• Korean Journal of Bronchoesophagology
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• v.4 no.1
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• pp.52-58
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• 1998

BACKGROUND： Aspiration is defined as the laryngeal penetration of secretions below the level of the true vocal cords. Aspiration can result in life-threatening complications, such as bronchospasm, airway obstruction, pneumonia, pulmonary abscess, sepsis, and death. The patient with high vagal palsy had significant aspiration and dysphagia OBJECTIVE： To formulate a step-by-step management paradign for the patients with high vagal palsy MATERIALS AND METHODS : The medical records of 23 patients who were diagnosed as high vagal palsy from September, 1995 to April, 1998 in Seoul National University Hospital were reviewed retrospectively. Eleven patients were managed conservatively and 12 patients were operated to treat chronic aspiration. RESULTS : The main etiologies of high vagal palsy were mass lesions of the skull base such as neurogenic tumor, pseudotumor, meningioma or nasopharyngeal carcinoma. Aspiration and dysphagia improved in 7 out of 11 patients who were managed conservatively after 2.2 months on the average. The patients who were refractory to the conservative management underwent surgery and showed improvement in 10 out of 12 patients. The employed surgical modalities were vocal cord medialization combined with cricopharyngeal myotomy in 7 patients, laryngotracheal separation in 3 patients and arytenoid adduction only in 2 patients. Two patients still had gastrostomy tube due to the persistent symptoms. Two patients had improved after surgery, but died of underlying disease. CONCLUSION : The patients with high vagal palsy are recommended to be managed conservatively for the first 2 months. If aspiration and dysphagia are persisting after conservative management, vocal cord medialization combined with or without cricopharyngeal myotomy should be considered. If failed, laryngotracheal separation or gastrostomy will be the next option based on the control of the oropharyngeal secretion.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.24 no.6
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• pp.546-554
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• 2021

Purpose: Malnutrition is a significant issue for pediatric patients with cancer. We sought to evaluate the effectiveness and complication rate of percutaneous endoscopic gastrostomy (PEG) placement in pediatric oncology patients. Methods: A retrospective chart review was performed on 49 pediatric oncology patients undergoing PEG placement at Johns Hopkins All Children's Hospital between 2000 and 2016. Demographic and clinical characteristics, complications, absolute neutrophil count at time of PEG placement and at time of complications, length of stay, and mortality were identified. Weight-for-age Z-scores were evaluated at time of- and six months post-PEG placement. Results: The overall mean weight-for-age Z-score improved by 0.73 (p<0.0001) from pre- (-1.11) to post- (-0.38) PEG placement. Improvement in Z-score was seen in patients who were malnourished at time of PEG placement (1.14, p<0.0001), but not in those who were not malnourished (0.32, p=0.197). Site infections were seen in 12 (24%), buried bumper syndrome in five (10%), and tube dislodgement in one (2%) patient. One patient (2%) with fever was treated for possible peritonitis. There were no cases of other major complications, including gastric perforation, gastrocolic fistula, clinically significant bleeding, or PEG-related death documented. Conclusion: Consistent with previous studies, our data suggests a relationship between site complications (superficial wound infection, buried bumper syndrome) and neutropenia. Additionally, PEG placement appears to be an effective modality for improving nutritional status in malnourished pediatric oncology patients. However, larger prospective studies with appropriate controls and adjustment for potential confounders are warranted to confirm these findings.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.24 no.3
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• pp.273-278
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• 2021

Purpose: Percutaneous endoscopic gastrostomy (PEG) is a safe method to feed patients with feeding difficulty. This study aimed to compare the outcomes of conventional PEG and laparoscopic-assisted PEG (L-PEG) placement in high-risk pediatric patients. Methods: In our tertiary pediatric department, 90 PEG insertions were performed between 2014 and 2019. Children with severe thoracoabdominal deformity (TAD), previous abdominal surgery, ventriculoperitoneal (VP) shunt, and abdominal tumors were considered as high-risk patients. Age, sex, diagnosis, operative time, complications, and mortality were compared among patients who underwent conventional PEG placement (first group) and those who underwent L-PEG placement (second group). Results: We analyzed the outcomes of conventional PEG placement (first group, n=15; patients with severe TAD [n=7], abdominal tumor [n=6], and VP shunts [n=2]) and L-PEG placement (second group, n=10; patients with VP shunts [n=5], previous abdominal surgery [n=4], and severe TAD [n=1]). Regarding minor complications, 1 (6.6%) patient in the first group underwent unplanned PEG removal and 1 (10%) patient in the second group had peristomal granuloma. We observed three major complications: colon perforation (6.6%) in a patient with VP shunt, gastrocolic fistula (6.6%) in a patient with Fallot-tetralogy and severe TAD, and pneumoperitoneum (6.6%) caused by early tube dislodgement in an autistic patient with severe TAD. All the three complications occurred in the first group (20%). No major complications occurred in the second group. Conclusion: In high-risk patients, L-PEG may be safer than conventional PEG. Thus, L-PEG is recommended for high-risk patients.

