Single Center Experience with Gastrostomy Insertion in Pediatric Patients: A 10-Year Review / 대한소아소화기영양학회지

PURPOSE: This study was performed to review the outcomes of gastrostomy insertion in children at our institute during 10 years. METHODS: A retrospective chart review was performed on 236 patients who underwent gastrostomy insertion from October 2005 to March 2015. We used our algorithm to select the least invasive method for gastrostomy insertion for each patient. Long-term follow-up was performed to analyze complications related to the method of gastrostomy insertion. RESULTS: Out of 236 patients, 120 underwent endoscopic gastrostomy, 79 had laparoscopic gastrostomy, and 37 had open gastrostomy procedures. The total major complication rates for endoscopic gastrostomy insertion, laparoscopic gastrostomy insertion, and open gastrostomy were 9.2%, 8.9%, and 8.1%, respectively. The most common major complication was gastroesophageal reflux requiring Nissen fundoplication (3.8%), and other complications included peritonitis (1.3%), hiatal hernia (1.3%), and bowel perforation (0.8%). Gastrostomy removal was successful in 8.6% and 5.0% of patients in the endoscopic and surgical gastrostomy groups, respectively. Gastrocutaneous fistula occurred in 60% of surgically inserted cases, requiring a second operation. CONCLUSION: This retrospective study was performed to review the outcome of gastrostomy insertion, as well as to introduce an algorithm that can be used for future cases. Further studies should be conducted to make a consensus on choosing the most appropriate method for gastrostomy insertion.

Cyclooxygenase-2 Inhibitor Reduces Hepatic Stiffness in Pediatric Chronic Liver Disease Patients Following Kasai Portoenterostomy

PURPOSE: The purpose of this study was to define the role of cyclooxygenase-2 inhibitors (COX-2i) in reducing hepatic fibrosis in pediatric patients with chronic liver disease. MATERIALS AND METHODS: From September 2009 to September 2010, patients over 2 years old who visited our outpatient clinic for follow-up to manage their chronic liver disease after Kasai portoenterostomy for biliary atresia, were included in this study. Volunteers were assigned to the study or control groups, according to their preference. A COX-2i was given to only the study group after obtaining consent. The degree of hepatic fibrosis (liver stiffness score, LSS) was prospectively measured using FibroScan, and liver function was examined using serum analysis before and after treatment. After 1 year, changes in LSSs and liver function were compared between the two groups. RESULTS: Twenty-five patients (18 females and 7 males) were enrolled in the study group. The control group included 44 patients (26 females and 18 males). After 1 year, the least square mean values for the LSSs were significantly decreased by 3.91±0.98 kPa (p=0.004) only in the study group. Serum total bilirubin did not decrease significantly in either group. CONCLUSION: COX-2i treatment improved the LSS in patients with chronic liver disease after Kasai portoenterostomy for biliary atresia.

Retrospective Assessment of the Validity of Robotic Surgery in Comparison to Open Surgery for Pediatric Choledochal Cyst

PURPOSE: We evaluated the validity of robotic surgery (RS) for pediatric choledochal cyst (CC) in comparison to open surgery (OS). MATERIALS AND METHODS: From January 2009 to April 2013, clinical data from 79 consecutive pediatric patients with CC, who underwent RS (n=36) or OS (n=43) performed by a single pediatric surgeon, were analyzed retrospectively. RESULTS: In the RS group, the age of the patients was significantly older, compared to the OS group. Operation and anesthesia times were significantly longer in the RS group than the OS group. Fluid input rates to maintain the same urine output were significantly smaller in the RS group than the OS group. The American Society of Anesthesiologists (ASA) physical status, length of postoperative hospital stay, and the incidence of surgical complications did not differ significantly between the two groups. CONCLUSION: Although early complications could not be avoided during the development of robotic surgical techniques, RS for pediatric CC showed results comparable to those for OS. We believe that RS may be a valid and alternative surgery for pediatric CC. After further development of robotic surgical systems and advancement of surgical techniques therewith, future prospective studies may reveal more positive results.

