Lower Esophageal Segment Research Articles

Pediatric Eosinophilic Esophagitis is Associated With Low Baseline Impedance.

Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder that requires repeat endoscopic evaluation(s) to assess response to treatment. This results in high health care costs and a procedural burden in affected children. Noninvasive alternate modalities to reassess disease activity have not been established. Low baseline impedance measured by multichannel pH impedance (pH-MII) is seen in adults with EoE, in keeping with poor mucosal integrity. We aimed to investigate the relationship between esophageal eosinophilia (or severity of eosinophilic infiltration) and baseline impedance in children with EoE. We retrospectively identified 15 children diagnosed with EoE at our institution who had undergone pH-MII within 30 days of 3-level esophageal biopsy. This group were not concurrently prescribed proton pump inhibitors and had negligible reflux parameters on pH-MII. Average impedance baseline was calculated upper, mid, and lower esophageal segments via baseline impedance automated analysis (RIAA) and mean nocturnal baseline impedance (MNBI) methods. Eosinophil count data for upper, mid, and lower esophageal segments in the EoE group was collated. A significantly lower baseline impedance was seen across the esophageal length in children with EoE, compared with 30 controls who had no differences in age or reflux burden on nonparametric testing. A relationship between baseline impedance and eosinophil number at corresponding esophageal segments was not established. Baseline impedance may be an important, less invasive adjunct in clinical practice to monitor treatment response in children with EoE. Larger prospective cohort studies should delineate optimally predictive baseline impedance thresholds for active and inactive disease.

Esophageal elongation using Foley catheter in long-gap esophageal atresia

Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a rare congenital anomaly that poses major surgical challenges, particularly when the distance between the two esophageal ends exceeds 3 cm. Many surgical techniques are advocated for bridging the gap between the two esophageal ends. In this paper, we propose a simple and effective technique to elongate the esophagus in the long gap EA. This technique has successfully been applied in two infants with type C EA/TEF, where a primary end to end esophageal anastomosis was not feasible. The technique uses two Foley catheters for traction of upper and lower esophageal ends in long-gap EA/TEF. This method helps preserve the native esophagus, providing comfortable suction of the upper esophageal pouch, and assuring postoperative continuous feeding through the lower esophageal segment.

A rapid, computational approach for assessing interfraction esophageal motion for use in stereotactic body radiation therapy planning

PurposeWe present a rapid computational method for quantifying interfraction motion of the esophagus in patients undergoing stereotactic body radiation therapy on a magnetic resonance (MR) guided radiation therapy system. Methods and materialsPatients who underwent stereotactic body radiation therapy had simulation computed tomography (CT) and on-treatment MR scans performed. The esophagus was contoured on each scan. CT contours were transferred to MR volumes via rigid registration. Digital Imaging and Communications in Medicine files containing contour points were exported to MATLAB. In-plane CT and MR contour points were spline interpolated, yielding boundaries with centroid positions, CCT and CMR. MR contour points lying outside of the CT contour were extracted. For each such point, BMR(j), a segment from CCT intersecting BMR(j), was produced; its intersection with the CT contour, BCT(i), was calculated. The length of the segment Sij, between BCT(i) and BMR(j), was found. The orientation θ was calculated from Sij vector components:θ = arctan[(Sij)y / (Sij)x]A set of segments {Sij} was produced for each slice and binned by quadrant with 0° < θ ≤ 90°, 90° < θ ≤ 180°, 180° < θ ≤ 270°, and 270° < θ ≤ 360° for the left anterior, right anterior, right posterior, and left posterior quadrants, respectively. Slices were binned into upper, middle, and lower esophageal (LE) segments. ResultsSeven patients, each having 3 MR scans, were evaluated, yielding 1629 axial slices and 84,716 measurements. The LE segment exhibited the greatest magnitude of motion. The mean LE measurements in the left anterior, left posterior, right anterior, and right posterior were 5.2 ± 0.07 mm, 6.0 ± 0.09 mm, 4.8 ± 0.08 mm, and 5.1 ± 0.08 mm, respectively. There was considerable interpatient variability. ConclusionsThe LE segment exhibited the greatest magnitude of mobility compared with the middle and upper esophageal segments. A novel computational method enables personalized, nonuniform esophageal margins to be tailored to individual patients.

Esophageal granular cell tumor: Clinical, endoscopic and histological features of 19 cases.

