Foreign Body Ingestion In Children Research Articles

Foreign Body Ingestion in Children: An Experience of 99 Cases in a Tertiary Care Center in Delhi.

Accidental ingestion of foreign bodies in children is critical, as the inability to effectively communicate can potentially lead to devastating consequences. We aimed to determine the epidemiology of foreign body ingestion and variability according to age, gender, type, and location of foreign body, and describe its management. The aim was to study the various types of foreign body ingestions in children admitted to pediatric surgery and their management. A retrospective study was conducted from January 2020 to June 2022 on children under the age of 12 years with a confirmed diagnosis of foreign body ingestion. Patients were clinically and radiologically assessed, after which standard protocols were followed wherein patients were followed by either observation or emergent management. Emergent management included removal of the foreign body by either endoscopy or surgery. Comparisons among multiple age groups, gender, type of foreign body, location of foreign body, and their management were analyzed. Out of 99 subjects in our study, there were 76 boys and 23 girls. The median age of presentation was 5 years. Most children were asymptomatic at presentation. The most frequently ingested foreign body was a coin in all age groups. The majority of the foreign bodies were suspected to be in the small bowel. The foreign bodies that had crossed the duodenojejunal flexure (n = 74, 74.7%) were managed conservatively with the observation of a variable period of a minimum of 24 h and a maximum of 48 h. 21 cases were managed by endoscopic removal, while three cases required surgical intervention. Overall, the most common gastrointestinal foreign body was a coin in all age groups. Button battery is the most worrisome foreign body; however, depending on its position, it can be managed conservatively. Upper GI foreign bodies can be safely removed endoscopically. Parental counseling is very important for the prevention of ingestion of foreign bodies.

Water-beads Ingestion with Intestinal Obstruction in Children: A Case Report

Background: Foreign body ingestion often occurs in the pediatric population and can cause no symptoms or even cause complications due to swallowing the foreign body. The aim of this case report is to increase clinician knowledge of cases of foreign body ingestion which can cause complications. Case: We report a case of foreign body ingestion water beads with complications of intestinal obstruction in a 1 year 2-month-old girl. The patient came with complaints of vomiting more than ten times containing fluid accompanied by decreased intake. The patient was suspected of swallowing water beads. The patient came to the emergency room with no signs of acute abdomen and the results of plain abdominal radiograph showed no foreign objects. The patient began to show symptoms of obstruction, not being able to defecate and not being able to pass gas. Physical examination revealed abdominal distention accompanied by inaudible bowel sounds. Abdominal CT scan results showed ileal obstruction. An exploratory laparotomy was performed, and two water beads were found intraoperative, which were the cause of the obstruction. The foreign body was removed. After surgery, the patient experienced gradual clinical improvement until he was discharged ten days after the procedure. Discussion: Foreign body ingestion in children is often not witnessed by anyone and may not cause symptoms until complications such as obstruction or peritonitis occur. Some foreign objects are radiolucent in plain radiographs. In emergency cases of foreign body ingestion, it is necessary to carry out emergency endoscopic procedures, even emergency surgical procedures in cases that cause complications. Conclusion: This case report increases clinician knowledge and awareness regarding the clinical approach in evaluating patients with suspected foreign body ingestion in children.

– Foreign body ingestion in children(<12 years) at a tertiary care hospital: a retrospective cohort study studying role of socioeconomic status and parental supervision.

– Foreign body ingestion in children(<12 years) at a tertiary care hospital: a retrospective cohort study studying role of socioeconomic status and parental supervision.

Ask Doctor Smartphone! An App to Help Physicians Manage Foreign Body Ingestions in Children.

Foreign body ingestion (FBI) represents the most common cause of emergent gastrointestinal endoscopy in children. FBI's management can be quite challenging for physicians because of the variability of the clinical presentation, and the decision tree becomes even more intricate because of patient-specific variables that must be considered in the pediatric age range (e.g., age of patients and neuropsychiatric disorders) in addition to the mere characteristics of the foreign body. We present an application for smartphones designed for pediatricians and pediatric surgeons based on the latest guidelines from the official pediatric societies. The app aims to help physicians manage FBI quickly and properly in children. The latest pediatric FBI management guidelines were reviewed and summarized. The flow chart we obtained guided the development of a smartphone application. A questionnaire was administered to all pediatric surgeon trainees at our institute to test the feasibility and helpfulness of the application. An app for smartphones was obtained and shared for free on the Google Play Store and Apple Store. The app guides the physician step by step in the diagnostic process, analyzing all patient- and foreign body-specific characteristics. The app consultation ends with a suggestion of the most proper decision to make in terms of further radiological investigations and the indication and timing of endoscopy. A questionnaire administered to trainees proved the app to be useful and easy to use. We developed an app able to help pediatricians and pediatric surgeons manage FBI in children, providing standardized and updated recommendations in a smart and easily available way.

