Upright epiglottis prevents aspiration in patients with nasopharyngeal carcinoma post-chemoradiation

NPC is the most widely found malignant tumor in the head and neck region in Indonesia. Chemoradiation therapy for NPC can induce swallowing disorders (dysphagia) that adversely affects a patients quality of life. This study aimed to assess the swallowing process by flexible endoscopic evaluation of swallowing in patients with nasopharyngeal carcinoma after chemoradiation. Thirty-nine patients with NPC who had chemoradiation therapy more than one month previously underwent flexible endoscopic evaluation of swallowing and were assessed for oral transport time, sensation, standing-secretion, pre-swallowing leakage, residue, penetration, aspiration, and silent aspiration. The most common structural abnormalities were an upright and swollen epiglottis (89.4%), poor oral hygiene, and velopharyngeal closure defects (56.4%). This examination also revealed a mild degree of standing secretion (38.5%) and aspiration (10.3%). No penetration was observed in 64.1% of the patients, and no silent aspiration was observed in any of the patients. A severe degree of residue (45.7%) was observed when administering oatmeal, while the residue was mild to moderate when administering gastric rice, crackers, and milk. The residue changed to a mild degree (32.3%–51.4%) in all food administrations after the watering maneuver. The highest penetration was noted after oatmeal administration (42.8%), and the highest aspiration was found after milk administration (8.6%). Standing secretion in almost all patients was caused by hyposensitivity of the hypopharynx. Persistent residue and hyposensitivity of the hypopharynx led to aspiration. The low percentage of aspiration and silent aspiration might have been caused by the upright and swollen epiglottis that prevented aspiration. Poor oral hygiene and a dry mouth led to prolonged oral transport. Therefore, most patients had hypopharyngeal abnormalities in the form of a swollen and upright epiglottis. Secretion and food residue were also detected. Drinking helps to expedite the swallowing process by facilitating oral phase transport and reducing residues.

Alimentary tract obstruction attributed to use of barbed suture for double tract reconstruction after robot-assisted proximal gastrectomy: a case report

Background Anastomotic stenosis following esophagojejunostomy reconstruction by the overlap method with absorbable barbed sutures occurs only rarely in patients who have undergone laparoscopic surgery. We report anastomotic stenosis by the overlap method that we attributed to the lack of tactile sensation during robot-assisted surgery. Case presentation An 83-year-old man underwent robot-assisted laparoscopic proximal gastrectomy and lymph node dissection at our hospital for treatment of gastric cancer. Double tract reconstruction followed with side-to-side esophagojejunostomy (overlap method) performed with an endoscopic linear stapler. On completion of the anastomosis, the enterotomy was closed under robotic assistance with absorbable barbed suture. Once solid foods were introduced, the patient had difficulty swallowing and felt as though his digestive tract was stopped up. When upper gastrointestinal endoscopy was performed, we found the anastomotic lumen to be coated with food residue. After rinsing off the residue with water, we could see barbed suture protruding into the anastomotic lumen that had become entangled upon itself, which explained how the food residue had accumulated. We cut the entangled suture under endoscopic visualization using a loop cutter. Conclusion This case highlights a stricture caused by insufficiently tensioning barbed suture, which subsequently protruded into the anastomotic lumen and became entangled upon itself. We believe this occurrence was associated with the lack of tactile sensation in robot-assisted surgery.

Intermittent neck swelling: an unusual presentation of achalasia cardia

Achalasia is a rare cause of neck swelling. We report the case of a 75-year-old woman, who presented with an intermittent, unilateral neck swelling, associated with dysphagia, weight loss and regurgitation. The patient underwent a gastroscopy and barium swallow. This confirmed a dilated oesophagus with poor motility and hold up of liquid and food residue above the gastro-oesophageal junction, thus revealing the swelling was secondary to severe achalasia. The patient was managed with botulinum toxin injections and pneumatic dilatations but the results were short lived. She is now having manometry and is being considered for a Heller myotomy or peroral oesophageal myotomy. Delayed diagnosis and treatment of achalasia can result in the development of a neck swelling, which could later cause airway compromise and subsequent mortality. Achalasia should therefore be considered in patients with an initial diagnosis of gastro-oesophageal reflux disease who do not respond to proton pump inhibitors.