Esophageal granular cell tumors (GCTs) are rare and often misdiagnosed. To demonstrate their clinicopathological features, the present study reports 19 cases and reviews the literature. There were 11 female and eight male esophageal GCT patients with a median age of 42.0 years. All the tumors were solitary. The majority of patient indications for endoscopy (89.5%) were non-specific and endoscopic therapy was performed in 17 cases with a relapse in one case after a 12-month follow-up. The endoscopic appearance of esophageal GCT was variable and the majority of tumors (80.0%) were located in the middle and lower esophageal segments. The size of the tumors ranged from 0.4 to 2 cm in diameter and the surface was white-gray, pink or yellow. Nine patients underwent an endoscopic ultrasound exam, eight of which demonstrated hypoechoic echostructures with a smooth margin and intracavity growth features. One case was derived from the muscularis propria layer with an irregular margin and intra- and extra-cavity growth features. The histological features could mimic other tumors and immunohistochemical stains are usually positive for S-100, periodic acid-Schiff, neuron-specific enolase and nestin. Three cases indicated pleomorphism and Ki-67 was locally positive. Esophageal GCTs are rare and endoscopic ultrasound features are variable. Immunohistochemical staining may aid in the diagnosis.

Esophageal pulse oximetry is more accurate and detects hypoxemia earlier than conventional pulse oximetry during general anesthesia

The esophagus is perfused directly by prominent arteries and may provide a more consistent tissue source for pulse oximetry. The goal of this study was to evaluate the sensitivity and accuracy of an esophageal pulse oximetry probe on patients during controlled hypoxemia in comparison to measurements obtained with conventional pulse oximetry (SpulseO(2)). Forty-five ASA I-II adult patients were included in this prospective observational study. Nellcor digital oximetric probes were placed on finger tips for SpulseO(2) before anesthesia. After tracheal intubation, an esophageal probe was placed in the lower segment of the esophagus for esophageal oximetric monitoring (SoesO(2)). All patients were disconnected from the breathing circuit to establish a controlled hypoxemia, and were re-connected to the breathing circuit and ventilated with 100% oxygen immediately when SoesO(2) dropped to 90%. Matched SoesO(2) and SpulseO(2) readings were recorded when SoesO(2) measurements were at 100%, 95%, 90% and the lowest reading. The time for SoesO(2) and SpulseO(2) to drop from 100% to 95%, 90% and return to 100% was recorded. Oxygen saturation from arterial blood samples (SartO(2)) was also measured at each time point respectively. The linear correlation coefficient of the regression analysis between SartO(2) and SoesO(2) was 0.954. The mean ± 2SD of the difference was 0.3% ± 4.3% for SoesO(2) vs. SartO(2) and 6.8% ± 5.6% for SpulseO(2) vs. SartO(2) (P < 0.001). The 95% confidence interval for the absolute difference between SoesO(2) and SartO(2) was 0.3% to 0.7% and 6.2% to 7.4% between SpulseO(2) and SartO(2). The time to reach 90% saturation measured with SoesO(2) was approximately 94 seconds earlier than the SpulseO(2) (P < 0.001). In conclusion, SoesO(2) is more accurate and enables earlier detection of hypoxemia when compared to conventional pulse oximetry during hypoxemia for patients undergoing general anesthesia.

Analysis of risk factors for upper gastrointestinal cancer in China: a multicentric population-based case-control study