Clinical Characteristics and Management of Benign Transient Non-Organic Ileus of Neonates: A Single-Center Experience

PURPOSE: The term benign transient non-organic ileus of neonates (BTNIN) is applied to neonates who present symptoms and plain radiographic findings of Hirschsprung's disease, but do not have aganglionic bowel and are managed well by conservative treatment. It can often be difficult to diagnose BTNIN because its initial symptoms are similar to those of Hirschsprung's disease. The aim of this study is to evaluate the clinical characteristics and proper treatment of BTNIN. MATERIALS AND METHODS: A retrospective review was made on the clinical data of 19 neonates who were treated for BTNIN between January 2008 and December 2011 at a single facility. RESULTS: Abdominal distension occurred in every patient (19/19). Other common symptoms included emesis (5/19), explosive defecation (5/19), and constipation (4/19). The vast majority of patients (15/19) experienced the onset of symptoms between 2 and 4 weeks of age. Radiograph findings from all of the patients were similar to Hirschsprung's disease. A barium study showed a transition zone in 33.4% (6/18) of the patients. However, rectal biopsy revealed ganglion cells in the distal rectum in 88.2% (15/17) of the patients, and anorectal manometry showed a normal rectoanal inhibitory reflex in 90% (9/10). All patients responded well to conservative treatment. Symptoms disappeared at the mean age of 4.9+/-1.0 months, and the abdominal radiographs normalized. CONCLUSION: BTNIN had an excellent outcome with conservative treatment, and must be differentiated from Hirschsprung's disease. A rectal biopsy and anorectal manometry were useful diagnostic tools in the differential diagnosis.

Minimally invasive surgery in infants with congenital diaphragmatic hernia: outcome and selection criteria / 대한외과학회지

PURPOSE: The aim of the study was to determine clinical indications for performing minimally invasive surgery (MIS) with acceptable results by reviewing our experience in congenital diaphragmatic hernia (CDH) repair and comparing outcomes of MIS with open surgery. METHODS: Medical records of patients who underwent CDH repair were reviewed retrospectively between January 2008 and December 2012, and outcomes were compared between MIS and open repair of CDH. RESULTS: From 2008 to 2012, 35 patients were operated on for CDH. Among these patients, 20 patients underwent open surgery, and 15 patients underwent MIS. Patients with delayed presentations (60.0% [9/15] in the MIS group vs. 20.0% [4/20] in the open surgery group; P = 0.015) and small diaphragmatic defect less than 3 cm (80.0% [12/15] in the MIS group vs. 0.0% [0/20] in the open surgery group; P < 0.001) were more frequently in the MIS group than the open surgery group. All 10 patients who also had other anomalies underwent open surgery (P = 0.002). Moreover, nine patients who needed a patch for repair underwent open surgery (P = 0.003). Patients in the MIS group showed earlier enteral feeding and shorter hospital stays. There was no recurrence in either group. CONCLUSION: CDH repair with MIS can be suggested as the treatment of choice for patients with a small sized diaphragmatic defect, in neonates with stable hemodynamics and without additional anomalies, or in infants with delayed presen tation of CDH, resulting in excellent outcomes.

Change in Quality of Life according to the Change in Atopic Dermatitis Severity / 소아알레르기및호흡기학회지

PURPOSE: The aim of this study was to longitudinally examine the correlation between the change of atopic dermatitis (AD) severity and the change of quality of life (QOL). METHODS: We assessed AD severity and QOL of patients and their families, by a prospective followed up for at least 12 months. AD severity was assessed, using the scoring of atopic dermatitis (SCORAD) index. A questionnaire based on dermatitis family impact (DFI), infants' dermatologic quality of life (IDQoL) and children's dermatology life quality index (CDLQI) were used to determine QOL. RESULTS: Seventy-nine AD patients were assessed for total and objective SCORAD and DFI. Among them, 45 patients that were less than 36 months old completed IDQoL and 13 patients that were equal to or more than 36 months old completed CDLQI. Objective SCORAD (oSCORAD) were correlated with DFI (r=0.235), IDQoL (r=0.602) and CDLQI (r=0.589) (P<0.05). At the 2nd interview, median oSCORAD (from 17.4 to 7.8), DFI (from 23.0 to 18.0) and IDQoL (from 9.0 to 6.0) were significantly decreased (P<0.01). The changes of oSCORAD were linearly related with the change of IDQoL (P<0.01), but neither with DFI (P=0.356) nor with CDLQI (P=0.267). Of the 64 patients with decreased oSCORAD, food allergy was accompanied more frequently in those with an increased DFI than those with a decreased DFI (60.7% vs. 27.8%, P<0.01). CONCLUSION: In this longitudinal study, the improvement of AD severity is correlated with the improvement of the patient's QOL, under the age of 3. To improve the family's QOL, we need to find out accompanying factors, such as food allergy, and to support the family accordingly.