Endoscopic removal of ingested foreign body in children: experience of a tertiary care hospital of Bangladesh

Purpose: Foreign body ingestion is a common incident in children & majority of ingested foreign body removed spontaneously, few percentages (10%) remain in GI tract. The timing of endoscopy depends on some clinical & radiological parameters. The aim of this study to is to observe clinical profile of foreign body ingestion in children in Bangladesh. Methods: This cross-sectional descriptive study was conducted from February 2016 to December 2019 in the department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. A total of 29 cases of upper GI tract foreign bodies were studied. Patients with history of ingested foreign body, were clinically examined. Asymptomatic foreign body ingestion was frequently observed. Routine neck and chest X-ray in both AP and lateral views were obtained for these cases. Flexible endoscopy for foreign body extraction with suitable foreign body retriever was used to remove the foreign bodies. Data were expressed as percentage & number. Results: Foreign body was commonly seen 22 (75.9%) in 1-5 years of age. Sex distribution of foreign body ingestion cases, where 15 (51.7%) were male child. Among the ingested foreign bodies only 3 (10.3%) were removed within 24 hours of ingestion, 10 (34.5%) cases were removed between 24-48 hours and the remaining 16 (55.2%) were removed after 48 hours. Coin was the most common foreign body 19(65.5%). Other foreign bodies were metallic chain 3 (10.3%), button battery 2 (6.9%), others 5 (17.2%). Conclusion: The study showed that foreign body ingestion is more common in 1-5 years age group, coin was the most commonly ingested foreign body.

Prevalence of Foreign Bodies Ingestion in Children

Foreign body ingestion is one of the common pediatric emergency conditions and can lead to childhood morbidity, and mortality. We think that the results of this study will be of utmost usefulness for pediatric surgeons when considering foreign bodies' ingestion in children. We decided to study the age distribution, nature, the site of impaction, and fate of foreign body ingestion in children. This cross-sectional study was conducted on 77 children with foreign body ingestion, from February 2017 to July 2021(54 months). A total of 77 patients with foreign body ingestion were diagnosed during the study period. Forty percent were boys and 60% were girls. The maximum age of participants was 1-2 years, accounting for 55%. Batteries were the most common foreign bodies ingested accounting for 26% followed by magnets (13%), and coins 6.5%. The most common site of foreign body impaction was the stomach (34%), colon (26%), and small bowel (23%). Majorities of foreign bodies (72%) were passed through the gastrointestinal tract without complication, 18 % required extraction by the upper endoscope, and 10% were removed surgically. We conclude that increasing awareness among parents to check the quality and safety protocols of electronic toys that contain batteries and magnets.

Foreign body ingestion in children: Definition of a nomogram to predict surgical or endoscopic intervention

Background and aimsForeign body ingestion (FBI) in children requires early identification to prevent adverse outcomes and may necessitate endoscopic or surgical intervention. This study aims to develop a nomogram that identifies children who require urgent surgical or endoscopic intervention by using the patient's medical history and clinical parameters collected at admission. MethodsThis study is a retrospective review (01/2015–12/2020) of a multicenter case series of children admitted for FBI. Data from 5864 records from 24 hospitals in Italy were analyzed. Logistic regression models were used to establish the probability of requiring surgical or endoscopic intervention based on patient history and clinical characteristics. The nomogram representing the results from the multivariable model was reported to examine the propensity for surgery/endoscopy. ResultsThe study identified a significant association between intervention and various factors, including type of foreign body (blunt: reference category, disk battery (odds ratio OR:4.89), food bolus (OR:1.88), magnets (OR:2.61), sharp-pointed (OR:1.65), unknown (OR:1.02)), pre-existing diseases or conditions (OR 3.42), drooling (OR 10.91), dysphagia (OR 5.58), vomiting (OR 3.30), retrosternal pain (OR 5.59), abdominal pain (OR 1.58), hematemesis (OR 2.82), food refusal/poor feeding (OR 2.99), and unexplained crying (OR 2.01). The multivariable regression model showed good calibration and discrimination ability, with an area under the ROC curve of 0.77. ConclusionsThis study developed the first nomogram to predict the probability of the need for surgical or endoscopic intervention in children with FBI, based on the information collected at admission. The nomogram will aid clinicians in identifying children who require early intervention to prevent adverse outcomes.