To explore the major risk factors for upper gastrointestinal cancer in high occurrence areas of esophageal and gastric cancer in China. Four high occurrence areas of esophageal cancer, namely Cixian and Shexian from Hebei province, Linxian from Henan province, Feicheng from Shandong province, and Zhuanghe from Liaoning province, which is a high occurrence area of gastric cancer, were selected for the study. The newly-diagnosed cases whose date of onset were after January 1st, 2009 were selected from the Cancer Registration Database in each district, and 751 cases diagnosed as cancers in lower segment of esophagus, cardiac and other subsite of stomach were randomly recruited. 2253 matched controls were selected to pair the cases at the ratio of 3:1. The relative information of the study objects were collected from the face-to-face interviews with trained staff by designed questionnaires, and the data was input by EpiData software. Statistic software SPSS 13.0 was applied to conduct both univariate and multivariate logistic regression analysis to evaluate odd ratios (OR) and 95% confident interval (CI). As univariate analysis shown, 66 objects in case group had irregular diet habit; while 90 in control group had (OR = 3.177; 95%CI: 2.127 - 4.745). A higher percentage in case group (83 objects) preferred fried food in comparison with only 214 in control group did (OR = 3.190; 95%CI: 2.061 - 4.927). 369 objects in case group, but only 119 in control group had history of gastrointestinal diseases (OR = 14.660; 95%CI: 11.342 - 18.948). 282 objects in case group had history of gastroesophageal reflux disease (GERD), which was much higher than the percentage in control group (432 objects), with OR = 3.137 (95%CI: 2.546 - 3.864). All the above factors could increase the risk for upper gastrointestinal cancer. 387 objects in case group and 1278 in control group reported they preferred fresh vegetables in daily diet, which was found to be a protective factor (OR = 0.609; 95%CI: 0.473 - 0.785). As multivariate analysis shown, history of gastrointestinal tract diseases (OR = 21.420; 95%CI: 15.484 - 29.632), irregular food diet (OR = 3.097; 95%CI: 1.740 - 5.514), pickled food (OR = 3.005; 95%CI: 1.873 - 4.819), and GERD (OR = 2.261; 95%CI: 1.673 - 3.057) were found to be risk factors for upper gastrointestinal cancer; while frequent fresh-vegetable diet was a protective factor (OR = 0.562; 95%CI: 0.396 - 0.800). Irregular lifestyle and unhealthy diet habit could be the major risk factors for upper gastrointestinal cancers among the residents from high occurrence areas of esophageal cancer and gastric cancer in China.

Effect of positive end expiratory pressure on thermo-regulatory function during general anesthesia in patients addicted to smoking

Objective To investigate the effect of positive end expiratory pressure (PEEP) on thermo-regulatory function during general anesthesia in patients addicted to smoking. Methods Twenty adult male ASA Ⅰ or Ⅱ patients who had been smoking more than or equal to 10 cigarettes per day for more than or equal to 6 years were studied. The patients underwent intra-abdominal surgery under general anesthesia and were randomly divided into 2 groups ( n = 10 each): control group (group C) and PEEP group (group P). Anesthesia was induced with propofol, fentanyl and vecuronium and maintained with inhalation of 1%-2% isoflurane and continuous iv infusion of remifentanil and vecuronium. The patients were mechanically ventilated after tracheal intubation. In group P PEEP of 10 cm H2O was added. Temperature probe was inserted into the lower segment of esophagus and placed on the anterior chest wall, medial surface of thigh anterior surface of forearm and palmar surface of the tip of index finger. Mean skin temperature (TMSK) was calculated according to Roberts. MAP, HR, TES, TMSK and the difference between TES and TMSK (TES-MSK) were recorded before induction of anesthesia (T0 ,baseline) and every 30 min after tracheal intubation. Esophageal temperature was taken as threshold of thermo-regulatory peripheral vasoconstriction when the difference between forearm and finger tip temperature = 0 ℃. The gain in the threshold was calculated according to Sessler. Results TES and TES-MSK significantly decreased,while TMsK increased after tracheal intubation in both groups ( P ＜ 0.05). There was no signifieant difference in TES, TMSK, TES-MSK, MAP, HR, the threshold of vasoconstriction and gain between the 2 gronps ( P ＞ 0.05). Conclusion PEEP cannot improve thermo-regulatory function during general anesthesia in smoking-addicted patients. Key words: Respiration, artificial; Body temperature regulation; Smoking; Anesthesia,general

In vitro Effect of Bethanechol and Suberyldicholine on Regions of Guinea Pig Esophagus

Tissue engineering and regenerative medicine is envisaged as the future option for esophageal replacement; however, engineering of a functional esophagus is impeded by the limited understanding of the anatomical complexity of this dynamic muscular organ. The aim of this study was to characterize the function of native esophageal tissue and determine differences in functional response to stimulation between anatomical sites. The in-vitro response of guinea pig esophageal preparations, from various anatomical sites, to muscle agonists was investigated. Esophageal strips were exposed to bethanechol, an agonist of muscarinic receptors located on smooth muscle, and suberyldicholine, an agonist of nicotinic receptors located on striated muscle, within a Schuler organ bath, to determine the contractile response on the various segments of the esophagus. The esophagus responded in a reliable and consistent manner to agonist stimulation. Bethanechol dose response curves were constructed with doses of 10 to 300 μM. The average maximal contractions to bethanechol exposure were 4.51, 4.80, 5.55, and 9.15 mN for upper, upper middle, lower middle, and lower esophageal segments, respectively. Responses to singular stimulation with 30 μM suberyldicholine in thepresence of tetrodotoxin (100 μM) gave average contractions of 1.07, 0.84, 2.60, and 3.02 mN forupper,upper middle, lower middle, and lower esophageal segments, respectively. Bethanechol and suberyldicholine-induced responses were greater in the lower esophagus in comparison to the upper esophageal segments. These findings pave the way for the use of an in-vitro bethanechol and suberyldicholine-induced contraction model for future assessment of engineered esophageal tissue.

