Intact Esophagus Research Articles

Chronic stridor in a toddler after ingestion of a discharged button battery: a case report

BackgroundButton battery (BB) ingestions (BBI) are increasingly prevalent in children and constitute a significant, potentially life-threatening health hazard, and thus a pediatric emergency. Ingested BBs are usually charged and can cause severe symptom within 2 h. Discharged BBs ingestion is very rare and protracted symptom trajectories complicate diagnosis. Timely imaging is all the more important. Discharged BBs pose specific hazards, such as impaction, and necessitate additional interventions.Case presentationWe present the case of a previously healthy 19-month-old girl who was admitted to our pediatric university clinic in Germany for assessment of a three-month history of intermittent, mainly inspiratory stridor, snoring and feeding problems (swallowing, crying at the sight of food). The child’s physical examination and vital signs were normal. Common infectious causes, such as bronchitis, were ruled out by normal lab results including normal infection parameters, negative serology for common respiratory viruses, and normal blood gas analysis, the absence of fever or pathological auscultation findings. The patient’s history contained no evidence of an ingestion or aspiration event, no other red flags (e.g., traveling, contact to TBC). Considering this and with bronchoscopy being the gold standard for foreign body (FB) detection, an x-ray was initially deferred. A diagnostic bronchoscopy, performed to check for airway pathologies, revealed normal mucosal and anatomic findings, but a non-pulsatile bulge in the trachea. Subsequent esophagoscopy showed an undefined FB, lodged in the upper third of the otherwise intact esophagus. The FB was identified as a BB by a chest X-ray. Retrieval of the battery proved extremely difficult due to its wedged position and prolonged ingestion and required a two-stage procedure with consultation of Ear Nose Throat colleagues. Recurring stenosis and regurgitation required one-time esophageal bougienage during follow-up examinations. Since then, the child has been asymptomatic in the biannual endoscopic controls and is thriving satisfactorily.ConclusionThis case describes the rare and unusual case of a long-term ingested, discharged BB. It underscores the need for heightened vigilance among healthcare providers regarding the potential hazards posed by discharged BBIs in otherwise healthy children with newly, unexplained stridor and feeding problems. This case emphasizes the critical role of early diagnostic imaging and interdisciplinary interventions in ensuring timely management and preventing long-term complications associated even to discharged BBs.

Conservative treatment of iatrogenic tracheal rupture (clinical case)

The objective was to demonstrate a clinical case of iatrogenic injury of the trachea, which, despite its large size (length 65, width up to 25 mm), wastreated conservatively and, thus, avoided risks for the patient associated with the need for technically complex surgical intervention.Materials and methods. A 65-year-old patient diagnosed with peripheral cancer of the lower lobe of the left lung pT2aN0M0 stage IB, who routinely underwent thoracoscopic left lower lobectomy with mediastinal lymph node dissection. During anesthesia, tracheal intubation with a double-lumen tube of the R. Shaw type was carried out with technical difficulties; during intubation, a defect in the posterior wall of the trachea in its membranous part was formed. The defect was diagnosed on the first postoperative day.Results. Despite the large size of the tracheal defect, the patient had no symptoms of respiratory failure, and there were also no signs of mediastinitis or damage to the esophagus, which almost completely covered the resulting hole in the posterior wall of the trachea. Such circumstances made it possible to avoid a potentially dangerous and complex surgical intervention, carry out conservative therapy and wait for the resulting defect to heal through granulation tissue. Enhanced antimicrobial therapy was carried out; in order to sanitize the tracheobronchial tree and monitor healing, fiber-optic bronchoscopy was performed, which made it possible to clearly demonstrate both the damage itself and the stages of its healing.Conclusions. The described case clearly demonstrates the potential for healing of even very extensive tracheal wall defects with conservative therapy. However, it is important to note that success in this clinical case was the result of a combination of circumstances – only the membranous part of the trachea was damaged; the defect was almost completely covered by the intact esophagus, which reduced the risk of developing mediastinitis and prevented the development of severe pneumomediastinum and subcutaneous emphysema. There were no signs of respiratory failure. The patient was transferred from the intensive care unit on the 13th day of the postoperative period, discharged from the hospital on the 22nd day.