Comparative Study of Different Operation Modes of Microbial Fuel Cells Treating Food Residue Biomass

Four multiple air–cathode microbial fuel cells (MFCs) were developed under the scope of using extracts from fermentable household food waste (FORBI) for the production of bioelectricity. The operation of the MFCs was assessed in batch mode, considering each cell individually. Τhe chemical oxygen demand (COD) efficiency was relatively high in all cases (> 85% for all batch cycles) while the electricity yield was 20 mJ/gCOD/L of extract solution. The four units were then electrically connected as a stack, both in series and in parallel, and were operated continuously. Approximately 62% COD consumption was obtained in continuous stack operation operated in series and 67% when operated in parallel. The electricity yield of the stack was 2.6 mJ/gCOD/L of extract solution when operated continuously in series and 0.7 mJ/gCOD/L when operated continuously in parallel.

Anaerobic digestion of dried/shredded food waste in a periodic anaerobic baffled reactor

The objective of the current work is to study the impact of the operational parameters' variation (HRT, OLR and T) on biomethane productivity in a Periodic Anaerobic Baffled Reactor (PABR). The feedstock used was a biomass product named FORBI (Food Residue Biomass), which is dried and shredded source-separated household food waste. The Periodic Anaerobic Baffled Reactor (PABR) is an innovative, high-rate bioreactor. Apart from the Hydraulic Retention Time (HRT) and the Organic Loading Rate (OLR), an important operational parameter is the Switching Period (T) of the feeding compartment: when T is high, the bioreactor operation is similar to an Anaerobic baffled reactor (ABR), while when it is low, the operation approaches that of an Upflow Anaerobic Sludge Blanket Reactor (UASBR). Nine distinct experimental phases were conducted, during which the operational parameters of the PABR were consecutively modified: the HRT varied from 9 to 2.5 days, T between 2 days and 1 and finally the OLR from 1.24 gCOD/Lbioreactor*d to 8.08 gCOD/Lbioreactor*d. The maximum biomethane yield was 384 LCH4/kgFORBI corresponding to the operation at HRT = 5 d, OLR = 2.14 gCOD/Lbioreactor*d and T = 2 days. Similar efficiency (333 LCH4/kg­FORBI) was achieved at higher OLR (4.53 gCOD/Lbioreactor*d).

Comparison of Roux-en-Y gastrojejunostomy and Billruth-II with Braun anastomosis for gastric reconstruction following partial gastrectomy

Background and aims: Partial gastrectomy surgeries are conducted frequently due to various reasons but there is no consensus regarding the method of choice for gastrointestinal reconstruction. In this study we aimed to compare billruth II with Braun anastomosis and Roux-en-Y gastrojejunostomy. Materials and methods: This prospective study was conducted on patients presented to surgery clinic at Besat and Taleghani hospital between 2018-2020 who were gastrectomy candidates. Patients undergoing Billruth 2 reconstruction with Braun anastomosis or Roux-en-Y gastrojejunostomy were enrolled in the study. Demographics, operation durative and intraoperative blood loss, early postoperative complications, re-admission within 30 days postoperation, 30-day and 90-day mortality were recorded. at an at least 3-month post-surgery period, patients were followed for late postoperative complications. If necessary, endoscopy was conducted and biopsy was taken. Analysis was performed with SPSS version 22. Results: 84 patients in two 42-patient groups were evaluated. All parameters were the same in two groups except operation duration and intraoperative bleeding (significantly higher in RY group), food residue (significantly higher in RY group) and bile in remnant stomach (significantly higher in B2B group). Conclusion: These two methods of reconstruction are comparable in terms of postoperative complications and mortality rates. Food residue and bile reflux are two determinants which should be kept in mind when choosing the surgery plan by surgeons. Keywords: gastrectomy, reconstruction, Billruth, Braun, Roux en Y anastomosis