Combination of Spit Fistula Advancement and External Traction for Primary Repair of Long-Gap Esophageal Atresia

Primary repair of long-gap esophageal atresia with almost complete absence of thoracic esophagus was usually believed to be impossible. Thus, esophageal replacement with colon or gastric interposition seemed inevitable. Esophageal lengthening techniques could be an alternative approach. Herewith we describe for the first time the successful combination of the stepwise subcutaneous advancement of the upper esophageal segment (Kimura's technique) with transthoracic traction on the lower esophageal segment (Foker's technique). This combined lengthening technique leads to the primary repair of a long-gap esophageal atresia.

Use of high-resolution endoscopic ultrasonography to examine the effect of tension on the esophagus during primary repair of long-gap esophageal atresia

We have shown that tension applied to the esophageal pouches in long-gap esophageal atresia allows primary repair without necessity for intestinal or gastric transposition. To determine whether the mural structure of the upper esophageal pouch is altered by tension. We examined the esophagus with high-resolution endoscopic ultrasonography. The upper pouch was examined before traction and the upper and lower esophagus were examined after primary repair. Of 11 patients examined, 7 were male. At initial surgery the age, weight and length of the patients (mean +/- SD) were 118 +/- 88 days, 4.7 +/- 1.2 kg and 54 +/- 4 cm, respectively. The gap length was 4.7 +/- 1.1 cm. The pretraction measurement of the muscularis propria of the upper pouch was similar to the postanastomotic measurement of the upper esophagus, and there was no statistically significant difference from the lower esophageal segments after anastomosis: 0.83 +/- 0.19, 0.80 +/- 0.15 and 0.81 +/- 0.22 mm, respectively (P = 0.90). The thickness of combined mucosa and submucosa was also very similar in all three measurements, respectively: 0.93 (0.21) mm vs. 1.06 (0.08) mm vs. 1.0 (0.11) mm (P = 0.14). The layers of the upper esophageal pouch are preserved in infants with esophageal atresia in whom esophageal length is increased with tension.

Is laryngopharyngeal reflux an important risk factor in the development of laryngeal carcinoma?

Laryngopharyngeal reflux (LPR) as a causative irritating factor in the development of laryngeal carcinoma has been suggested. However, the association between LPR and laryngeal carcinoma remains unclear. The aim of this study was to compare the prevalence and severity of reflux between patients with laryngeal carcinoma and clinical LPR. The intention was to find out if a correlation exists between the laryngeal findings and the level of acid reflux. The study population consisted of 29 patients with laryngeal cancer (group I), 33 LPR patients with normal laryngeal findings (group II) and 70 LPR patients with related laryngeal pathology (group III). The results of 24-h, double-channel ambulatory esophageal pH monitoring were analyzed comparing the three groups. The occurrence and severity of abnormal acid reflux at the upper and lower esophageal segments were evaluated. The incidence of LPR or gastroesophageal reflux (GER) did not vary in any of the three groups (LPR was present in 62, 42 and 56% of the patients, while GER was present in 45, 24 and 37% of the patients, respectively). Patients with LPR or GER from the three groups did not differ significantly in terms of the number of acid reflux episodes and percentage of times when the pH was <4. Our data do not support the hypothesis that LPR can be an independent risk factor in the development of larynx cancers. However, the data also do not thoroughly exclude the possibility. The reason why LPR leads to variable pathologies in the larynx may be uncovered by studies probing the differences between patients via detailed examinations of the local anti-reflux barriers such as epithelial morphology and functions.

Gastroesophageal reflux disease: symptoms versus pH monitoring results.