Clinical characteristics and treatment of esophageal atresia: a single institutional experience / 대한외과학회지

PURPOSE: Treatment for esophageal atresia has advanced over several decades due to improvements in surgical techniques and neonatal intensive care. Subsequent to increased survival, postoperative morbidity has become an important issue in this disease. The aim of our study was to analyze our experience regarding the treatment of esophageal atresia. METHODS: We reviewed and analyzed the clinical data of patients who underwent surgery for esophageal atresia at Severance Children's Hospital from 1995 to 2010 regarding demographics, surgical procedures, and postoperative outcomes. RESULTS: Seventy-two patients had surgery for esophageal atresia. The most common gross type was C (81.9%), followed by type A (15.3%). Primary repair was performed in 52 patients. Staged operation was performed in 17 patients. Postoperative esophageal strictures developed in 43.1% of patients. Anastomotic leakages occurred in 23.6% of patients, and recurrence of tracheoesophageal fistula was reported in 8.3% of patients. Esophageal stricture was significantly associated with long-gap (> or =3 cm or three vertebral bodies) atresia (P = 0.042). The overall mortality rate was 15.3%. The mortality in patients weighing less than 2.5 kg was higher than in patients weighing at least 2.5 kg (P = 0.001). During the later period of this study, anastomotic leakage and mortality both significantly decreased compared to the earlier study period (P = 0.009 and 0.023, respectively). CONCLUSION: The survival of patients with esophageal atresia has improved over the years and the rate of anastomotic leakage has been significantly reduced. However, overall morbidities related to surgical treatment of esophageal atresia still exists with high incidence.

Second Serial Transverse Enteroplasty Procedure in an Infant with Extreme Short Bowel Syndrome

The serial transverse enteroplasty (STEP) procedure is a novel technique to lengthen and taper the bowel in patients with short bowel syndrome. The advantages of STEP include not only technical ease and simplicity, but also the ability to repeat the procedure. Herein, we report a case of extreme short bowel syndrome that was successfully treated by the second STEP procedure. A 3-day old newborn girl underwent STEP because of jejunal atresia with the small bowel length of 15 cm, but her bowel elongation was not enough to escape from short bowel syndrome. At the age of 6 months, she underwent a second STEP procedure. The bowel lengthening by the second STEP made her tolerable to enteral feeding with body weight gain and rescued her from short bowel syndrome. This case showed that second STEP is very helpful in treatment of extreme short bowel syndrome.

Initial Experience of Robot-assisted Resection of Choledochal Cyst in Children

Although laparoscopic surgery for hepatobiliary disease in children is possible, it is technically challenging. In an attempt to overcome these difficulties, the da Vinci Robotic Surgical System(R) was used to facilitate the minimally invasive treatment of choledochal cyst in six children. In early consecutive three cases, we experienced three complications; a case of laparotomy conversion, a case of late stenosis of the hepaticojejunostomy, and a case of leakage from a hepaticojejunostomy. However, in the last three cases the complete resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy were performed using the robotic surgical system without complication. We think robot-assisted choledochal cyst resection in children appears safe and feasible, and may increase the variety of complex procedures in pediatric surgical fields.

Home intravenous antibiotic treatment for intractable cholangitis in patients with biliary atresia following Kasai portoenterostomies / 대한외과학회지

PURPOSE: Patients with biliary atresia (BA) treated with Kasai portoenterostomy may later develop intractable cholangitis (IC) that is unresponsive to routine conservative treatment. It may cause biliary cirrhosis and eventually hepatic failure with portal hypertension. Control of IC requires prolonged hospitalization for the administration of intravenous antibiotics. To reduce the hospitalization period, we designed a home intravenous antibiotic treatment (HIVA) which can be administered after initial inpatient treatment. In this study, we reviewed the effects of this treatment. METHODS: We reviewed medical records of 10 patients treated with HIVA for IC after successful Kasai portoenterostomies performed for BA between July 1997 and June 2009. RESULTS: The duration of HIVA ranged from 8 to 39 months (median, 13.5 months). The median length of hospital stay was 5.7 days per month for conventional treatments to manage IC before HIVA and, 1.5 days per month (P = 0.012) after HIVA. The median amount of medical expenses per month was reduced by about one tenth with HIVA. One patient underwent liver transplantation due to uncontrolled esophageal variceal bleeding, but the other nine patients had acceptable hepatic function with native livers. CONCLUSION: HIVA may be an effective primary treatment for IC after Kasai portoenterostomies for BA, and reduce length of hospital stay and medical expense.

Association of infant feeding practices in the general population with infant growth and stool characteristics

This was a prospective cohort study of 976 infants from birth to 12 months of age. Infants were fed breast milk, goat infant formula, cow infant formula, or a combination of formula and breast milk during the first 4 months of age. Data on type of milk feeding and infant growth (weight and height) were collected at birth and at 4, 8, and 12 months during routine clinical assessment. The number and consistency of bowel motions per day were recorded based on observational data supplied by the mothers. Infants fed breast milk or goat or cow infant formula during the first 4 months displayed similar growth outcomes. More of the infants fed cow infant formula had fewer and more well-formed bowel motions compared with breast-fed infants. The stool characteristics of infants fed goat formula resembled those of infants fed breast milk.

