Even in the hands of the expert endoscopists, an occasional instrumental perforation of the esophagus occurs. But instrumental perforation of the esophagus should not be difficult to diagnose if the possibility is borne in mind. Occasionally patient with esophageal perforations show little reaction at first, but usually they develop systemic manifestation if surgical management is delayed. Early surgical drainage of esophageal perforation is very important & effective therapeutic method. The delayed surgical treatment of esophageal perforation would have increased the morbidity & mortality by allowing mediastinitis & empyema thoracis. We have experienced 6 cases of delayed surgical management of instrumental perforation of esophagus from May 1974 to April 1986 in the department of thoracic and cardiovascular surgery, Yonsei University, college of the medicine. The ages ranged from 4 years to 57 years. The underlying esophageal diseases consisted of esophageal stricture in 3 cases, foreign bodies in the esophagus in 2 cases and esophageal ca. in one case. Most clinical manifestations on admission were high fever, chest discomfort, chest pain, dysphagia and subcutaneous emphysema. Most complications due to esophageal rupture were acute mediastinitis with or without empyema thoracis. Failure to diagnose promptly and failure to promptly institute adequate treatment undoubtedly were largely responsible for this patients death. All 6 patients had been taken delayed surgical drainage more than 24 hours following esophageal perforation. One patient had been in the open drainage state for long time and the another patient has been in the tracheostomy with postintubation vocal cord ulceration. The third patient died due to respiratory failure and sepsis due to fulminant mediastinitis & empyema thoracis. Even if the patients with esophageal perforation have been taken delayed surgical management, the patients should be survived with aggressive & effective surgical drainage with intensive post-operative care.
Park, Seong Hoon;Kim, Joo Hyun;Lee, Jun Won;Jeong, Hii Sun;Lee, Dong Jin;Kim, Byung Chun;Suh, In Suck
Archives of Plastic Surgery
/
v.44
no.6
/
pp.550-553
/
2017
Esophageal perforation is a rare but potentially fatal complication of robot-assisted thyroidectomy (RAT). Herein, we report the long-term outcome of an esophageal reconstruction with a jejunal free flap for esophageal rupture after RAT. A 33-year-old woman developed subcutaneous emphysema and hoarseness on postoperative day1 following RAT. Esophageal rupture was diagnosed by computed tomography and endoscopy, and immediate surgical exploration confirmed esophageal rupture, as well as recurrent laryngeal nerve injury. We performed a jejunal free flap repair of the 8-cm defect in the esophagus. End-to-side microvascular anastomoses were created between the right external carotid artery and the jejunal branches of the superior mesenteric artery, and end-to-end anastomosis was performed between the external jugular vein and the jejunal vein. The right recurrent laryngeal nerve injury was repaired with a 4-cm nerve graft from the right ansa cervicalis. Esophagography at 1 year after surgery confirmed that there were no leaks or structures, endoscopy at 1 year confirmed the resolution of vocal cord paralysis, and there were no residual problems with swallowing or speech at a 5-year follow-up examination. RAT requires experienced surgeons with a thorough knowledge of anatomy, as well as adequate resources to quickly and competently address potentially severe complications such as esophageal rupture.
