Abstract: An apparatus includes a shaft, the shaft including a plurality of stepped sections along the length of the shaft. The apparatus further includes a plurality of electrodes disposed along the length of the shaft, each electrode characterized by a geometric aspect ratio of the length of the electrode to the outer diameter of the electrode. Each electrode is located at a different stepped section of the plurality of stepped sections of the shaft and includes a set of leads. Each lead of the set of leads is configured to attain an electrical voltage potential of at least about 1 kV. The geometric aspect ratio of at least one electrode of the plurality of electrodes is in the range between about 3 and about 20.

Abstract: A method for controlling an ablation power applied to a catheter includes: receiving, by a controller, a detected contact force from a sensor assembly of the catheter, the sensor assembly being configured to detect a contact force applied to the electrode; controlling, by the controller, a power supplied to an electrode of the catheter to have a deactivated power level when the detected contact force is less than a first threshold contact force; controlling, by the controller, the power supplied to the electrode of the catheter to have a first power level when the detected contact force is greater than the first threshold contact force; and controlling, by the controller, the power supplied to the electrode of the catheter to have a deactivated power level when the detected contact force is greater than a cutoff contact force, the cutoff contact force being greater than the first threshold contact force.

Abstract: An emitter assembly can include a proximal shaft, a distal shaft, a shunt that connects the proximal shaft to the distal shaft, and a tip that is connected to a distal end of the distal shaft. An inner conductor can extend through the proximal shaft, the shunt, and the distal shaft and into the tip to provide microwave energy to the tip. An outer conductor can extend into the shunt. The shunt can therefore form an electrical connection between the outer conductor and a proximal ring of electrically conductive material formed on an exterior surface of the distal shaft. Distal shaft can be made of a thermally conductive but electrically insulated material to facilitate transfer of heat from the distal shaft to the proximal shaft.

Abstract: Disclosed is a treatment device for occluding a body lumen, including: an elongated body which can be inserted into the body lumen; a flat portion forming section which is supported by the elongated body, is expandable widthwise on a more distal side than the elongated body, and deforms the body lumen into a form having a flat portion at a distal portion of the flat portion forming section upon the expansion of the flat portion forming section within the body lumen; and an administering section which administers, toward the flat portion formed by the flat portion forming section, a treatment which acts to occlude the flat portion.

Abstract: A fixation apparatus may be attached to first and second anatomical structure segments. Images of the fixation apparatus and the attached anatomical structure segments may then be captured. In some examples, the images need not necessarily be orthogonal with respect to one another. Configuration information associated with the fixation apparatus may then be received. Additionally, first image information may be received, for example including indications of one or more locations, within the images, of at least part of one or more elements of the fixation apparatus. Additionally, second image information may be received, for example including indications of one or more locations, within the images, of at least part of the first and the second anatomical structure segments. Manipulations to the fixation apparatus for correction of the anatomical structure deformity may then be determined, and indications of the determined manipulations may then be provided to one or more users.

Abstract: A computer-assisted surgery system for obtaining a distance between at least two fixed points relative to a bone comprises a first accelerometer unit located at a first fixed location on the bone, and producing first acceleration data during a movement of the bone. A second accelerometer unit is located at a second fixed location on the bone, and simultaneously producing second acceleration data during the movement. A gyroscope unit is fixed to the bone and simultaneously producing angular rates of change of said movement. A processor unit obtains the acceleration data and the angular rates of change for calculating the distance between the first fixed position and the second fixed position on the bone using a distance value of a distance vector between the accelerometer units. An interface outputs the distance between the first fixed position and the second fixed position relative to the bone. A method for calculating a distance between at least two points on a bone is provided.

Abstract: A surgical system comprises an instrument and a teleoperated instrument operation system. The instrument comprises a drive member having an end effector coupled to the distal end and a ratchet assembly coupled to the proximal end. The ratchet assembly includes a pin, a gear, and a spring- loaded button. A lever is coupled to and configured to pivot relative to the ratchet assembly to engage the spring-loaded button to disengage the pin from the gear. The lever in a first position places the ratchet assembly in a gripping position in which the end effector grips a surgical accessory. The lever in a second position places the ratchet assembly in a release position in which the end effector releases the surgical accessory. The lever is movable while compressing the spring-loaded button. The teleoperated instrument operation system comprises a capture mechanism configured to move the lever between the first and second positions.