The reason why some patients with gastroesophageal reflux disease (GERD) have symptoms of upper aerodigestive system irritation, while others mainly have gastroenterologic symptoms, is not well established. This retrospective case series study was designed to examine the existence of a correlation between symptoms and reflux characteristics, based on data obtained from esophageal pH monitoring. The study population consisted of 139 patients; 97 patients presented with laryngopharyngeal symptoms of GERD, including unexplained hoarseness, throat clearing, chronic cough, laryngospasm, globus, throat pain, and 42 patients presented with gastroenterologic symptoms, including heartburn and regurgitation. The results of 24-hour, double-channel ambulatory esophageal pH monitoring were analyzed comparing 2 symptom groups. The incidence of abnormal acid reflux at the upper and lower esophageal segments and the effects of upright and supine positions on reflux parameters were evaluated. The incidence of laryngopharyngeal reflux was significantly higher in the laryngopharyngeal symptom group than in the other (52% versus 38%). The patients with laryngopharyngeal reflux from both groups showed no significant differences in terms of number of acid reflux episodes, percentage of times pH was 4, and esophageal acid clearance. Upright and supine parameters did not show significant differences between the patient groups. Upright acid reflux episodes were, however, common in both groups at the lower esophageal and laryngopharyngeal segments. Recent studies suggesting that otolaryngologic patients commonly show upright, daytime reflux with normal esophageal clearance and that typical GERD patients commonly have supine, nocturnal reflux with prolonged esophageal clearance are not supported by this study. This study indicates that acid reflux parameters and positional changes are not sufficient to explain why patients with GERD experience different symptoms. The regional symptoms of GERD may be attributed to the impairment of epithelial resistance, motor activity, and buffering systems for the esophageal antireflux barrier.

Gastroesophageal reflux disease: symptoms versus pH monitoring results

Objectives The reason why some patients with gastroesophageal reflux disease (GERD) have symptoms of upper aerodigestive system irritation, while others mainly have gastroenterologic symptoms, is not well established. This retrospective case series study was designed to examine the existence of a correlation between symptoms and reflux characteristics, based on data obtained from esophageal pH monitoring. Methods The study population consisted of 139 patients; 97 patients presented with laryngopharyngeal symptoms of GERD, including unexplained hoarseness, throat clearing, chronic cough, laryngospasm, globus, throat pain, and 42 patients presented with gastroenterologic symptoms, including heartburn and regurgitation. The results of 24-hour, double-channel ambulatory esophageal pH monitoring were analyzed comparing 2 symptom groups. The incidence of abnormal acid reflux at the upper and lower esophageal segments and the effects of upright and supine positions on reflux parameters were evaluated. Results The incidence of laryngopharyngeal reflux was significantly higher in the laryngopharyngeal symptom group than in the other (52% versus 38%). The patients with laryngopharyngeal reflux from both groups showed no significant differences in terms of number of acid reflux episodes, percentage of times pH was 4, and esophageal acid clearance. Upright and supine parameters did not show significant differences between the patient groups. Upright acid reflux episodes were, however, common in both groups at the lower esophageal and laryngopharyngeal segments. Conclusion Recent studies suggesting that otolaryngologic patients commonly show upright, daytime reflux with normal esophageal clearance and that typical GERD patients commonly have supine, nocturnal reflux with prolonged esophageal clearance are not supported by this study. This study indicates that acid reflux parameters and positional changes are not sufficient to explain why patients with GERD experience different symptoms. The regional symptoms of GERD may be attributed to the impairment of epithelial resistance, motor activity, and buffering systems for the esophageal antireflux barrier.

Study of controlling acute hemorrhage from esophageal varices rupture with technique of traditional Chinese medicine

Objective: To find a method for inducing Chinese drugs to adhere to the esophageal mucosa to control bleeding from ruptured esophageal varices.Methods: The site and time that the Chinese drugs adhere to esophageal mucosa were observed in 30 healthy volunteers under the specific condition of standing and lying posture. Seventy episodes bled with ruptured esophageal varices patients (treated group 36 episodes in 25 patients and control group 34 episodes in 27 patients) suffering from cirrhosis of liver were treated by the technique of drug adhesion.Results: (1) The adhesion of Chinese hemostatie drugs remained in the lower segment of esophagus for more than 15 minutes in lying posture, longer than that in standing posture (P 0. 05).Conclusion: This drug adhesion technique provides a new approach to control hemorrhage from ruptured esophageal Variees.

Mechanical studies of the esophageal function.