Ten cases with esophageal foreign body were treated surgically from July 1980 to October 1995 at the Departme t of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital. The mean age was 45.3 years, with a range from 25 to 71. Out of ten cases, 6 were female and four were male. Common symptoms were dysphagia, fever, foreign body sensation and neck pain. Three cases of foreign bodies were of fish bones, two of bubble paclcage of drugs, one case of a Eeer bottle cap, one of a piece glass, one of a bathtub plug, one of chicken and one of a bean. The diagnosis was established by esophagography using a water soluble contrast material and esophagoscopy. Among of ten cases, two had esophageal stricture due to the ingestion of Aye at a young age. One case had experienced psychological problems. All foreign bodies were removed by surgical procedures. Five cases were treated by cervical esophagostomy, one case by right thoracotomy, one case by retrograde bougienation through gastrostomy and two cases by cervical incision and drainage for cervical abscess. Three cases developed pos operative esophageal leaks which healed spontaneously and transient hoarseness developed in one case. One case developed traumatic pneumothorax and subcutaneous emphysema which was treated by closed thoracostomy. There were no operative deaths. C(ocean J Thorac Cardiovasc Surg 1997;30:1117-20)
Purpose: The standard treatment of esophageal cancer is the Ivor-Lewis operation, which consists of an abdominal phase involving gastric tube formation, and a chest phase involving esophagectomy and anastomosis. We aimed to report our experience of performing thoracic esophagectomy with the laparoscopic gastric pull up (LGPU) technique and its surgical outcomes. Methods: Clinicopathologic data and short-term surgical outcomes of 14 patients who underwent LGPU for thoracic esophageal cancer from August 2008 to May 2016 were retrospectively reviewed. Results: Mean age of the patients was 62.3 years and mean body mass index was $21.7kg/m^2$. Eleven patients had medical comorbidities. Patients' mean American Society of Anesthesiologists score was 2. Mean operation time was 428.5 minutes, with the mean abdominal operation time being 138.9 minutes. There was no open conversion case. Three patients had pneumonia, three patients had surgical site infection, and one patient had subcutaneous emphysema within 30 days after surgery. One patient had minor anastomosis site leakage. There was one 30-day mortality case. One patient with postoperative aspiration pneumonia developed acute respiratory distress disease, and died due to sepsis. Mean postoperative intensive care unit stay was 3.5 days, and mean postoperative hospital stay was 20.6 days. Nasogastric tubes were removed on average at 3.4 days, and mean oral intake time was 3.4 days. Conclusion: If the gastrointestinal surgeon has extensive experience in laparoscopic procedures, LGPU will be a safe and feasible technique for thoracic esophagectomy in patients with intrathoracic esophageal cancer.
Naichuan Su;Sana Harroui;Fred Rozema;Stefan Listl;Jan de Lange;Geert J.M.G. van der Heijden
Journal of the Korean Association of Oral and Maxillofacial Surgeons
/
v.49
no.1
/
pp.2-12
/
2023
The current study aimed to explore the types and frequencies of uncommon complications associated with third molar extractions based on a scoping review of case reports and case series. The study used an electronic literature search based on PubMed and Embase up to March 31, 2020, with an update performed on October 22, 2021. Any case reports and case series that reported complications associated with third molar extractions were included. The types of complications were grouped and the main symptoms of each type of complication were summarized. A total of 51 types of uncommon complications were identified in 248 patients from 186 studies. Most types of complications were post-operative. In the craniofacial and cervical regions, the most frequent complications included iatrogenic displacement of the molars or root fragments in the craniofacial area, late mandibular fracture, and subcutaneous emphysema. In other regions, the most frequent complications include pneumomediastinum, pneumorrhachis, pneumothorax, and pneumopericardium. Of the patients, 37 patients had life-threatening uncommon complications and 20 patients had long-term/irreversible uncommon complications associated with third molar extractions. In conclusion, a variety of uncommon complications associated with third molar extractions were identified. Most complications occurred in the craniofacial and cervical regions and were mild and transient.
Background : Surgical tracheostomy(ST) is usually performed by surgeons in operating room. For a patient with mechanical ventilation, however, transportation to operating room for ST could be dangerous for patients. In addition, ST is often delayed due to unavailability of operating room or surgeon. Percutaneous dilatational tracheostomy(PDT), although novel in Korea, is gaining popularity as a bedside procedure in the hospitals of western countries. We evaluated the technical ease and safety of PDT in comparison with ST. Method : Thirty-eight patients in medical intensive care unit (ICU) who were either under mechanical ventilation for more than 7 days or required airway protection, were randomly assigned to ST(18 patients) or PDT(20 patients). Between two groups, there was no significant clinical difference except that female to male ratio was higher in the ST group. ST was performed by second year residents of the department of otolaryngology while PDT was performed by third grade medical resident and pulmonologist under bronchoscopic guide using Ciaglia Percutaneous Tracheostomy Set(Cook Critical Care, Bloomington, USA) in medical ICU. The following factors were compared between two groups : number of delayed cases after the decision for tracheostomy, procedural time, complications related to tracheostomy. Results : Delayed cases were 11 in ST group and 3 in PDT group (P<0.05). Procedural time was significantly shorter in PDT group ($15.6{\pm}7.1min$) than in ST group ($29.1{\pm}11.6min$, P<0.0001). Complications related to tracheostomy occurred in 5 cases in ST group : accidental decannulation (1), subcutaneous emphysema (2) and minor bleeding (2), and in 4 cases in PDT group : minor bleeding (2), subcutaneous emphysema (1) and premature extubation (1) (P>0.05). Conclusion : Since percutaneous dilatational tracheostomy was easy to practice and its complications were not different from surgical tracheostomy, PDT can be a useful bedside procedure for mechanically ventilated patients.