The clinical effects of hospitalization in a low pollutant room on atopic dermatitis

BACKGROUND: Environmental pollutants are thought to be one of major triggers of atopic dermatitis (AD). OBJECTIVE: We attempted to evaluate the clinical effects of environment with low indoor pollutant levels on AD management. METHODS: Fifty-one children (mean age 1.7 years) with moderate to severe AD who failed to show improvement with conventional management were recruited. Disease severity was assessed by SCORAD (Scoring of AD) indices. They were admitted in a low pollutant oom for 3-4 days (mean 3.3 days) which was designed to keep low levels of dust, house dust mites, micro-organisms, and indoor air pollutants such as total volatile organic compounds (TVOCs), particulate matter (PM), and so on. Air pollutant levels in the low pollutant room were lower than primary standards defined by the Korean Ministry of Environment. we compared disease severity on admission and after discharge, and the pollutant levels of each patient's home and low pollutant room. RESULTS: The SCORAD was significantly reduced from 42.0 ± 11 .5 to 29.8 ± 8.9 (p < 0.001) by management in a low pollutant room. PM₂.₅, PM₁₀, formaldehyde, TVOCs, carbon dioxide, bacterial suspensions, and indoor molds were significantly higher in the patient's home than low pollutant room. Out of 29 patients who deteriorated after discharge to their home, 8 patients were admitted again, and their SCORAD was rapidly decreased from 53.1 ± 16.2 to 39.2 ± 9.8 (p = 0.036). CONCLUSION: Indoor air pollutants are likely to affect AD in susceptible individuals. Environmental control to lower indoor air pollutant levels might be necessary for better management of AD in some patients.

Meconium Obstruction in Neonates-Clinical Characteristics and Treatment

Meconium obstruction (MO) in neonates arises from highly viscid meconium and the poor motility of the premature gut. Recently the incidence of the MO in neonates has been increasing, but, the diagnosis and treatment of this disease have not yet been clarified. Between March 2004 and April 2010, 24 neonates were treated for MO at Severance Children's Hospital. Their clinical characteristics and treatment were reviewed retrospectively. Twenty neonates were diagnosed with MO and 4 neonates were diagnosed with Hirschsprung's disease (HD). The mean birth weight and gestational age of the 20 neonates with MO were 1.45+/-0.90kg and 31.1+/-4.6 weeks, respectively. Thirteen neonates (65%) diagnosed with MO weighed less than 1.5kg and 10 neonates (50%) weighed less than 1kg. Half of the neonates with MO were treated by non-operative methods and the other half were treated by operative methods. Compared with the group that weighed over 1.5kg, the group that weighed less than 1.5kg were more frequently operated upon (61.5% vs. 28.5%), and contrast enemas were performed later and more frequently. Also the group that weighed less than 1.5kg had a higher mortality rate (15.4% vs. 0%). Three of the four neonates with HD were diagnosed with long-segment aganglionosis. In conclusion, MO occurred in very low birth weight neonates more often and must be differentiated from HD. Also, MO in very low birth weight neonates should be treated with special attention due to more a complicated clinical course.

High Incidence of Hiatal Hernia in Esophageal Atresia and Its Etiologic Factors

Hiatal hernia is a very rare disease in the pediatric population. However information from our esophageal atresia postoperative follow-up program has hypotheses; "Hiatal hernia may more frequently occur in postoperative esophageal atresia patients (EA group) than in the general pediatric population (GP group)" and "The tension on the esophagus after esophageal anastomosis may be an important etiologic factor of hiatal hernia in EA group". To prove the first hypotheses, we compared the incidence of hiatal hernia in the GP group with the incidence in the EA group. The Incidence in the GP group was obtained from national statistic data from Statistics Korea and Health Insurance Review and Assessment Service of Korea. The incidence in the EA group was obtained from the medical record and the imaging studies of our esophageal atresia postoperative follow-up program. To prove the second hypothesis, the presumptive risk factors for the development of hiatal hernia in EA group, such as the type of esophageal atresia, degree of esophageal gap, the stage operation and the redo-operation with resection and re-anastomosis of esophagus were analyzed statistically. The total number of patients in the EA group was ninety-nine and there were 5 hiatus hernias. The incidence of EA group (5 %) is significantly higher than incidence of GP group (0.024 %). (p=0.0001) The statistical analysis of the presumptive risk factors for hiatal hernia development in EA group failed to show any evidence of correlation between postoperative esophageal tension and the hiatal hernia. This study shows that the postoperative patients with esophageal atresia have high occurrence of hiatal hernia and should be followed up carefully to detect hiatal hernia.