RECREATIONAL NITROUS OXIDE INHALATION AS AN UNUSUAL CAUSE OF SPONTANEOUS PNEUMOMEDIASTINUM AND PNEUMORRHACHIS SECONDARY TO BAROTRAUMA

RECREATIONAL NITROUS OXIDE INHALATION AS AN UNUSUAL CAUSE OF SPONTANEOUS PNEUMOMEDIASTINUM AND PNEUMORRHACHIS SECONDARY TO BAROTRAUMA

Dynamic esophageal patency assessment: an effective method for prenatally diagnosing esophageal atresia

Esophageal atresia is a major anomaly with a low prenatal detection rate. We propose a sonographic method termed dynamic esophageal patency assessment. This study aimed to assess the feasibility and performance of the dynamic esophageal patency assessment in a high-risk population. A prospective study was conducted in a single tertiary fetal ultrasound unit for 12 months. The study group included pregnant women referred for a targeted scan because of one or more of the following: (1) polyhydramnios; (2) small or absent stomach; (3) vertebral, anal atresia, cardiac, tracheoesophageal fistula, renal, and limb abnormalities; (4) first-degree relative with esophageal atresia; and (5) genetic mutation associated with esophageal atresia. In addition to dynamic esophageal patency assessment, a comprehensive anomaly scan was carried out. The fetal esophagus was observed during swallowing. Cases that demonstrated uninterrupted fluid propagation through the esophagus were classified as normal. Cases that demonstrated interrupted fluid propagation, with the formation of a pouch, were classified as abnormal. Cases with unclear visualization of the esophagus or cases that failed to demonstrate either fluid propagation or a pouch were classified as undetermined. Dynamic esophageal patency assessment results were compared with postnatal findings, considered "gold standard." Test performance indices and intra- and interobserver agreements were calculated. For 12 months, 130 patients were recruited, and 132 fetuses were scanned. The median gestational age (interquartile range) at the time of scan was 31.4 weeks (29.0-35.3). Of 132 fetuses enrolled, 123 (93.2%) were normal, 8 (6%) were abnormal, and 1 (0.8%) was undetermined. Excluded from test performance analysis were 3 cases that were terminated without postmortem autopsy (1 was abnormal and 2 were normal), and a fourth case was excluded as it was classified as undetermined. The detection rate of esophageal atresia was 100%, with no false-positive or false-negative case. Sensitivity, specificity, and positive and negative predictive values of the dynamic esophageal patency assessment were 100%. The Kappa coefficient was 1 for both inter- and intraobserver agreements (P<.0001). The median time (interquartile range) required to complete the dynamic esophageal patency assessment was 6.00 minutes (3.00-13.25). The dynamic esophageal patency assessment is a feasible and highly effective method of ascertaining an intact esophagus and detecting esophageal atresia in suspected cases.

3D biomechanical properties of the layered esophagus: Fung-type SEF and new constitutive model.