Abstract: A computer-implemented method for providing a visual representation of material removal from an object by a cutting tool during a cut procedure is described. The method may comprise tracking consecutive cuts a cut trajectory of the cutting tool during the cut procedure, shape sweeping the consecutive poses of the cutting tool, and, for example, accumulating a union of the cut trajectory in a voxelized constructive solid geometry (CSG) grid to produce an object space representation of the union of the cut trajectory. The computer-implemented method may further comprise performing a CSG operation on object space representation of the union of the cut trajectory and a model of the object, and displaying a result of the CSG operation at a display screen.

Abstract: A display may display a region of an anatomy that is not within the field of effect of an instrument. The additional views may assist in determining a location and orientation of an instrument. The instrument may be tracked with a tracking system to make the determination of image data to display.

Abstract: A system and an apparatus for guiding an instrument may be provided, the apparatus comprising a main body; a holding member for holding an instrument, the holding member coupled to the main body; and one or more actuating members configured to effect movement of the holding member such that said movement of the holding member is capable of providing rotational movement of an instrument about a pivot point external the apparatus. The holding member may preferably be configured to co-operate with a compliance device, said compliance device capable of holding the instrument.

Abstract: A medical instrument assembly including a handle assembly having a first handle portion and a second handle portion proximate the second end, wherein the second handle portion is slidably engaged with the first handle portion. A first localization element is attached to the first handle portion and a second localization element is attached to the second handle portion. A medical instrument is mechanically coupled to the second handle portion and a translation of the second handle portion with respect to the first handle portion causes a coincident and coextensive translation of the medical instrument. The amount of translation of the medical instrument is adapted to be determined by calculating the distance between the first localization element and the second localization element. The first and second localization elements may be electromagnetic sensors which positions may be determined by a navigation system.

Abstract: A computer-assisted imaging and localization system assists the physician in positioning implants and instruments into a patient's body. The system displays overlapping images—one image of the surgical site with the patient's anatomy and another image showing the implant(s) or instrument(s). The overlapping image of the implant/instrument is moved over the static image of the anatomy as the implant/instrument is moved. These moving image of the implant/instrument can be an unaltered image or an image altered to intensify or mitigate the anatomical or non-anatomical aspects of the moving image. Sliding these images over one another helps the surgeon in positioning devices or instruments with a high degree of accuracy and with a limited number of additional x-rays.

Abstract: A medical robot system, including a robot coupled to an effectuator element with the robot configured for controlled movement and positioning. The system may include a transmitter configured to emit one or more signals, and the transmitter is coupled to an instrument coupled to the effectuator element. The system may further include a motor assembly coupled to the robot and a plurality of receivers configured to receive the one or more signals emitted by the transmitter. A control unit is coupled to the motor assembly and the plurality of receivers, and the control unit is configured to supply one or more instruction signals to the motor assembly. The instruction signals can be configured to cause the motor assembly to selectively move the effectuator element.

Abstract: A surgical instrument includes a catheter, a distal segment, a needle, and a tracking sensor. The catheter is configured to be inserted into an anatomical passageway of a patient and includes a catheter lumen. The distal segment includes a port that communicates with the catheter lumen. The needle is slidably disposed within the catheter lumen and is translatable relative to the catheter between a retracted position and an extended position. A needle distal end is configured to extend through the port when the needle is in the extended position. The tracking sensor is coupled to the needle and is configured to generate a signal corresponding to a location of the needle distal end within the patient.

Abstract: A medical robot system, including a robot coupled to an effectuator element with the robot configured for controlled movement and positioning. The system may include a transmitter configured to emit one or more signals, and the transmitter is coupled to an instrument coupled to the effectuator element. The system may further include a motor assembly coupled to the robot and a plurality of receivers configured to receive the one or more signals emitted by the transmitter. A control unit is coupled to the motor assembly and the plurality of receivers, and the control unit is configured to supply one or more instruction signals to the motor assembly. The instruction signals can be configured to cause the motor assembly to selectively move the effectuator element.