Neodymium magnets migrated into an internal supravesical hernia: a rare case of foreign body ingestion in children

BackgroundForeign body (FB) ingestion is a common event in children. The management of the ingested FB depends on the location, type, number, size of the FBs, patient age, and symptoms. Although most FBs pass spontaneously through the gastrointestinal tract without causing serious injuries, the ingestion of multiple high-powered magnetic pieces, especially neodymium magnets (NMs) increases the risks of morbidity and mortality. Supravesical hernia (SH) is rarely occurs in children, and few studies have reported SH in pediatric patients. We report an extremely rare case of ingested NMs that migrated into an internal SH in a pediatric patient.Case presentationA 3-year-old boy who had accidentally swallowed two NMs 3 days ago presented with vomiting and lower abdominal pain. X-ray imaging and computed tomography (CT) suspected the presence of a 1.0-cm radiopaque FB located in the terminal ileum dorsal side of the bladder. Although his abdominal pain was gradually getting better after oral feeding, repeat abdominal X-ray imaging showed that the FB was in a stagnant in position. Therefore, surgical intervention was planned to remove the FB 1 week after his admission. Under general anesthesia, laparoscopic and fluoroscopic examinations were performed and the cecum was found adhered to the retroperitoneum between the right medial umbilical fold and the right wall of the urinary bladder. The FB was presumed to be located at the tip of the incarcerated cecum in the retroperitoneal space. Peritoneum incision was started near the medial inguinal fossa, and the Retzius space was opened in a manner similar to the transabdominal pre-peritoneal approach for inguinal hernia repair. Consequently, the patient was diagnosed with internal SH with FB migration. The incarcerated cecum was pulled out, which revealed intestinal wall perforation. The FB remained in the retroperitoneal space in the pelvic cavity. The FB was easily removed using intestinal forceps and identified as combined two NMs. The postoperative course was good, and the patient was discharged on postoperative day 5.ConclusionsWe experienced an extremely rare case of a pediatric patient who swallowed multiple NMs that migrated into an internal SH, and the laparoscopic minimally invasive removal was successful.

Foreign body ingestion trends in children in the Daegu-Kyungpook Province, Korea before and during the COVID-19 period: a repeated cross-sectional study.

During the coronavirus disease 2019 (COVID-19) period, children spent more time at home, which is where most foreign body ingestions (FBIs) in children occur. We compared the rate of FBI in children in the Daegu-Kyungpook Province during COVID-19 to the rate in the 2 years before the COVID-19 period. The period from January to December in the year 2020 was defined as the COVID-19 period, and the corresponding time period in 2018 and 2019 was defined as the pre-COVID-19 period. Medical records were analyzed retrospectively for pediatric patients aged 0-15 years who visited outpatient and emergency rooms at seven tertiary referral hospitals in Daegu-Kyungpook Province. The annual occurrence rate of FBIs in patients visiting seven tertiary referral hospitals was not different during COVID-19 compared to that in the pre-COVID-19 period and the median age of these patients during the COVID-19 and pre-COVID-19 periods was similar. However, occurrence rates increased in the groups aged 0-3 and 4-6 years but decreased in the group aged 7-15 years during the COVID-19 period. The proportion of male patients as well as inpatients increased significantly during the COVID-19 period (both P=0.01). The proportion of foreign bodies located in the post-pyloric region increased during the COVID-19 period (P=0.02). The most common symptom, foreign body sensation in the neck, was similar in both groups. There was no significant difference in the foreign body removal method between the two groups. The occurrence rates of swallowing of toys, coins, magnets, button batteries, and superabsorbent polymers non-significantly increased; and the food ingestion rate decreased, while the non-food ingestion rate increased in all age groups during the COVID-19 period. The FBI rate in children did not differ during the COVID-19 period compared to that in the pre-COVID-19 period. The occurrence of FBI in boys, the number of foreign bodies located in the post-pyloric region, and the number of hospitalizations due to FBI increased during the COVID-19 period.