Most current studies on the passive biomechanical properties of esophageal tissues directly use the exponential strain energy function (SEF) to fit and calculate the constants of the constitutive equation. In the context of the extensive application of exponential SEF, in-depth research on the exponential SEF is still lacking. The purpose of this study is to combine the exponential function with the polynomial SEF to obtain the most suitable constitutive equation to describe the three-dimensional passive behavior of the esophagus. fresh pig esophagus with a length of 13cm in the middle position was selected as esophageal samples. The esophageal sample was separated into muscular layer and mucosal layer with surgical scissors. Stretch-inflation mechanical tests of the intact esophagus, esophageal muscular, and esophageal mucosa were carried out on a triaxial test machine. The external radius, axial force, and internal pressure were recorded simultaneously. The seven-parameter Fung-type SEF and several new SEFs combining polynomials and exponents were used to fit the experimental data curves. The stretch-inflation test data and the morphometric parameters at the zero-stress state of the layered esophagus were obtained. The new SEF with polynomial and exponential combination is more suitable to describe describing the three-dimensional passive biomechanical properties of esophageal tissue. Among them, New-Fung13 SEF is more suitable for describing the passive biomechanical properties of intact esophageal tissue, Sokolis-Fung13 SEF is more suitable for the esophageal muscle layer, and New-Fung10 SEF is more suitable for the esophageal mucosa. The constitutive parameters of the optimal constitutive model for each layer of the esophagus were obtained.

Creation of a High Fidelity, Cost Effective, Real World Surgical Simulation for Surgical Education

Background How do surgical residents learn to operate? What is a surgical plane? How does one learn to see and dissect the plane? How do surgical residents learn tissue handling and suturing (sewing)? One method to learn and practice performing surgery is through the use of simulation training. Surgical training models include laparoscopic box trainers (a plastic box with holes for instruments) with synthetic materials inside to simulate tissues, or computer-based virtual reality simulation for laparoscopic, endoscopic, and robotic techniques. These methods, however, do not use real tissues. They lack the haptic and kinesthetic feedback of real tissue. These simulations fail to recreate the fidelity of soft tissues, do not foster the ability to accurately see surgical planes, do not accurately mimic the act of dissecting surgical planes, do not allow for complex surgical procedures, and do not provide accurate experience to learn tissue handling and suturing. Despite their poor performance, these plastic and virtual trainers are extremely costly to purchase, maintain, and keep up to date - with prices starting at $700 for basic plastic training boxes to thousands of dollars for virtual simulation. Also, there are additional costs of maintenance and software curriculum. Despite the cost of software, virtual simulators do not include a simulation for every surgery. Our aim was to create a life-like surgical simulation as close to real world as possible that allows trainees to learn how to see and dissect surgical planes, learn how soft tissues move, and learn the dynamics of soft tissue manipulation. We created a laparoscopic simulator using porcine tissues for gallbladder removal, acid reflux surgery, and surgery to treat swallowing difficulties (cholecystectomy, Nissen fundoplication, and Heller myotomy, respectively). Second year general surgery residents were able to practice these procedures on real tissues, enabling them to learn the steps of each procedure, increase manual dexterity, improve use of laparoscopic equipment, all while maintaining life-like haptic, soft-tissue feedback and enabling them to develop the ability to see real surgical planes. Methods The abdomen was recreated by purchasing intact porcine liver, gallbladder, (Cholecystectomy simulation) and intact esophagus, stomach, and diaphragm (Nissen and Heller simulation) from a packing supplier. Each organ system was placed into a laparoscopic trainer box with the ability to re-create laparoscopic ports. Surgical residents were then able to perform the procedures using real laparoscopic instruments, laparoscopic camera/video imaging, and real-time electrocautery. The simulation included all critical steps of each procedure such as obtaining the critical view of safety and removing the gallbladder from the liver bed (cholecystectomy), wrapping the stomach around the esophagus and laparoscopic suturing (Nissen fundoplication), and dissecting the muscular portion of the esophageal wall (Heller myotomy). Because these porcine tissues were readily available, several stations were set-up to teach multiple residents during each session (10-12 residents / session). Discussion Surgeons develop haptic perception of soft tissues by cutaneous or tactile feedback and kinesthetic feedback (Okamura, 2009). Kinesthetic feedback is the force and pressure transmitted by the soft tissues along the shaft of the laparoscopic instruments (Okamura, 2009). This soft tissue simulation re-creates the ability to experience what soft tissue feedback feels like, outside a normal operative environment. Real tissue learning allows trainees to learn how to see surgical planes, learn how soft tissues feel and move, develop proficiency in surgical dissection, and learn how to suture laparoscopically. This is the only model that recreates the movement of soft tissues and visualization of dissection planes outside the operative environment. Because this model utilizes the laparoscopic instruments used in the operating room, residents also develop familiarity with laparoscopic instruments, thus, flattening another learning curve. A literature review found that this is the only real tissue simulation being performed for foregut procedures used specifically for resident training. By building a realistic, anatomical model with inherent accurate soft tissue surgical planes, surgical trainees can have a more realistic surgical experience and develop skills in a safe, low pressure environment without sacrificing the hepatic learning and surgical visualization that is critical to performing safe laparoscopic surgery. All residents that participated in the stimulation reported positive feedback and felt that is contributed to their surgical education.