Abstract: A robotic catheter procedure system is provided. The robotic catheter procedure system includes a bedside system and a remote workstation. The bedside system includes a percutaneous device and a drive mechanism configured to engage and to impart an axial force to the percutaneous device and to advance and retract the percutaneous device. The bedside system includes an actuator providing torque to the drive mechanism to impart the axial force to the percutaneous device, and the torque provided by the actuator is variable. The remote workstation includes a user interface configured to receive a first user input and a control system operatively coupled to the user interface. The control system is configured to communicate a control signal to the actuator. The control signal is based upon the first user input and a second input, and the actuator provides torque to the drive mechanism in response to the control signal.

Abstract: A method for determining the position of a rotatable jaw of an attachment relative to a non-rotatable jaw is disclosed. The method comprises assembling the attachment to a surgical robot, rotating a first rotatable driver of the robot to align the first driver with a first rotatable drive of the attachment, and rotating a second rotatable driver of the robot to align the second driver with a second rotatable drive of the attachment. The method further comprises evaluating the amount of rotation required to align the first driver with the first drive and the amount of rotation required to align the second driver with the second drive, calculating a difference between the amount of rotation of the first driver and the amount of the rotation of the second driver, and determining the position of the rotatable jaw relative to the non-rotatable jaw based on the calculated difference.

Abstract: Surgical tools having a two degree-of-freedom wrist, wrist articulation by linked tension members, mechanisms for transmitting torque through an angle, and minimally invasive surgical tools incorporating these features are disclosed. An elongate intermediate wrist member is pivotally coupled with a distal end of an instrument shaft so as to rotate about a first axis transverse to the shaft, and an end effector body is pivotally coupled with the intermediate member so as to rotate about a second axis that is transverse to the first axis. Linked tension members interact with attachment features to articulate the wrist. A torque-transmitting mechanism includes a coupling member, coupling pins, a drive shaft, and a driven shaft. The drive shaft is coupled with the driven shaft so as to control the relative orientations of the drive shaft, the coupling member, and the driven shaft.

Abstract: A method of operating an end effector of a surgical instrument includes supplying voltage to a motor disposed in a transmission mechanism of a surgical instrument having a shaft and an end effector at a distal end of the shaft; moving a component of the end effector between a first position and a second position via a drive system coupled to the motor; and placing a limit switch in a first state during moving of the end effector component, and in a second state when the end effector component is at one of the first position or the second position.

Abstract: Robot main body having robotic arm, remote control device including robotic arm operational instruction input part for operator to control by touching, to input operational instruction for robotic arm, and contactless action detecting part configured to detect contactless action including at least one given operation instructing action of operator, and control device communicably connected to remote control device and configured to control operation of robot main body, are provided.

Abstract: Provided is a master console for a surgical robot. The master console includes: a base unit including a first base and a second base, the first and second bases being provided parallel to each other; and a foot pedal unit between the first base and the second base, wherein the foot pedal unit includes at least one foot pedal switch capable of being manipulated by a foot of an operator, a foot panel configured to support the at least one foot pedal switch, and a footrest extending outward from the foot panel.

Abstract: Systems and methods for monitoring one or more cables of surgical tools are provided. The systems generally include a surgical tool with an end effector that has at least one function and a drive system that is operably coupled to the end effector and operably coupled to at least one motor. The drive system has at least one cable, and the drive system is configured to drive the at least one function on the end effector through actuation of the at least one cable. A control system is configured to actuate the at least one motor to drive the drive system and to preemptively detect failure of the at least one cable of the drive system.

Abstract: A gimbal for a robotic surgical system includes a support link, an input link, and a vibration assembly. The input link extends from the support link and the vibration assembly is mounted to the support link. The vibration assembly includes a central support, an end cap, and a voice coil. The end cap is moveable relative to the central support. The voice coil has an inner member that is fixed to the central support and an outer member that is fixed to the end cap. The voice coil is configured to vibrate the gimbal in response to a voltage being applied to one of the inner or outer members.

Abstract: Systems and methods for a sterile imaging protective system are described. The system preferably includes a first flexible drape with a cavity configured to surround an imaging intensifier and a second drape that is attached to an operating table or patient drape. The second drape has a proximal portion, a distal portion, a pocket therebetween with a top sterile portion and a lower portion, and a plurality of reusable fasteners that allows the second drape to be repeatedly moved from a collapsed configuration to an expanded configuration. When in the expanded configuration, the second drape is releasably attached to the first drape. The system may also include a third drape located on the opposite side of the operating table as the second drape. The drapes preferably allow sterility to be maintained during movement of the c-arm imaging system.