Endoscopic Management of Pediatric Foreign Body Ingestions and Food Bolus Impactions: A Retrospective Study from a Tertiary Care Center

Abstract Background Foreign body (FB) ingestion is a common pediatric problem with the majority of these occurring in children younger than 3 years. Management varies depending on the age of the patient, ingested object(s), its location along the digestive tract, and the available expertise. We aim to report our experience with endoscopic management of FB ingestions in children (<18 years). Materials and Methods We retrospectively reviewed and analyzed endoscopic and medical records from our hospital database of all pediatric patients (<18 years) who presented with FB ingestion between January 2011 and December 2021. Results Our analysis included a total of 368 patients. FB ingestions and/or food bolus impactions were noted in 242 and 11 children, respectively while 115 (31.25%) had spontaneously passed off FB from the digestive tract. Most common FB was coin (28.5%) followed by animal bones (26.2%). Endoscopic management of FBs and food bolus impaction was successful in 247 children (97.63%), while endoscopic FB retrieval failed in 6 children including 1 with fish bone and 5 with button batteries. A total of 9 out of 11 children with food bolus impaction had underlying esophageal pathology, the commonest being corrosive stricture (n = 7). No mortality related to endoscopic intervention was reported. Conclusions Endoscopic retrieval of ingested FBs and food bolus impaction in children is a safe and effective approach when performed by experienced endoscopists and is associated with a high success rate and a lower incidence of complications with reduced hospital stay.

Foreign body ingestion in children and their follow-up in a tertiary care hospital – A prospective study

Background: Foreign body (FB) ingestion is a common pediatric surgery emergency, with potential complications such as perforation, obstruction, and bleeding. The demographics, characteristics, and management of these cases can vary based on factors such as age, gender, and type of FB ingested. Aims and Objectives: This study aimed to analyze these factors in a prospective study of children with FB ingestion. Materials and Methods: This was a prospective observational study done under 13 years of age with FB ingestion who presented to a tertiary care hospital over a period of 15 months. Results: A total of 133 cases were included, with a mean age of 6.15 years and a higher prevalence in males (60.2%). The most common age group affected was 5–13 years (50.4%). The mean length of ingested FB was 2.77 cm, with 52.6% of cases ingesting FBs >2 cm. The majority of FBs were blunt (92.5%) and circular in shape (61.7%). The primary reason for ingestion was playing (95.5%). The most common site of FB impaction was the intestine (50.4%). Most cases were managed by observation(93.2%). Conclusion: FB ingestion is a common pediatric emergency, with a higher prevalence in males. Most cases can be managed by observation, and endoscopic removal or PR may be required in a small proportion of cases. Awareness of the risk factors and clinical presentation of FB ingestion can aid in prompt diagnosis and management of these cases.

Management of foreign body ingestion in pediatric population: A single-center study

Abstract Background: Children of all ages may ingest a foreign body (FB). Most (>95%) of ingestions are accidental. Gastrointestinal tract obstruction or impaction by a FB depends on the physical properties of the object such as size, shape, and composition. The majority of ingested FBs are low-risk objects and can be managed without imaging or intervention where as high-risk objects and symptomatic children may require careful observation and surgical intervention. The aim of our study is to discuss our experience of management of FB ingestion in children in IPGME&R and SSKM Hospital, a tertiary care centre and to identify the high-risk FBs ingested and discuss the symptoms where conservative managements can be done even in sharp objects. Materials and Methods: This observational single institute-based study was conducted in the Department of Pediatric Surgery in IPGME&R and SSKM Hospital and data were collected and analyzed statistically. Results: A total of 84 patients came with ingested FBs (Boy – 59 and Girl – 29) and 22 were sharp FBs. Among nonsharp FBs, coins are most common 40 (47.6% of all FBs). Most of them were asymptomatic 75 (89.3%) and among all four required surgical intervention and eight were removed by endoscopy. In 72 patients, no intervention was required for FB ingestion including 16 sharp objects. Conclusion: Most of the ingested FBs are expelled through stool spontaneously. Nonsharp FBs such as magnets and button battery large size are high-risk objects and require active surgical intervention and sharp FBs need very much careful observation after admission and very few requires surgical intervention. Endoscopic removal is indicated in some early cases.