Esophageal stress softening recovery is altered in STZ-induced diabetic rats

This study investigated stress softening recovery in intact, separated muscle and mucosa-submucosa esophageal tubes in streptozotocin-induced diabetic rats. Fifteen Wistar rats were made diabetic (DM group) by intraperitoneal injection of 50 mg kg−1 streptozotocin and another 11 rats served as Sham group by injection of saline. All rats survived for 8-weeks. Three series of inflation-deflation loadings at luminal pressure levels of 0.5, 1.0 and 2.0 kPa were carried out on different esophageal tubes. Five distension cycles on each pressure level were done in Ca++-free Krebs solution before and after KCl activation in Ca++-containing Krebs solution. The wall stiffness and stored energy recovery were compared between two groups. The stiffness was biggest in the DM group for the intact tube at pressure 0.5 kPa (P < 0.01) and for the muscle tube at all pressure levels (P < 0.05). Energy recovery induced by stress softening and stiffness loss recovery were significantly smaller in the DM group than in the Sham group for the intact esophagus and separated tubes at all pressure levels (P < 0.05, P < 0.01). In conclusion, the reversible stress softening and passive stiffness recovery were altered in STZ-induced diabetic rats. This study fills a gap in the knowledge about diabetes-induced esophageal remodeling.

Effect of glucocorticoid on IL-33 expression in esophageal carcinoma model mice and its related mechanism

Objective To investigate the effect of glucocorticoid (GC) on interleukin (IL)-33 expression in esophageal carcinoma model mice. Methods A total of 18 BALB/c mice were randomly divided into three groups such as Model group, GC group and control group. The mice in Model group drank the concentration of 100 μg/ml 4NQO solution for 16 weeks, then drank sterilized water for injection to 24 weeks; The mice in GC group were injected Dexamethasone (400 μg/mouse) into abdominal cavity for 24 weeks on the basis of the mice in Model group; The mice in Control group drank propylene glycol solution for 16 weeks, then drank sterilized water for injection to 24 weeks. All of the mice were taken blood from tail vein every four weeks. Serum levels of IL-33 were detected by enzyme linked immunosorbent assay (ELISA) method. All mice were sacrificed after 24 weeks and then the quality of intact esophagus were weighed and compared. The expression of IL-33 and ST2 protein in esophageal tissues was detected by Western blotting, and the staining of IL-33 was observed by immunohistochemistry method. Results The esophageal weight in Model group, GC group and Control group was (4.75±1.78), (2.06±0.02) and (0.08±0.01) g, respectivetly. The differences was significantly between the each group (P<0.05). The expression of IL-33 and ST2 protein, the serum level of IL-33 in Model group were significantly higher than those in GC group and Control group. The differences were statistically significant (all P<0.05). The expression of IL-33 and ST2 protein, the serum level of IL-33 in GC group were significantly higher than those in Control group. The differences were also statistically significant (all P<0.05). IL-33 staining was the most frequent in the cytoplasm of epithelial cells of esophageal mucosa in Model group A, followed by GC and Control group. Conclusion IL-33 has a significant correlation with esophageal carcinoma and GC can inhibit tumor growth by inhibiting IL-33/ST2 signal transduction pathway. Key words: Esophageal carcinoma; Interleukin-33/ST2; Glucocorticoid