• Journal of Chest Surgery
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• v.21 no.5
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• pp.856-862
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• 1988

The survival rate after resectional operation for carcinoma of the esophagus is still very low and many factors contribute to these poor results. We analyze the clinical results of 56 operated patients among 62 esophageal cancer patients between March, 1974 and July, 1988. Among the 62 patients, 52 patients were squamous cell carcinoma and 8 were adenocarcinoma, one was leiomyosarcoma and one was adenosquamous cell carcinoma. The classification of esophageal cancer was based on TNM classification of American Joint Committee on cancer". Among the operated patients, stage I was 5[9.6%], stage II was 13[25%], stage III was 26[50%], stage IV was 8[15.4%]. And its one year survival rate was 80%, 69%, 11.5%, 0% for each stages. The rate of resectability was 30.3% and resection of esophagus with esophagogastrostomy and extended lymph node dissection was performed on 17 patients without distant metastasis or adjacent organ invasion. Substernal esophago-colono-gastrostomy, Celestine tube insertion and feeding gastrostomy was performed on remained 39 patients. The analysis of postoperative survival duration revealed the superiority of esophagectomy with extended lymph node dissection over other palliative operation. [1 year survival rate: 79% versus 21%] We concluded that the survival rate of esophageal resection with lymph node dissection group was superior to nonresective palliative operation group. And transthoracic approach was superior to extrathoracic approach in involved lymph node dissection and esophageal resection in locally invaded cases.ases.

• The Journal of Korean Medicine
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• v.22 no.3
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• pp.42-50
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• 2001

Objectives : Dysphagia is common and severe problems of acute stroke determining the prognosis of stroke only second to mental change, and results in secondary fatal complications such as aspiration pneumonia, malnutrition, dehydration, etc. Therefore, we were to investigate the clinical characteristics of dysphagia accompanied by acute ischemic stroke. Methods : We selected subjects through clinical notes retrospectively, whose main problems included dysphagia resulted from acute stroke within 72 hours from onset who were admitted to the Internal Medicine Department of Wonkwang Oriental Medicine Hospital from Jan. 2000 to Apr. 2001. We assessed the severity of dysphagia from admission to discharge using a staging method : stage 0 is normal without dysphagia, stage 1 is nearly normal except for intermittent dysphagia, stage 2 is compensated abnormal swallowing requiring adjusted diets or delayed feeding time, stage 3 is uncompensated abnormal swallowing resulted in weight loss down to 10% of initial and daily aspiration, coughing, and vomiting, stage 4 is uncompensated abnormal swallowing resulting in weight loss beyond 10% and recommended for non-oral feeding, and stage 5 is 100% non-oral feeding by L-tube, or gastrostomy or NPO state. Results : Dysphagia was improved statistically significantly from the mean stage of $3.6{\pm}0.29$ on admission to $1.88{\pm}0.32$ on discharge (P<0.05). On average $7.1{\pm}1.48$ days were required for improving more than one stage level. As patients were older and the stage of dysphagia was worse on admission, severity of dysphagia was more difficult to improve (correlation coefficiency was 0.55 and 0.77 respectively, P<0.05). Aspiration pneumonia was complicated in 13 patients of the total 25 at mean dysphagia stage of $3.36{\pm}0.37$. However, any specific values such as lesion size, lesion site, sex, age, past history and NIH Stroke Scale on admission did not affect it (P>0.05). Conclusion : Clinical course of dysphagia was determined about I week from the onset. Aspiration pneumonia was mainly complicated during oral feeding periods. If there were no improvement of dysphagia over 2-3 weeks, then non-oral feeding such as Levin tube or gastrostomy must be considered.

• Clinical Endoscopy
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• v.56 no.2
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• pp.239-244
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• 2023

Tuberculosis is an adverse event in patients with Crohn's disease receiving anti-tumor necrosis factor (TNF) therapy. However, tuberculosis presenting as a bronchoesophageal fistula (BEF) is rare. We report a case of tuberculosis and BEF in a patient with Crohn's disease who received anti-TNF therapy. A 33-year-old Korean woman developed fever and cough 2 months after initiation of anti-TNF therapy. And the symptoms persisted for 1 months, so she visited the emergency room. Chest computed tomography was performed upon visiting the emergency room, which showed BEF with aspiration pneumonia. Esophagogastroduodenoscopy with biopsy and endobronchial ultrasound with transbronchial needle aspiration confirmed that the cause of BEF was tuberculosis. Anti-tuberculosis medications were administered, and esophageal stent insertion through endoscopy was performed to manage the BEF. However, the patient's condition did not improve; therefore, fistulectomy with primary closure was performed. After fistulectomy, the anastomosis site healing was delayed due to severe inflammation, a second esophageal stent and gastrostomy tube were inserted. Nine months after the diagnosis, the fistula disappeared without recurrence, and the esophageal stent and gastrostomy tube were removed.