Park Jae Hong;Chei Chang Seck;Hwang Sang Won;Kim Han Yong;Yoo Byung Ha;Kim Dae Hwan
Journal of Chest Surgery
/
v.39
no.3
s.260
/
pp.220-225
/
2006
Background: Spontaneous pneumomediastinum is an uncommon, benign, self-limited disorders that usually occurs in young adults without any apparent precipitating factors or disease. The purpose of this study was to review our experience in dealing with this entity and describe a reasonable course of assessment and management. Material and Method: A retrospective case series was conducted to identify adults patients with SPM who were diagnosed and treated in a single institution between 2001 and 2005. Result: Fifteen patients were identified who included 14 men and 1 women with a mean age of 26 years. Presenting symptoms were chest pain in 12 patients ($80\%$), dyspnea in 5 patients ($33\%$), and throat discomfort in 4 patients ($26\%$). Two cases were associated with use of inhalational drugs and 3 cases were associated with exercise. The predisposing factors were asthma, excessive exercise, and vomiting in spontaneous pneumomediastinum. The physical findings were subcutaneous emphysema in 10 patients ($77\%$). Chest radiography and computerized tomography were the diagnostic methods in all cases with CT scan revealing six cases with associated pulmonary abnormalities. Esophagogram and flexible bronchoscopy were selectively used. Fifteen patients ($100\%$) were admitted to the hospital. Their mean hospital stay was 3 days. All patients were conservatively treated. In a follow-up of 3 years no complications or recurrences were observed. Conclusion: Most simple spontaneous pneumomediastinum cases were benign diseases and most of them ($77\%$) had shown typical chest pain, dyspnea and subcutaneous emphysema. Inhalational drug use was not a major cause of SPM; however, increased use of bronchoinhalers was a suspicious cause of SPM.
A severe crushing injury of the chest produce a very striking syndrome referred to as traumatic asphyxia. This syndrome is characterized by bluish-red discoloration of the skin which is limited to the distribution of the valveless veins of the head and neck. And also if it is characterized by bilateral subconjunctival hemorrhages and neurological manifestations. But these clinical entities faded away progressively in a few weeks. Apporximately 90% of the patients who live for more than a few hours will recover from traumatic asphyxia when it occurs as a single entity. And so, death results from either severe associated injuries of from subsequent infection, rather than from pulmonary or cardiac insufficiency in traumatic asphyxia. We have experienced 4 cases of traumatic asphyxia with severe crushing thoracic injuries at department of the chest surgery, Captial Armed forces General Hospital during about 3 years from April 1977 to Aug. 1980. The 1st 22 year-old male was struct 2$\frac{1}{2}$ ton truck on the road and was transferred to this hospital immediately. He had taken tracheostomy due to severe dyspnea with contusion pneumonia and for removal of a large amount of bronchial secretion. The 2nd case was 23 year-old male who was got buried in a chasm. In this case, the heavy metal post tumbled over him back while at work. The 3rd case was 39 year-old male who leapt out of a window in 5th story while fire broke out in living room by oil stove heating. He had multiple rib fracture with right hemothor x and right colle's fracture and pelvic bone fracture. The last 22 year-old male was run over by a gun carriage. The wheel of this gun carriage passed over his thorax and right chin. He was brought to this hospital by helicopter. when he was first examined at emergency room, he was in semicomatose state and has pneurmomediastinum with multiple rib fracture and severe subcutaneous emphysema. As soon as he arrived, bilateral closed thoracostomy was performed and cardiopulmonary resuscitation was done. In hospital 8th weeks, chest series showed fibrothorax in right side even if chest wall stabilized. All 4 cases had multiple petechiae over their facees and chest and bilateral subconjunctival hemorrhages referred to as traumatic asphyxia. 3 cases except one case who received splenectomy, had been suffered from contusion pneumonia and had been treated with respiratory care. In these 3 cases, they had warning of impending injury before accident, and took a deep breath hold it and braces himself. And also, even if he had not impending fear in remaining one case, he had taken a deep breath and had got valsalva maneuver for pulling off the heavy metal post. Intrathoracic pressure rose suddenly and resulted to traumatic asphyxia in this situation. All these cases were recovered completely without sequelae except one fibrothorax, right.