Friction behavior between endoscopy and esophageal internal surface

During gastrointestinal endoscopy, endoscopy is pushed into human digestive tract with the aid of outside force, which may cause a series of complications due to repeatedly inserting, rotating, pushing and retrieving operation. These are serious friction damage problems that few studies have focused on. In this paper, the friction behavior between the front-tip of gastroscopy and esophageal wall tissue during endoscopy was studied by using a UMT-II Micro-Tribometer. Fresh porcine esophagus of different anatomical sites (thoracic, abdominal and cervical esophagus) and layers in vitro was chosen as the tissue samples. The normal force was from 0.2 to 1.0N, the sliding speed was from 0.1 to 0.9mm/s, and the unidirectional sliding displacement was 22mm to simulate the endoscopy manipulation. Results showed that the typical “stick-slip” phenomena appeared in the process of the front-tip sliding on the esophageal internal surface, which was related to the alternating deformation, recovery as well as the energy dissipation of esophageal tissue. The friction coefficient decreased with the increasing normal load and increased with the increasing sliding speed. Since the physiological structure and mechanical property of esophagus were diverse in different anatomical sites and layers, there would be a lower friction coefficient in the thoracic esophagus compared with the cervical and abdominal esophagus. Besides, the friction coefficient in intact esophagus was larger than that in layered esophagus. The results can provide the basic data for safety operation and damage control during gastrointestinal endoscopy.

Diabetes-induced mechanophysiological changes in the esophagus.

Esophageal disorders are common in diabetes mellitus (DM) patients. DM induces mechanostructural remodeling in the esophagus of humans and animal models. The remodeling is related to esophageal sensorimotor abnormalities and to symptoms frequently encountered by DM patients. For example, gastroesophageal reflux disease (GERD) is a common disorder associated with DM. This review addresses diabetic remodeling of esophageal properties and function in light of the Esophagiome, a scientifically based modeling effort to describe the physiological dynamics of the normal, intact esophagus built upon interdisciplinary approaches with applications for esophageal disease. Unraveling the structural, biomechanical, and sensory remodeling of the esophagus in DM must be based on a multidisciplinary approach that can bridge the knowledge from a variety of scientific disciplines. The first focus of this review is DM-induced morphodynamic and biomechanical remodeling in the esophagus. Second, we review the sensorimotor dysfunction in DM and how it relates to esophageal remodeling. Finally, we discuss the clinical consequences of DM-induced esophageal remodeling, especially in relation to GERD. The ultimate aim is to increase the understanding of DM-induced remodeling of esophageal structure and sensorimotor function in order to assist clinicians to better understand the esophageal disorders induced by DM and to develop better treatments for those patients.

Pursestring Stapled Anastomotic Technique for Minimally Invasive Ivor Lewis Esophagectomy

We describe a pursestring stapled anastomotic technique for minimally invasive Ivor Lewis esophagectomy, in which a pursestring is hand sewn through the muscular layer of the intact esophagus by using one piece of 3-0 Prolene suture. The anvil of a circular stapler is inserted through an esophageal incision, 2 to 3 cm distal to the pursestring, and secured by the pursestring. The esophagus is transected, and the mucosa of the proximal stump is retained 5 mm longer than the adjacent muscular layer. The gastroesophageal anastomosis is completed and embedded by using the previously reserved 2 cm of mediastinal pleura.