Clinical Analysis and Laparoscopic Surgical Experience for an Appendiceal Mucocele / 대한내시경복강경외과학회지

PURPOSE: A mucocele of the appendix is an infrequent entity of appendiceal pathology. A preoperative diagnosis is important to determine for appropriate treatment and to avoid unintended rupture of the mucocele during surgery. The purpose of our study was to identify the clinical features of an appendiceal mucocele (AM) and to describe the experience of the use of the laparoscopic approach for an AM. METHODS: Between July 1998 and July 2008, 32 cases of AM were diagnosed. We reviewed the clinicopathological characteristics and surgical experience for an AM. RESULTS: The incidence of an AM was 0.66% for 4825 performed appendectomies. Most cases manifested with symptoms of abdominal pain (84.4%), but two cases were determined based on CT incidental findings. A preoperative diagnosis of a mucocele was determined for 34.4% of the cases. The use of ultrasonography, CT and colonoscopy helped to achieve a correct diagnosis. Open surgery was performed in 15 cases and laparoscopic surgery was performed in 17 cases. For patients that underwent an appendectomy, the mean operation time and diet-start date were significantly shorter for patients that underwent laparoscopic surgery as compared to patients that underwent open surgery (p=0.030, p=0.007, respectively). Pathology identified mucosal hyperplasia (25%), mucinous cystadenoma (59.4%) and a simple mucocele (15.6%). The mean duration of follow-up was 46 months. Recurrence or development of pseudomyxoma peritonei and complications after laparoscopic surgery were not seen. CONCLUSION: Laparoscopic resection of an AM was feasible when there was no mucinous spillage. Close follow-up is recommended in all patients due to the risk of recurrence in the form of pseudomyxoma peritonei or a gastrointestinal neoplasm.

Health Promotion Lifestyle According to Self-Perception of Obesity and Objective Status Measured by Bioelectric Impedance Analysis in College Women

PURPOSE: The purpose of this study was to identify congruence between self-perception and objective status of obesity according to %Fat, and to investigate health promotion lifestyle in college women. METHODS: The participants were a convenience sample of 392 college women who were eligible and agreed to participate in this study. Respondents were asked questions using a health promotion lifestyle profile and were evaluated for their body composition using InBody 3.0. The data were analyzed with SPSS 14.0 program, which was used for Chi square, ANOVA, and post-hoc comparison with Scheffe. RESULTS: The major findings were as follows; 1) Overall, 41.8% of participants misclassified their perceived status of weight by %Fat standards and kappa was 0.329. 2) Two percent were underweight by BMI but overweight by %Fat and 39.0% normal weight by BMI but overweight by %Fat. 3) There were significant differences in health promotion lifestyle according to self-perception of body weight but there was no difference in health promotion lifestyle according to %Fat standards. CONCLUSION: These findings suggest the necessity for development and application of tailored health promotion program based on self-perception of body weight and %Fat in order to reform incorrect body image and health behavior in college women.

Couvade Syndrome of Pregnant Women's Spouses / 여성건강간호학회지

PURPOSE: This study was intended to investigate the types and seriousness of the couvade syndrome, pregnancy-related physical and psychological symptoms among expectant fathers whose spouses were pregnant. METHOD: The subject was consists of 100 expectant fathers at one hospital in Seoul, Korea. The pregnant women had not been diagnosed any medical complication. Data were analyzed by SPSS/PC program. RESULT: 1) The total mean score was 1.85: the mean score of perceived physical symptoms (1.87) revealed higher than the mean score of psychological symptoms (1.81). 2) With the respect to the general characteristics of subjects, there were statistically significant correlations between subject's level of education and couvade symptoms (r=-.209, p=.037), gestational age and couvade symptoms (r=-.227, p=.023), family total income and couvade symptoms (r=-.198, p=.048), perceived self health status and couvade symptoms (r=-.254, p=.011). 3) With the respect to the general characteristics of subjects, there were statistically significant differences in pregnant woman's age (t=1.363, p=.044),occupation of subject (F=3.594, p= .009), educational level of subject (t=3.506, p=.002), family total income (F=16.822, p= .000), perceived self health status (F=3.151, p=.047). CONCLUSION: Couvade syndrome is an issue for nurses who perform an important role in the care of pregnant women and their spouses.