Background: Spontaneous pneumomediastinum is an uncommon disorder with few cases reported. It usually occurs in young males and has benign self-limiting course without any apparent concomitant factor. It is seen after intrathoracic pressure changes leading to alveolar rupture. The clinical experiences of two medical centers were reviewed to aid in optimal management. Material and Method: Retrospective review between March 2003 and August 2010 with spontaneous pneumomediastinum patients was performed. Result: 24 patients were identified with a diagnosis of spontaneous pneumomediastinum. These 24 patients were comprised of 18 men and 6 women with mean age 18.9 years (range 10 ~ 33). The major initial complaints were chest pain (79.2%), throat pain (62.5%), and subcutaneous emphysema (41.7%). The triggering events were exercise (16.7%), coughing (12.5%) and vomiting (12.5%). No apparent triggering event was noted in 54.2% of patients. In all cases, chest radiograph and computed tomography was done. Diagnostic computed tomography was required in 25%. White blood cell counts and C-reactive protein (CRP) were checked, and their initial mean values were $9,790{\pm}3,240/{\mu}L$ Land $1.31{\pm}1.71mg/dL$, final mean values were $5,440{\pm}1,665/{\mu}L$ Land $0.72{\pm}0.73mg/dL$, respectively. 23 patients were admitted (average $5.0{\pm}1.8$) and the symptoms were self-limiting in all cases without complications. Conclusion: Spontaneous pneumomediastinum is a benign condition with mild inflammatory signs that often presents with chest or throat pain. Secondary causes must be ruled out to avoid an unfavorable outcome with less invasive study. Because of very rare complications and recurrence, outpatient basis and shortened hospitalization may be feasible.
Ahn, Chul Min;Hwang, Sang Yun;Byun, Min Kwang;Lee, Jin Hyoung;Chung, Wou Young;Moon, Jin Wook;Park, Moo Suk;Min, Yoo Hong;Kim, Se Kyu;Chang, Joon;Kim, Sung Kyu;Kim, Haeryoung;Kim, Hoguen;Kim, Young Sam
Tuberculosis and Respiratory Diseases
/
v.57
no.2
/
pp.183-187
/
2004
Bronchiolitis obliterans (BO) is a nonspecific inflammatory injury affecting primarily the small airways. Its inflammatory process is characterized by fibrotic obliteration of the lumen of bronchioles. BO can be idiopathic or associated with connective tissue disease, inhaled toxins, infections, drugs, and chronic graft-versus-host-disease (GVHD). Pulmonary complications occur in 40~60% of patients who undergo allogeneic bone marrow transplantation (BMT), causing 10~40% of transplant-related deaths. BO is a characteristic pulmonary complication which occurs usually within a few years after BMT. Documented complications of BO include air-leak syndromes such as pneumomediastinum, subcutaneous emphysema and pneumothorax. We report a case of a 30-year-old male patient with BO due to chronic GVHD after allogenic BMT who presented with recurrent bilateral pneumothoraces.
본 웹사이트에 게시된 이메일 주소가 전자우편 수집 프로그램이나
그 밖의 기술적 장치를 이용하여 무단으로 수집되는 것을 거부하며,
이를 위반시 정보통신망법에 의해 형사 처벌됨을 유념하시기 바랍니다.
[게시일 2004년 10월 1일]
이용약관
제 1 장 총칙
제 1 조 (목적)
이 이용약관은 KoreaScience 홈페이지(이하 “당 사이트”)에서 제공하는 인터넷 서비스(이하 '서비스')의 가입조건 및 이용에 관한 제반 사항과 기타 필요한 사항을 구체적으로 규정함을 목적으로 합니다.
제 2 조 (용어의 정의)
① "이용자"라 함은 당 사이트에 접속하여 이 약관에 따라 당 사이트가 제공하는 서비스를 받는 회원 및 비회원을
말합니다.
② "회원"이라 함은 서비스를 이용하기 위하여 당 사이트에 개인정보를 제공하여 아이디(ID)와 비밀번호를 부여
받은 자를 말합니다.