• Journal of Nutrition and Health
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• v.25 no.7
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• pp.668-683
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• 1992

To evaluate the current practices of the tube feeding and the status of tube feeding patient 76 adult in-patients at 6 hospitals located in Seoul and Chung-buk province were examined through reviewing patient charts observing patients and interviewing patients nurses dietitians patients' family or care-givers. The results were as follows : 1) An average age of the patients was 54.5 years with 41% over 60 years old. Patients with decreased mental status dysphagia esophageal obstruction and respiratory problem were fed by tubes. 2) The range of duration of tube feeding is between 4 days and 6 years. Most patients were received formula through nasogastric tube(89.5%) while 7.9% of gastrostomy and 2.6% of jejunostomy. Administration method for formula were bolus feeding regardless of the route of formula delivery. 3) Mean total calories received for men were 1590 kcal and 1450 kcal for female. Mean volume per meal was 282m, l and mean frequency of feeding was 5.68 while mean feeding interval 3$\frac{1}{4}$ hours and mean rate of infusion 68.4ml/min. All patients received hospital-blenderi-zed formula as the major source of nutrition. Home-blenderized formula and commercial formula as a supplement were used 35%, 13.2% respectively. 4) Thirty-eight percent of patients was hypoalbuminemia and 61% was at the moderate level of deficiency in hemoglobin. 5) Complications associated with tube feeding were diarrhea (22.4%) constipation(21.1%) vomiting(11.8%) and so on. 6) Serum albumin levels of patients who have complications associated with tube feeding were significantly lower than those of patients without complications In planning a tube feeding regimen the type of a formula must be integrated with both a delivery system and a protocol for administering the tube feeding. the multidisciplinary effort required to deliver enteral therapy is essential to improve current practices used at hospitals.

• Journal of Chest Surgery
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• v.21 no.6
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• pp.1084-1094
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• 1988

Conservative management of 3 iatrogenic perforations of intrathoracic esophagus was reviewed. The primary disorders were achalasia in 2 patients and congenital tracheoesophageal fistula in 1 patient. Perforation occurred after treatment of the primary disorders in the distal esophagus in 2 patients and mid-thoracic esophagus in 1 patient. All the perforations appeared late after the previous treatments and the inflammation spread to mediastinum and pleural cavity in all the 3 patients. Conservative management of esophageal perforation was carried out with intraluminal drainage from the perforated site of esophagus[insertion of Levin`s tube and continuous suction], pleural drainage and feeding of liquid diet through gastrostomy tube with Fowler`s position. The patients revealed spontaneous closure of perforated sites about 3 to 4 weeks after this conservative management without open thoracotomy. This result suggests that this conservative management may be accepted as therapeutic method in the thoracic esophageal perforations regardless of cause and time of the perforation.

• Journal of Chest Surgery
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• v.51 no.1
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• pp.76-80
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• 2018

Early diagnosis followed by primary repair is the best treatment for spontaneous esophageal perforation. However, the appropriate management of esophageal leakage after surgical repair is still controversial. Recently, the successful adaptation of vacuum-assisted closure therapy, which is well established for the treatment of chronic surface wounds, has been demonstrated for esophageal perforation or leakage. Conservative treatment methods require long-term fasting with total parenteral nutrition or enteral feeding through invasive procedures, such as percutaneous endoscopic gastrostomy or a feeding jejunostomy. We report 2 cases of esophageal leakage after primary repair treated by endoscopic vacuum therapy with continuous enteral feeding using a Sengstaken-Blakemore tube.

• Neonatal Medicine
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• v.25 no.4
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• pp.186-190
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• 2018

Esophageal atresia (EA) with proximal tracheoesophageal fistula (TEF; gross type B) is a rare defect. Although most patients have long-gap EA, there are still no established surgical guidelines. A premature male infant with symmetric intrauterine growth retardation (birth weight, 1,616 g) was born at 35 weeks and 5 days of gestation. The initial diagnosis was pure EA (gross type A) based on failure to pass an orogastric tube and the absence of stomach gas. A "feed and grow" approach was implemented, with gastrostomy performed on postnatal day 2. A fistula was detected during bronchoscopy for recurrent pneumonia; thus, we confirmed type B EA and performed TEF excision and cervical end esophagostomy. As the infant's stomach volume was insufficient for bolus feeding after reaching a body weight of 2.5 kg, continuous tube feeding was provided through a gastrojejunal tube. On the basis of these findings, esophageal reconstruction with gastric pull-up was performed on postnatal day 141 (infant weight, 4.7 kg), and he was discharged 21 days postoperatively. At 12 months after birth, there was no catch-up growth; however, he is currently receiving a baby food diet without any complications. In patients with EA, bronchoscopy is useful for confirming TEF, whereas for those with long-gap EA with a small stomach volume, esophageal reconstruction with gastric pull-up after continuous feeding through a gastrojejunal tube is worth considering.