Foreign Body Ingestion in Children: A Case Report and Management Strategies

Introduction: Foreign body ingestion in children is a common pediatric emergency that can result in serious complications if not managed promptly. Observation: it is a case report of an 18-month-old infant who ingested a knife while playing with his 3-year-old sister. The patient was stable but required a surgical approach due to the size of the object and the risk of esophageal injury during removal. Discussion: Children between 6 months to 3 years are at the highest risk for foreign body ingestion. The most common foreign bodies ingested by children are small objects such as coins, toys, magnets, button batteries, and small parts of other objects. Symptoms can vary depending on the type and location of the foreign body and can range from choking, difficulty breathing, and vomiting to blood in stool or vomit and fever. Sharp and elongated objects, as well as batteries and magnets, can cause life-threatening complications such as airway obstruction, esophageal perforation, or bowel obstruction. The approach to management depends on the type and location of the foreign body, and preventing foreign body ingestion in children is critical to avoiding the need for management. Various measures, such as keeping small objects out of reach, providing age-appropriate toys, and supervising young children during playtime, can be implemented to prevent foreign body ingestion in children. Conclusion: Foreign body ingestion is a common pediatric emergency that can lead to serious complications if not managed promptly. Prevention is key in reducing the incidence of foreign body ingestion in children.

Button Battery Ingestions cause the Majority of Severe Complications.

Foreign body ingestion in children is a clinically important reason for presentation to the emergency department. The individual outcome ranges from benign spontaneous courses to severe complications. Fatal outcomes occur rarely and complications are related to patient's age as well as type and location of the foreign body. The aim of our present study was to evaluate the outcome of children and adolescents with foreign body ingestion with a focus on complications, which mainly occurred after button battery ingestion. We reviewed medical records of patients between 0 and 18 years of age who had presented to the paediatric emergency department of our hospital with suspected foreign body ingestion between January 2011 and March 2021 (123 months). Clinical, imaging, and endoscopic data as well as treatment modalities were analysed. In the ten10 year period under review, a total of 1,162 children and adolescents (6 months - 18 years) presented to our emergency room with suspected foreign body ingestion. Among those, 398 ingestions (34%) could be verified radiologically and/or endoscopically, while in the remaining 764 cases (66%) the suspicion could not be confirmed. The majority of patients with verified ingestion (n=324; 81%) presented with ingestion of a metallic foreign body. We observed 55 cases with verified ingestion of a button battery. Five of these cases had severe complications, with a near-fatal course in two patients who developed an oesophageal-tracheal fistula. In contrast to all other ingestions of foreign bodies in children, button battery ingestions lead to mucosal damage and severe complications in a significant number of children.

Foreign body ingestion in children attending Rapareen Teaching Hospital: a single-centre experience

Foreign body ingestion in children attending Rapareen Teaching Hospital: a single-centre experience

Assessment of Awareness Level Among Parents Regarding Foreign Body Ingestion in Children in Arar, Saudi Arabia

Assessment of Awareness Level Among Parents Regarding Foreign Body Ingestion in Children in Arar, Saudi Arabia

SYSTEMATIC REVIEW OF FOREIGN BODY INGESTION

Background: Foreign body ingestion is a predominant worry in pediatric population, with up to 75% of cases happening in childrenyounger than 4 years of age. Pediatric population consume a wide scope of foreign bodies, some of which are more perilous and hazardous than others. Objective: A growing number of research on foreign body ingestion in children nevertheless, there is no clear consensus on signs, symptoms, complications and management of foreign body ingestion among pediatric population. The goal of this systematic review was to determine the significance of foreign body ingestion in pediatric population as far as impaction site, signs and symptoms, and techniques for expulsion. Methods: Authors began with recognizing the important examination proof that spots light on the significance of foreign body ingestion in pediatric population as far as impaction site, signs and symptoms, and techniques for expulsion. We led electronic writing look in the accompanying data sets: Ovid Medline (2015 to present), Ovid Medline Daily Update, Ovid Medline in process and other non-filed references, Ovid Embase (2015 to present), The Cochrane Library (latest issue) and Web of Science. Just examinations in English language will be incorporated. The precise selection was acted in close collaboration with a clinical examination curator. Results: A total of 3503 children with foreign body aspiration were identified from 11 studies (Table in supplementary document). Studies were reported from different places around the world. One study were from Kingdom of Saudi Arabia. Among study participants, there were 2040 males (58.23%) and 1463 females (14.77%). The most common ingested foreign body was coin in six studies. The most common site for impaction of foreign body was esophagus as reported in five studies. Endoscopy was used in as a method of extraction. Conclusion: Children are prone to ingesting foreign bodies. Depending on the type of foreign body, location, and length of impaction, patients may appear asymptomatically or symptomatically with a wide range of symptoms.