IL-25-Induced Immunotherapy Against Obesity and the Associated Metabolic Syndrome

Background/Aim: UES contractile reflex was described in 1957 by Creamer and Schlegel. The physiological role of this reflex in preventing pharyngeal reflux of gastric content and protecting the airway has been studied extensively. However, to date the defect of this reflex has not been described. Our aim was to characterize the UES pressure response to a variety of esophageal distensions in a group of patients with complaints of regurgitation and refluxattributed supraesophageal complications. Methods: We studied 8 patients (51 ± 20 yrs., 2F) with complaints of regurgitation and supraesophageal symptoms as well as 12 healthy asymptomatic controls (25 ± 5 yrs., 6F) in the supine position. Of the 8 patients, 6 had an intact esophagus, 1 had colonic interposition, and 1 had a partial esophagectomy and gastric pull-up. We tested the UES response to esophageal distension; simulating GE reflux by rapid and slow infusion of normal saline (10, 20, 30, and 60 mL) and air (10, 20, 30, 50 mL) and each injection was repeated 3 times. UES and esophageal pressures were monitored by high resolution intraluminal manometry. Pharyngeal reflux/regurgitation was monitored by high resolution esophagopharyngeal impedance recording. Patients were instructed to signal if pharyngeal reflux was perceived. Results: There were significant differences in the UES response to rapid and slow fluid injections between patients and controls (Chi-square< 0.0001) (Table). All patients but none of the controls reported pharyngeal reflux during slow and rapid esophageal fluid infusion. UES contraction(C) was absent during slow infusion only in patient group. Pharyngeal reflux was documented by impedance in six of eight patients with intact esophagus. All rapid fluid infusions produced UES contraction in the control group, while only 70-75% of rapid fluid infusions produced a UES contraction in patients. UES response to air distension, however, was relaxation(R) in both groups. Conclusions: UES contractile response to slow esophageal fluid distention is defective in patients with complaints of regurgitation and supraesophageal complications, allowing escape of refluxate into the pharynx. UES response to esophageal slow fluid infusion can serve as a test for recognizing this defect.

Glial Cell Line Derived Neurotrophic Factor Prevents High Fat Diet Induced Obesity

Background/Aim: UES contractile reflex was described in 1957 by Creamer and Schlegel. The physiological role of this reflex in preventing pharyngeal reflux of gastric content and protecting the airway has been studied extensively. However, to date the defect of this reflex has not been described. Our aim was to characterize the UES pressure response to a variety of esophageal distensions in a group of patients with complaints of regurgitation and refluxattributed supraesophageal complications. Methods: We studied 8 patients (51 ± 20 yrs., 2F) with complaints of regurgitation and supraesophageal symptoms as well as 12 healthy asymptomatic controls (25 ± 5 yrs., 6F) in the supine position. Of the 8 patients, 6 had an intact esophagus, 1 had colonic interposition, and 1 had a partial esophagectomy and gastric pull-up. We tested the UES response to esophageal distension; simulating GE reflux by rapid and slow infusion of normal saline (10, 20, 30, and 60 mL) and air (10, 20, 30, 50 mL) and each injection was repeated 3 times. UES and esophageal pressures were monitored by high resolution intraluminal manometry. Pharyngeal reflux/regurgitation was monitored by high resolution esophagopharyngeal impedance recording. Patients were instructed to signal if pharyngeal reflux was perceived. Results: There were significant differences in the UES response to rapid and slow fluid injections between patients and controls (Chi-square< 0.0001) (Table). All patients but none of the controls reported pharyngeal reflux during slow and rapid esophageal fluid infusion. UES contraction(C) was absent during slow infusion only in patient group. Pharyngeal reflux was documented by impedance in six of eight patients with intact esophagus. All rapid fluid infusions produced UES contraction in the control group, while only 70-75% of rapid fluid infusions produced a UES contraction in patients. UES response to air distension, however, was relaxation(R) in both groups. Conclusions: UES contractile response to slow esophageal fluid distention is defective in patients with complaints of regurgitation and supraesophageal complications, allowing escape of refluxate into the pharynx. UES response to esophageal slow fluid infusion can serve as a test for recognizing this defect.