③ "회원 아이디(ID)"라 함은 회원의 식별 및 서비스 이용을 위하여 자신이 선정한 문자 및 숫자의 조합을
말합니다.
④ "비밀번호(패스워드)"라 함은 회원이 자신의 비밀보호를 위하여 선정한 문자 및 숫자의 조합을 말합니다.
제 3 조 (이용약관의 효력 및 변경)
① 이 약관은 당 사이트에 게시하거나 기타의 방법으로 회원에게 공지함으로써 효력이 발생합니다.
② 당 사이트는 이 약관을 개정할 경우에 적용일자 및 개정사유를 명시하여 현행 약관과 함께 당 사이트의
초기화면에 그 적용일자 7일 이전부터 적용일자 전일까지 공지합니다. 다만, 회원에게 불리하게 약관내용을
변경하는 경우에는 최소한 30일 이상의 사전 유예기간을 두고 공지합니다. 이 경우 당 사이트는 개정 전
내용과 개정 후 내용을 명확하게 비교하여 이용자가 알기 쉽도록 표시합니다.
제 4 조(약관 외 준칙)
① 이 약관은 당 사이트가 제공하는 서비스에 관한 이용안내와 함께 적용됩니다.
② 이 약관에 명시되지 아니한 사항은 관계법령의 규정이 적용됩니다.
제 2 장 이용계약의 체결
제 5 조 (이용계약의 성립 등)
① 이용계약은 이용고객이 당 사이트가 정한 약관에 「동의합니다」를 선택하고, 당 사이트가 정한
온라인신청양식을 작성하여 서비스 이용을 신청한 후, 당 사이트가 이를 승낙함으로써 성립합니다.
② 제1항의 승낙은 당 사이트가 제공하는 과학기술정보검색, 맞춤정보, 서지정보 등 다른 서비스의 이용승낙을
포함합니다.
제 6 조 (회원가입)
서비스를 이용하고자 하는 고객은 당 사이트에서 정한 회원가입양식에 개인정보를 기재하여 가입을 하여야 합니다.
제 7 조 (개인정보의 보호 및 사용)
당 사이트는 관계법령이 정하는 바에 따라 회원 등록정보를 포함한 회원의 개인정보를 보호하기 위해 노력합니다. 회원 개인정보의 보호 및 사용에 대해서는 관련법령 및 당 사이트의 개인정보 보호정책이 적용됩니다.
제 8 조 (이용 신청의 승낙과 제한)
① 당 사이트는 제6조의 규정에 의한 이용신청고객에 대하여 서비스 이용을 승낙합니다.
② 당 사이트는 아래사항에 해당하는 경우에 대해서 승낙하지 아니 합니다.
- 이용계약 신청서의 내용을 허위로 기재한 경우
- 기타 규정한 제반사항을 위반하며 신청하는 경우
제 9 조 (회원 ID 부여 및 변경 등)
① 당 사이트는 이용고객에 대하여 약관에 정하는 바에 따라 자신이 선정한 회원 ID를 부여합니다.
② 회원 ID는 원칙적으로 변경이 불가하며 부득이한 사유로 인하여 변경 하고자 하는 경우에는 해당 ID를
해지하고 재가입해야 합니다.
③ 기타 회원 개인정보 관리 및 변경 등에 관한 사항은 서비스별 안내에 정하는 바에 의합니다.
제 3 장 계약 당사자의 의무
제 10 조 (KISTI의 의무)
① 당 사이트는 이용고객이 희망한 서비스 제공 개시일에 특별한 사정이 없는 한 서비스를 이용할 수 있도록
하여야 합니다.
② 당 사이트는 개인정보 보호를 위해 보안시스템을 구축하며 개인정보 보호정책을 공시하고 준수합니다.
③ 당 사이트는 회원으로부터 제기되는 의견이나 불만이 정당하다고 객관적으로 인정될 경우에는 적절한 절차를
거쳐 즉시 처리하여야 합니다. 다만, 즉시 처리가 곤란한 경우는 회원에게 그 사유와 처리일정을 통보하여야
합니다.
제 11 조 (회원의 의무)
① 이용자는 회원가입 신청 또는 회원정보 변경 시 실명으로 모든 사항을 사실에 근거하여 작성하여야 하며,
허위 또는 타인의 정보를 등록할 경우 일체의 권리를 주장할 수 없습니다.