Management of Foreign Body Ingestion in Children: A Single-center Experience

Objective: Foreign body (FB) ingestion is frequently encountered in childhood, and although the clinical results are often benign, it has high morbidity and mortality rates. Although guidelines for managing these children are available, there are still controversial aspects of the treatment recommendations. This study aimed to evaluate the treatment options for children who swallow FBs. Methods: The study included 439 patients admitted with FB ingestion. Demographic and clinical features, type, size and localization of FB, treatment approach, and the timing of endoscopy were retrospectively scanned from hospital records. Results: Most patients were male (58.3%) and 69.7% of the patients were aged <5 years. The most common symptom (42.3%) was nausea and vomiting and 82.5% of the patients were asymptomatic. The most common localization was the intestines (59.7%). While 84.1% of swallowed FBs came out with a spontaneous passage without complications, the endoscopic removal procedure was successful at the rate of 91.8%. The most frequently swallowed FB was coins (39.6%). Spontaneous elimination rates were higher for small coins and endoscopic removal rates were higher for large coins (p<0.001). The rate of emergency endoscopy was significantly higher in cases who swallowed a 2.6 cm coin (p<0.001). It was found that all sharp/pointed objects located in the intestine on admission came out spontaneously without complications. Sharp/pointed objects and button batteries located in areas accessible by esophagogastroduodenoscopy were more frequently removed using the endoscopic technique (p<0.001). In the cases with the ingestion of a single magnet or superabsorbent FB (giant growing toys), the FB came out with spontaneous passage without any adverse clinical outcome. Conclusion: It can be suggested that this study of a large sample, showing the management of FBs without complications, will be of guidance in clarifying controversial aspects of the treatment.

Foreign Body Ingestion among Children of Northern Sarawak: A Retrospective Single Centre Experience

Foreign body ingestion (FBI) is a common problem among children around the world. The management modality may differ according to the materials and clinical presentation. This study aims to assess the clinical, endoscopic, and therapeutic aspects of this FBI among children in a district hospital in northern Sarawak. A single-centre retrospective study was conducted for FBI in children of northern Sarawak from January 2018 until April 2020. A total number of 36 children were admitted during the 28 months duration with a 19:17 ratio of male:female. The children were between the age of 8 months and 10 years old with a median age of 4 ± 0.3 yrs. Coins (52%), fish bones (11%), and batteries (5%) were the most commonly ingested objects. The clinical features included asymptomatic presentation (47%), vomiting (36%), throat pain (8%), and choking sensation (8%). Routine radiological examination ensured the discovery of the FBI in 88% of the cases. Among the 36 children admitted, 19 (52%) children were managed conservatively while 17 (47%) children required endoscopic removal of foreign bodies without operative management. The length of stay in the hospital ranges from 1 day to 9 days (mean 2.52 days). FBI in children is more common at a younger age. Clinical findings depend on the shape of the ingested materials, the patient’s age, and the time of referral as they mostly could be managed conservatively. Upon failure of a conservative approach, a safe and uncomplicated removal should be performed.

Foreign Body Ingestion in Children Complicated by Duodenal Perforation: Case Report

Ingestion of a foreign body (FB) is a common accident among children. The majority of ingested foreign bodies are eliminated spontaneously and few of them leads to some rare but serious complication such as complication that requires urgent surgical management. In this article we report the case of an accidental nail ingestion in a 2 years old child complicated with a duodenal perforation. Emergency surgical care was performed, with nail removal and duodenal primary closure. The follow-up was uneventful and the recovery was smooth.