Molecular imaging via novel application of fluorescent lectins permits rapid endoscopic identification of dysplasia in barrett's oesophagus

IntroductionEarly detection of oesophageal adenocarcinoma (AC) or high grade dysplasia (HGD) improves prognosis but may missed at endoscopy.HypothesisGlycosylation alterations in the progression to AC could be detected using lectins to...

Porcine Small Intestine Submucosa Matrix (Surgisis) for Esophageal Perforation

We present a case of traumatic cervical esophageal perforation complicated by delayed diagnosis and foreign body presence successfully repaired with acellular matrix biomaterial made from porcine submucosa (Surgisis mesh [Wilson-Cook, Winston-Salem, NC]). With metal plating eroding into the esophagus from a spinal fixation procedure, the mesh was applied to the defect just under the cricopharyngeus. The patient re-commenced oral intake after 7 days, and an endoscopy at 4 weeks revealed a well-incorporated mesh in an intact esophagus with normal caliber. In this case, Surgisis mesh (Wilson-Cook) proved effective in providing temporary esophageal integrity to allow healing in an infected field where diversion was impossible.

Strain-energy function and three-dimensional stress distribution in esophageal biomechanics

Knowledge of the transmural stress and stretch fields in esophageal wall is necessary to quantify growth and remodeling, and the response to mechanically based clinical interventions or traumatic injury, but there are currently conflicting reports on this issue and the mechanical properties of intact esophagus have not been rigorously addressed. This paper offers multiaxial data on rabbit esophagus, warranted for proper identification of the 3D mechanical properties. The Fung-type strain-energy function was adopted to model our data for esophagus, taken as a thick-walled (1 or 2-layer) tubular structure subjected to inflation and longitudinal extension. Accurate predictions of the pressure–radius–force data were obtained using the 1-layer model, covering a broad range of extensions; the calculated material parameters indicated that intact wall was equally stiff as mucosa–submucosa, but stiffer than muscle in both principal axes, and tissue was stiffer longitudinally, concurring our histological findings (Stavropoulou et al., Journal of Biomechanics. 42 (2009) 2654–2663). Employing the material parameters of individual layers, with reference to their zero-stress state, a reasonable fit was obtained to the data for intact wall, modeled as a 2-layer tissue. Different from the stress distributions presented hitherto in the esophagus literature, consideration of residual stresses led to less dramatic homogenization of stresses under loading. Comparison of the 1- and 2-layer models of esophagus demonstrated that heterogeneity induced a more uniform distribution of residual stresses in each layer, a discontinuity in circumferential and longitudinal stresses at the interface among layers, and a considerable rise of stresses in mucosa, with a reduction in muscle.

Public Health and Potential Complications of Novel Fashion Accessories: An Unusual Foreign Body in the Upper Gastrointestinal Tract of an Adolescent

Various foreign bodies (FB) may be ingested. Most of them harmlessly pass through the anus but sharp or pointed ones are likely to cause complications. Although FB's ingestion is commonly seen by the emergency room personnel, a case of an ingested tongue-ring in the stomach of a female adolescent has not been reported. A 16-year-old female was referred to us for swallowing a tongue-ring while eating, a day after she had swallowed its clip. After finishing her meal, she had replaced the ingested tongue-ring with a similar one! She had a history of accidental swollowing the clip during breakfast a day before as well. She had no history of mental illness, alcohol or drug abuse. An abdominal X-ray confirmed their presence in the gastrointestinal tract. On endoscopy, an intact esophagus' mucosa, a stomach filled with food, her tongue-ring in its greater curvature and a patulous pyloric channel were observed. She was turned in the right lateral position and small amounts of water were carefully used in order to shift the food residues to the antrum. The slippery object was grasped by a biopsy forceps and it was pulled out gently. The procedure was uneventful and she was discharged home on the same day. Our case of a tongue-ring ingested by an adolescent demonstrates a troublesome and possibly dangerous consequence of certain fashion accessories' easy adoption especially by younger subjects. It does not only send a social message, but it also might represent the first example of a potentially emerging medical condition.