Abstract: A medical bag comprises a flexible shell and having opening and a zip fastener for closing the opening. The zip fastener includes two sliders arranged to close the zip from opposing ends in a direction towards each other along the length of the zip fastener. The sliders are movable between an open configuration in which they are located at opposing ends of the zip fastener and a closed configuration in which they are located at a stop position at the centre of the zip fastener. The bag further includes a pair of positioned at a common location along the length of the zip coincident with the stop position of the sliders. The handles are located on opposing sides of the zip fastener and are arranged to enable a person to impart forces in opposing directions away from the zip transverse to the length of the zip to open the zip when the zip is closed with the sliders located at the stop position to enable the bag to be ripped open in a very rapid manner to access the medical equipment in time critical situations.

Abstract: A surgical instrument and accessory organizer comprising a base pad having a lower surface and an upper surface and, the upper surface comprising at least one section for retaining instruments having a flat portion; at least one section for retaining instruments with a handle; at least one section for retaining fluids; and a plurality of perforations extending from the lower surface to the upper surface for removably attaching at least one retaining member adapted to maintain at least one of an instrument and an object in place.

Abstract: A package including at least one bumper having an elliptical shape that extends from a first end to a second end along a first plane and having a protrusion that extends from a first front along a second plane; and a first tray having a first cavity that extends from a second front along the second plane, wherein the first cavity includes at least one groove configured and dimensioned to receive the at least one bumper.

Abstract: A handle assembly for use with a surgical instrument includes a housing defining a contact wall, a movable handle, a plunger, a linkage, and a feedback mechanism. The plunger is disposed at least partially within the housing and defines a longitudinal axis. The linkage interconnects the movable handle with the plunger such that actuation of the movable handle results in longitudinal translation of the plunger relative to the housing. The feedback mechanism is configured to provide audible feedback to a user, and includes an indicator snap wire and a track defined by a wall of the housing. The snap wire is configured to move along the track in response to longitudinal translation of the plunger. The snap wire is configured to engage the contact wall of the housing to create a sound that is audible to a user when the movable handle has been actuated a predetermined amount.

Abstract: There is provided a medical observation apparatus including: a control section configured to control, on a basis of a predetermined operation related to a movement of an imaging field of view, the movement of the imaging field of view in an imaging device supported by an arm including a plurality of links joined to each other by joint sections. The control section controls the movement of the imaging field of view by performing a cropping range control that crops an imaging range of the imaging device on the basis of the predetermined operation.

Abstract: A method of producing a modification plan for producing a surgical guide from an impression element includes: obtaining surface data representing a configuration of a surface of an impression element providing an impression of a surgical site; obtaining image data of a patient's anatomy; obtaining surgical plan data providing a surgical plan with respect to features in the image data representing anatomical features of the patient's anatomy; registering the impression element using the surface data and the image data with anatomical features of the patient's anatomy; and producing a modification plan from the surgical plan data using the registration of the impression element with anatomical features of the patient's anatomy, the modification plan being a plan for modifying the impression element.

Abstract: A system for video-assisted surgery includes one or more displays, a memory including at least one preoperative image, and a camera coupled to capture a video. A controller is coupled to the memory, the camera, and the one or more displays, and the controller includes logic that when executed by the controller causes the system to perform a variety of operations. The system may capture a video of a surgical area, including anatomical features, using the camera, and display the video of the surgical area on the one or more displays. The system may also display the at least one preoperative image on the one or more displays at the same time as the video. The location of the anatomical features shown in the video is displayed as an accentuated region on the at least one preoperative image.

Abstract: An end effector coupler for a surgical arm can include a body, a proximal coupler, and a tool lock. The tool lock can releasably retain a tool stem to the end effector coupler. The tool lock can include a keyed opening, a pin bore, a pin disposed in the bin bore, a biasing element located in the pin bore, and a pin release including an actuator, the pin release operable to retract the pin into to the body to disengage the pin from the tool stem allowing release of the tool stem from the keyed opening.

