD, FACS, Jounju Presbyterian Hospital (JPH), Jounju "Head and Neck Cancer"; 1971: Hae-Sung Yoo, MD, PhD, Seoul (NMC), "Esophageal Surgery"; 1972: Byung-Chol Min, MD, PhD, FACS. Seoul (SNU), "Gallstone"; 1973: Kyu-Chol Whang, MD, PhD, Seoul (YU), "Gastric Cancer"; 1975: Jin-Pok Kim, MD, PhD, FACS, Seoul (SNU), "Kidney Transplantation"; Soo-Tae Kim, MD, PhD, FACS, Seoul (SNU), "Liver Transplantation"; 1977: Hyung-Jin Lee, MD, PhD, Busan (BNU), "Biliary Surgery for Liver Fluke"; 1980: Chan-Kyu Kim, MD, PhD, Seoul (YU), "Portal Hypertension"; 1982: Kwang-Yun Kim, MD, PhD, Koryo Hospital (KH), Seoul, "Colon Surgery in Korea."

From 1984 the individual research fund had been increased and many institutes independently performed the research. And the society started to have a presidential lecture on his overall research result.

The subjects of presidential lectures were as follows: 1984: Yong-Chol Park, MD (EU), "Acute Abdomen"; 1985: Nak-Whan Paik, MD, PhD, Inje University, (IU), Kimhae, "Choledochoduodenostomy"; 1986: Chun-Kyu Kim, MD, Seoul (YU), "Portal Hypertension"; 1987:Hyung-Jin Lee, MD, Seoul (BNU), "Gastric Physiology After Peptic Ulcer Surger"; 1988: Sun-Taek Chang, MD, Seoul (CU), "Multiple Organ Failure"; 1989: Sun-Hee Hong, MD, Daegu (KNU), "Surgical Treatment of Peptic Ulcer"; 1990: Kwang-You Kim, MD, PhD, Seoul (KH), "Rectal Cancer"; 1991: Soo-Tae Kim, MD, PhD, Seoul (SNU), "Hepatic Transplantation"; 1992: Jin-Pok Kim, MD, PhD, FACS (Hon), Seoul (SNU), "Gastric Surgery"; 1993: Kyun-Bal Hur, MD, PhD, Soonchunhyang University (SU), Seoul, "Intrahepatic Calculi"; 1994: Young-Kuk Cho, MD, PhD, Seoul (CNU), "Clinical and Basic Researches on Gastric Cancer"; 1995: Ki-Sub Son, MD, PhD, Daejeon (CNU), "Intrahepatic Stone"; 1996: Il-Woo Whang, Daegu (KNU), "30-Years' Experience of Portal Hypertension"; 1997: Chi-Kyu Won, MD, PhD, ACS, Hanyang University (HU), Seoul, "Current Status of Surgery"; 1998: Sang-Eun Moon, MD, PhD, FACS, Seoul (BNU), "Hepatic Regeneration"; 1999: Kyong-Sik Lee, , MD, PhD, FACS, Seoul (YU), "Biological Substaging of Breast Cancer for Evaluation of Prognosis and Biological Treatment"; 2001: Hyuk-Sang Lee, MD, PhD, Kimhae (IU), "Curative Resection of Pancreatic Endocrine Tumors Aided by Imagings and by Imamura Doppman Test"; 2002: Jin-Sik Min, MD, PhD, FACS, Seoul (YU), "Past, Present, and Future of Cancer Surgery"; 2003: In-Chul Kim, MD, PhD, Seoul (CU), "Liver Transplantation."

Corresponding author and reprints: Jin-Pok Kim, MD, PhD, FACS (Hon), Inje University Paik Medical Center & Korea Gastric Cancer Center, 85 Jurdong-2Ka, Chung-Ku, Seoul, Korea (e-mail: jinpokkim@chollian.net).

Accepted for publication May 4, 2003.

I thank Sang-Joon Kim, MD, PhD, and Hyuck-Joon Lee, MD, SNU Hospital, for their help in collecting statistical data of cancer and transplantation cases in South Korea.