Long gap esophageal atresia: lengthening technique and primary anastomosis

Objective The treatment of long gap esophageal atresia remains a major surgical challenge. The authors describe a modification of a lengthening technique based on tissue expansion to avoid sutures cutting through the esophagus. Methods Between January 2004 and August 2006, 4 patients did not respond to stretching, and underwent this modified esophageal lengthening technique using silastic tubes. Results and Follow-up All infants recovered and have an intact esophagus. All infants developed gastroesophageal reflux. Thal antireflux procedure was performed in the first infant. The other 3 patients were managed conservatively. Follow-up ranged between 6 and 34 months. Conclusions The tissue expansion principle can be successfully applied in the esophagus through external traction. Silastic tube fixation at esophageal ends may help to apply even traction and avoid sutures cutting through the esophageal tissue.

Success and failure with neonatal tracheo-oesophageal anomalies

In seven and a half years, one surgical team treated 67 consecutive neonates with oesophageal atresia and/or tracheo-oesophageal fistula. According to Waterston's classification, 28 were in group A, 12 in group B and 27 in group C. The mortality rate during the initial admission was 10 per cent, all seven deaths being unavoidable in infants in group C with multiple anomalies. Birthweight alone had no bearing upon the chances of survival. Primary oesophageal repair, including one suture-fistula procedure and one delayed primary repair, was attempted in 54 (84 per cent) of the 64 patients with atresia and was successful in 46 (85 per cent). All three H-type tracheo-oesophageal fistulae were successfully divided in infants in group A. Recurrent tracheo-oesophageal fistula developed in four (7 per cent) infants, one of whom (group A) underwent successful repair. One disrupted anastomosis was successfully resutured (group A), so an intact oesophagus was finally achieved in 51 patients, of whom six (12 per cent) developed anastomotic strictures and 21 (41 per cent) underwent surgery for gastro-oesophageal reflux. Of the 60 early survivors, 10 (17 per cent) underwent aortopexy for tracheomalacia. Whenever possible, primary repair is advocated in all infants. Even for those in group C with multiple, severe associated anomalies, the combined early and late mortality was no greater following primary repair (7 died of 12 operated) than after staged repair (4 died of 7 operated), but major anastomotic complications were more common in infants in group C (5 out of 19) than in those in groups A and B (3 out of 38).

Biomechanical properties of the layered oesophagus and its remodelling in experimental type-1 diabetes

Passive biomechanical properties in term of the stress–strain relationship and the shear modulus were studied in separated muscle layer and mucosa–submucosa layer in the oesophagus of normal and STZ (streptozotocin)-induced diabetic rats. The mucosa–submucosa and muscle layers were separated using microsurgery and studied in vitro using a self-developed test machine. Stepwise elongation and inflation plus continuous twist were applied to the samples. A constitutive equation based on a strain energy function was used for the stress–strain analysis. Five material constants were obtained for both layers. The mucosa–submucosa layer was significantly stiffer than the muscle layer in longitudinal, circumferential and circumferential–longitudinal shear direction. The mechanical constants of the oesophagus show that the oesophageal wall was anisotropic, the stiffness in the longitudinal direction was higher than in the circumferential direction in the intact oesophagus ( P < 0.001 ) and in the muscle layer ( P < 0.05 ). Diabetes-induced pronounced increase in the outer perimeter, inner perimeter and lumen area in both the muscle and mucosa–submucosa layer. The growth of the mucosa–submucosa layer ( P < 0.001 ) was more pronounced than the muscle layer ( P < 0.05 ). Furthermore, the circumferential stiffness of the mucosa–submucosa layer increased 28 days after STZ treatment. In conclusion, the oesophagus is a non-homogeneous anisotropic tube. Thus, the mechanical properties differed between layers as well as in different directions. Morphological and biomechanical remodelling is prominent in the diabetic oesophagus.