Abstract: A medical device support system including a central shaft; an extension arm; and a brake assembly. The extension arm has a support for a medical device and a hub at its proximal end mounted to the central shaft for pivotable movement about the central shaft. The brake assembly is secured in the hub for rotation therewith and includes first and second discrete arc shape clamp pieces that are detachably coupled to one another at one end for flexural movement relative to a coupling joint and that are free at an opposite end. The brake assembly includes an actuator configured to flex the first and second clamp pieces relative to the coupling joint toward and away from each other to respectively increase and decrease a frictional braking force to the central shaft.

Abstract: A cleansing unit for enhanced sanitation compliance and for eradicating a healthcare facility-hosted opportunistic infections, the unit comprising: a hands-free automatic dispenser of disinfectant agent that dispenses such agent either directly on at least one agitation membrane support post having a condom-like mounted textured sheath or directly on the auscultation portion of the stethoscope, said textured sheath designed to provide a frictional agitation of an auscultation portion of a stethoscope to effectively clean and sanitize the stethoscope, and method thereof.

Abstract: Medical procedure related objects (e.g., instruments, supplies) tagged with transponders (e.g., RFID transponders, dumb transponders) are accounted for in a medical or clinical environment via an accounting system using a number of antennas and interrogators/readers. A first set of antennas and RFID interrogator(s) interrogate portions of the environment for RFID tagged objects, for example proximate a start and an end of a procedure. Shielded packaging and/or shielded receptacles shield tagged objects, preventing interrogation except for those objects in unshielded portions of the environment. A shielded receptacle may include an antenna to interrogate the contents thereof in a relatively noise-free environment. A data store may maintain information including a current status or count of each instrument or supply, for instance as checked in or checked out. A handheld antenna and/or second set of antennas interrogates a body of a patient for retained instruments or supplies tagged with dumb transponders.

Abstract: A method includes determining, from a first image, a first region comprising teeth, wherein the first region comprises a first set of pixel locations. A first parametric function is generated based on intensities at the first set of pixel locations. Image data comprising new contours of the mouth is received, wherein one or more of the teeth have a different position in the image data than in the first image. A second region comprising the teeth is determined from the image data, wherein the second region comprises a second set of pixel locations for the teeth. A new image is then generated based on the image data and the first parametric function, wherein a shape of the teeth is based on the image data and a color of the teeth is based on applying the first parametric function to the second set of pixel locations for the teeth.

Abstract: Dental implant, having a central body (1) with a substantially conical or frustoconical shape and having, extending from the end with a larger cross-section, a connection seat (701) able to receive a stump pin; this central body (1) is provided with a blade (2) positioned in a longitudinal mid-plane of said central body (1) and has a length so as to protrude beyond the end of said central body (1) which has a smaller cross-section; said central body (1) and the blade (2) are able to give the implant a substantially wedge-like form able to expand the bone during insertion.

Abstract: A method of taking a dental impression of dentition including conditioning a surface comprising one or more of dentition and a dental appliance by the application thereto of a wetting agent to form a controlled hydrophilic wet film. The wetting agent includes water, a surfactant, and an additive. The controlled hydrophilic wet film is hydrophilic and is formed by brushing the wetting agent onto the dentition. The brushing controls the thickness and hydrophilicity of the controlled hydrophilic film to a thickness and hydrophilicity that is capable of inducing flow of an impression material that comes into contact with the controlled hydrophilic film. The flow is sufficient to flow into sub-gingival places. The film is contacted with a dental impression material selected from the group consisting of hydrophilic and hydrophobic dental impression materials.

Abstract: An intraoral scanner and computing system for capturing images and generating three-dimensional models. The intraoral scanner includes a handle, a mouthpiece extending from the handle, a flood illuminator projecting light from the mouthpiece, a structured light projector projecting a light pattern from the mouthpiece, and stereo camera capturing images through the mouthpiece. An optimal image of each of different materials within the captured images are combined to create a high dynamic range image. The structured light pattern in the high dynamic range image is used to determine three-dimensional measurements and create a three-dimensional model.

Abstract: A method of analyzing a positional relationship between a dental restoration and a dental substructure. The method has steps of scanning a reference area and determining the shape of the dental substructure in its positional relationship to the reference area, and thereby providing a virtual dental substructure model and scanning the reference area along with scanning at least a portion of the dental restoration in fit position with the dental substructure to provide a virtual assembly model. The method further has the step of providing fitting quality information between the dental restoration model and the dental substructure model. The method utilizes superposing of further virtual models to provide the fitting quality information. The method facilitates the assessment of the quality of the fit between a dental restoration and a dental substructure.