The discussion centers on the use of mechanical principles, mathematical modeling, and concurrent manometric and videofluoroscopic data to study the esophageal function. Basic principles of mechanics indicate that intrabolus pressure must be distinguished from the direct contractile squeeze of the circular muscle on the manometric assembly. Because these two regions are mechanically distinct, pressure amplitude is not a proper indicator of the forces characterizing esophageal bolus transport. In the application of computer simulations to the transport of a fluid bolus through the aortic arch regions, it was discovered that separate contraction waves must exist in the upper and lower esophageal segments when bolus retention occurs. Through detailed analysis of enhanced concurrent manometric and videofluoroscopic data in human volunteers, we have found that a dual-wave characteristic across the transition zone is a normal reflection of the change in muscle types, each muscle type producing a separate contraction wave. In normal transport, these two contraction waves are properly coordinated spatially and temporally. However, during bolus retention, a mismatch in space and time between these two waves takes place. Analysis suggests that this mismatch is neurological rather than histological in origin, and occurs primarily within the lower smooth-muscle segment.

Barrett Esophagus

Letters15 May 1991Barrett EsophagusN. Mullai, MD, Kulumani M. Sivarajan, MD, Gail Shiomoto, MDN. Mullai, MDSearch for more papers by this author, Kulumani M. Sivarajan, MDSearch for more papers by this author, Gail Shiomoto, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-114-10-913_1 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptTo the Editors: Sartori and colleagues (1) reported Barrett esophagus after chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil. The hypothesis was that the drugs induced mucosal erosions and ulcerations and re-epithelialization by undifferentiated stem cells that differentiated into various cell types characteristic of Barrett esophagus.However, it was unclear why these changes were noticed only in the lower esophageal segment rather than the entire esophagus, because mucositis has no predeliction for the lower esophagus. This suggests that gastroesophageal reflux, induced either by vomiting or disturbed functioning of the lower esophageal sphincter by the chemotherapeutic drugs, is the likely culprit for the...

A CASE OF ESOPHAGEAL LEIOMYOMA OCCURRING IN A YOUNG PERSON

Esophageal leiomyoma is the most common benign tumor of the esophagus, but rarely occurs in young persons. The following is a report of a case of esophageal leiomyoma in a 19-year-old female.A 19-year-old female was admitted to our hospital for a submucosal tumor of the esophagus in October, 1988. She had been complaining of dysphagia occasionally since about 13-year-old. A diagnosis of leiomyoma was made after examination by esophagography, esophagoscopy, CT scan, and echo esophagoscopy. Lower esophageal segment was resected through thoracotomy and laparotomy on the left side followed by esophagogastrostomy. The tumor as large as about 5×4×2 cm was present in the inferior esophageal segment. The cut surface of the solid tumor was gray-white. A histological diagnosis of leiomyoma was made.Only 10 cases of esophageal leiomyoma under 20 years of age, including this case have been reported in the Japanese literature. It was predominant in women and often large in size.

The suture fistula technique in the repair of selected cases ofesophageal atresia

Correction of esophageal atresia with tracheoesophageal fistula can present a difficult problem when distance and tension between upper and lower esophageal segments are too great for primary anastomosis. Alternatives have included staged procedures with upper pouch elongation or interpositions. In 1974, Shafer and David described an operation in which the lower segment was divided, closed, and then merely apposed to the unopened upper pouch. A central "necrosing suture" was placed through the lumina of both segments. Spontaneous fistulization between the two segments occurred postoperatively, and the resultant channel was then progressively dilated with woven silk bougies. This technique has been employed at Babies Hospital in five children. The results were excellent in four. One child failed to fistulize, and following a complicated postoperative course, died at home from accidental dislodgement of his tracheostomy tube. All five children required antireflux procedures but ultimately did well with regard to esophageal function.

Suture fistula as a means of connecting upper and lower segments in esophageal atresia

A technique is described whereby a fistula is created between the upper and lower esophageal segments by means of a silk suture.

Mallory-Weiss syndrome.

Of six patients with Mallory-Weiss syndrome, none had a history of alcoholism. Hematemesis followed one or more bouts of retching and/or vomiting of nonbloody material in all but one of the patients. This characteristic history permits recognition of the condition in most instances. Surgical intervention was necessary in each case to control profuse hemorrhage. A generous gastric incision with thorough examination of the cardia and lower esophageal segment is mandatory to locate the lacerations which are then simply oversewn. The successful management of these patients is attributed to increased awareness of the entity and improvement in the supportive care of patients with massive hemorrhage. A total of 303 cases of Mallory-Weiss syndrome have been reported in the English literature.