② 당 사이트가 관계법령 및 개인정보 보호정책에 의거하여 그 책임을 지는 경우를 제외하고 회원에게 부여된
ID의 비밀번호 관리소홀, 부정사용에 의하여 발생하는 모든 결과에 대한 책임은 회원에게 있습니다.
③ 회원은 당 사이트 및 제 3자의 지적 재산권을 침해해서는 안 됩니다.
제 4 장 서비스의 이용
제 12 조 (서비스 이용 시간)
① 서비스 이용은 당 사이트의 업무상 또는 기술상 특별한 지장이 없는 한 연중무휴, 1일 24시간 운영을
원칙으로 합니다. 단, 당 사이트는 시스템 정기점검, 증설 및 교체를 위해 당 사이트가 정한 날이나 시간에
서비스를 일시 중단할 수 있으며, 예정되어 있는 작업으로 인한 서비스 일시중단은 당 사이트 홈페이지를
통해 사전에 공지합니다.
② 당 사이트는 서비스를 특정범위로 분할하여 각 범위별로 이용가능시간을 별도로 지정할 수 있습니다. 다만
이 경우 그 내용을 공지합니다.
제 13 조 (홈페이지 저작권)
① NDSL에서 제공하는 모든 저작물의 저작권은 원저작자에게 있으며, KISTI는 복제/배포/전송권을 확보하고
있습니다.
② NDSL에서 제공하는 콘텐츠를 상업적 및 기타 영리목적으로 복제/배포/전송할 경우 사전에 KISTI의 허락을
받아야 합니다.
③ NDSL에서 제공하는 콘텐츠를 보도, 비평, 교육, 연구 등을 위하여 정당한 범위 안에서 공정한 관행에
합치되게 인용할 수 있습니다.
④ NDSL에서 제공하는 콘텐츠를 무단 복제, 전송, 배포 기타 저작권법에 위반되는 방법으로 이용할 경우
저작권법 제136조에 따라 5년 이하의 징역 또는 5천만 원 이하의 벌금에 처해질 수 있습니다.
제 14 조 (유료서비스)
① 당 사이트 및 협력기관이 정한 유료서비스(원문복사 등)는 별도로 정해진 바에 따르며, 변경사항은 시행 전에
당 사이트 홈페이지를 통하여 회원에게 공지합니다.
② 유료서비스를 이용하려는 회원은 정해진 요금체계에 따라 요금을 납부해야 합니다.
제 5 장 계약 해지 및 이용 제한
제 15 조 (계약 해지)
회원이 이용계약을 해지하고자 하는 때에는 [가입해지] 메뉴를 이용해 직접 해지해야 합니다.
제 16 조 (서비스 이용제한)
① 당 사이트는 회원이 서비스 이용내용에 있어서 본 약관 제 11조 내용을 위반하거나, 다음 각 호에 해당하는
경우 서비스 이용을 제한할 수 있습니다.
- 2년 이상 서비스를 이용한 적이 없는 경우
- 기타 정상적인 서비스 운영에 방해가 될 경우
② 상기 이용제한 규정에 따라 서비스를 이용하는 회원에게 서비스 이용에 대하여 별도 공지 없이 서비스 이용의
일시정지, 이용계약 해지 할 수 있습니다.
제 17 조 (전자우편주소 수집 금지)
회원은 전자우편주소 추출기 등을 이용하여 전자우편주소를 수집 또는 제3자에게 제공할 수 없습니다.
제 6 장 손해배상 및 기타사항
제 18 조 (손해배상)
당 사이트는 무료로 제공되는 서비스와 관련하여 회원에게 어떠한 손해가 발생하더라도 당 사이트가 고의 또는 과실로 인한 손해발생을 제외하고는 이에 대하여 책임을 부담하지 아니합니다.
제 19 조 (관할 법원)
서비스 이용으로 발생한 분쟁에 대해 소송이 제기되는 경우 민사 소송법상의 관할 법원에 제기합니다.
[부 칙]
1. (시행일) 이 약관은 2016년 9월 5일부터 적용되며, 종전 약관은 본 약관으로 대체되며, 개정된 약관의 적용일 이전 가입자도 개정된 약관의 적용을 받습니다.