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INTRODUCTION:Benign esophageal anastomotic leaks can be effectively treated by the placement of esophageal stents. Endoscopic therapy for esophageal anastomotic leaks remains non-standardized. Partially covered self-expanding metal stents (PSEMS) are superior to fully covered stents in the treatment of anastomotic leaks by providing a better seal and therefore promoting quicker healing with shorter time to oral intake. However, the removal of partially covered SEMS is technically challenging due to these stents’ inherent risk of stimulating mucosal hyperplasia and without special technique will lead to esophageal perforation, avulsion or fistula formation during attempted removal. Generally, anastomotic leaks require at least 4 weeks of stent dwelling for clinical success with an average treatment time of 6–8 weeks with recommendations for stent removal by 3 months.CASE DESCRIPTION/METHODS:A 69-year-old man with esophageal adenocarcinoma of the distal esophagus status post neoadjuvant chemoradiation followed by Ivor-Lewis esophagectomy with pyloroplasty presented to the hospital with hematemesis and found to have developed two anastomotic leaks within one month of surgery. He was treated with PSEMS measuring 12.5 cm × 20 mm (25 mm at ends). Three months after placement, elective EGD revealed previously placed stent covering the anastamosis with tissue ingrowth at the uncovered ends. Coagulation using argon plasma at 0.8 liters/minute and 55 watts was performed to free the uncovered ends of the stent by destruction of ingrown tissue. The proximal end was freed, however, some tissue remained over the distal end even after extensive attempts at coagulation and debridement. Two days later, the procedure was repeated with continued fulguration to ablate the remaining ingrown tissue at the uncovered ends using argon plasma and a soft over-the-scope cap was used to remove the necrosed tissue. Stent was eventually removed with rat-tooth forceps.DISCUSSION:There are many described methods for partially covered esophageal stent removal. We propose a safe and effective method for the removal of partially covered esophageal SEMS with the use of Argon Plasma Coagulation, a soft over-the-scope cap and rat-tooth forceps after an extended stent dwelling time of three months. With this efficient, safe and effective method of stent removal, it is essential that the use of partially covered esophageal SEMS be standard of care in the temporary management of anastomotic leaks.Watch the video: http://bit.ly/2SooiEC.

INTRODUCTION:Auto-brewery syndrome (ABS), also known as gut fermentation syndrome, is a rarely diagnosed medical condition in which the ingestion of carbohydrates results in endogenous alcohol production. The patient in this case report had fungal yeast forms in the upper small bowel and cecum, which likely fermented carbohydrates to alcohol. Treatment with antifungal agents allowed subsequent ingestion of carbohydrates without symptoms. He had been exposed to a prolonged course of antibiotics before this occurred. We postulate that the antibiotic altered his gut microbiome, allowing fungal growth.CASE DESCRIPTION/METHODS:A healthy 46-year-old male who complained of memory loss, mental changes, and episodes of depression for over three years after antibiotic therapy (cephalexin) for a traumatic thumb injury. He was given a carbohydrate meal and blood alcohol level became elevated to 57 mg/dL without any exogenous alcohol while under observation. Saccharomyces cerevisiae (brewer's yeast) and Saccharomyces boulardii were detected in his stool. To investigate further, an upper and lower endoscopy were performed. Fungal cultures from cecal secretions grew Candida Albicans and Candida Parapsilosis. He was started on a carbohydrate free diet and intravenous micafungin therapy for six weeks after which secretions from a repeat endoscopy showed absence of fungal growth. He was also started on a probiotic to competitively inhibit fungal growth in his gut. A repeat carbohydrate challenge test was negative for endogenous alcohol production now. Approximately 2 years later, he remains asymptomatic and has resumed his previous lifestyle, including eating a normal diet.DISCUSSION:A large Middle Eastern study involving 1400 subjects who were teetotalers detected very small endogenously produced alcohol levels using gas chromatography and mass spectrometry. Saccharomyces cerevisiae which can convert carbohydrates to endogenous alcohol, was detected in our patient's stool. This fungus uses acetate for anaerobic alcohol fermentation. It should be noted that the earliest symptoms of ABS may be mood changes, delirium, and brain fog rather than the medical manifestation of alcohol inebriation. A multidisciplinary approach with early psychiatrist involvement is suggested. Any patient denying alcohol ingestion but who has elevated blood alcohol levels or positive breathalyzer results should be investigated for ABS. This could be a treatable condition with dietary modifications, appropriate antifungal therapy and probiotic use.

Sit-to-stand movement (STS) is a mundane activity, controlled by the central-nervous-system (CNS) via a complex neurophysiological mechanism that involves coordination of limbs for successful execution. Detailed analysis and accurate simulations of STS task have significant importance in clinical intervention, rehabilitation process, and better design for assistive devices. The CNS controls STS motion by taking inputs from proprioceptors. These input signals suffer delay in transmission to CNS making movement control and coordination more complex which may lead to larger body exertion or instability. This paper deals with the problem of STS movement execution in the presence of proprioceptive feedback delays in joint position and velocity. We present a high-gain observer (HGO) based feedback linearization control technique to mimic the CNS in controlling the STS transfer. The HGO estimates immeasurable delayed states to generate input signals for feedback. The feedback linearization output control law generates the passive torques at joints to execute the STS movement. The H 2 dynamic controller calculates the optimal linear gains by using physiological variables. The whole scheme is simulated in MATLAB/Simulink. The simulations illustrate physiologically improved results. The ankle, knee, and hip joint position profiles show a high correlation of 0.91, 0.97, 0.80 with the experimentally generated reference profiles. The faster observer dynamics and global boundness of controller result in compensation of delays. The low error and high correlation of simulation results demonstrate (1) the reliability and effectiveness of the proposed scheme for customization of human models and (2) highlight the fact that for detailed analysis and accurate simulations of STS movement the modeling scheme must consider nonlinearities of the system.