Abstract: A layered denture having at least one of an integrated layer, balanced occlusion, and a root approximating structure is disclosed. The resulting denture may be suitable for use without an underlying reinforcement bar and may provide enhanced aesthetics by approximating natural dentition and roots both above and below the gum line.

Abstract: Apparatus and methods for endodontic treatment of teeth provide effective cleaning of organic material (such as pulp and diseased tissue) from the root canal system. In an embodiment, a compressor system generates high pressure liquid (e.g., water) that flows through an orifice to produce a high-velocity collimated jet of liquid. The high-velocity jet is directed toward a surface of a tooth, for example, an exposed dentinal surface, and impingement of the jet onto the surface generates an acoustic wave that propagates throughout the tooth. The acoustic wave effectively detaches organic material from dentinal surfaces and tubules. The detached organic material is flushed from the root canal system by the liquid jet and/or by additional irrigation.

Abstract: An oral irrigator handle has a handle housing with a swivel assembly for connection to a hose further connected to a fluid source. A tip for directing a focused stream of fluid is releasably connected to a first end of the handle. The swivel assembly is received within the housing and fluidly coupled to tip. The hose is connected to the swivel assembly and fluidly coupled to the tip via the swivel assembly. The swivel assembly prevents translation of rotational movement of the handle or the hose to the other.

Abstract: A system for ultrasonic cleaning of dental appliances provides nested containers adapted to communicate ultrasonic energy therethrough to provide cleaning of a dental appliance contained within the innermost container using a standard ultrasound machine without cross-contamination with liquid from the main ultrasound bath.

Abstract: A device is disclosed for taking critical measurements of a dental patient's anatomical features to aid in building prosthetic teeth in a minimal number of patient visits. The device to a multi-functional tool for dental professionals to acquire valuable anatomical data.

Abstract: A periodontal endoscope includes an imaging handle having an imaging end that supports a camera sensor and an introducer including an introducer blade such that the introducer blade is selectively rotatable about the camera sensor for engaging gingival tissue in the field of view for any rotational orientation of the introducer blade relative to the camera while illuminated by an optical fiber bundle. An automatic illuminance controller controls an illumination light source at least within each frame as the frame is scanned based on dynamic range of the camera sensor such that high intensity areas of the frame receive a reduced amount of illumination light by reducing the illumination drive signal as compared to low intensity areas of the frame which receive an increased amount of illumination light by increasing the illumination drive signal relative to the high intensity areas.

Abstract: Disclosed is a method, user interface and system for detecting and monitoring development of a dental condition. In particular the invention relates to detecting and monitoring such a development by comparing digital 3D representations of the patient's set of teeth recorded at a first and a second point in time.

Abstract: A catheter device is disclosed for transvascular delivery of a medical device to a cardiac valve region of a patient. The catheter device comprises an elongate sheath (2) with releasable locking members for controllably locking the elongate sheath in a shape at least partly along its length from a relaxed state to a locked state when positioned in relation to a cardiac valve. Furthermore, alignment members (5) are provided to provide for a desired positioning in relation to the cardiac valve. Embolic protection (8) is further provided.

Abstract: An artificial stomach for replacing the normal stomach of a patient is disclosed. The artificial stomach comprises a food reservoir adapted to collect food, an inlet connected to a first opening to the food reservoir and further being adapted to upstream connect to the patient's gastrointestinal tract. The artificial stomach further comprises an outlet connected to a second opening of the food reservoir and further being adapted to downstream connect to the patient's gastrointestinal tract. An outer wall encloses both the food reservoir and a servo reservoir for regulating the size of the food reservoir, the food reservoir and the servo reservoir being separated by a flexible inner wall.

Abstract: An apparatus enables concurrent restoration of a gastroesophageal valve and tightening of the lower esophageal sphincter. The apparatus comprises a longitudinal member having a distal end arranged to be received within a stomach, a tissue shaper at the distal end of the longitudinal member that forms a gastroesophageal valve from stomach tissue, and a tissue gatherer that gathers fundus tissue at or aboral to the gastroesophageal junction to reduce an esophageal opening into the stomach and tighten the lower esophageal sphincter. A fastener deployer then deploys at least one fastener pair to maintain both the restored gastroesophageal valve and the tightened lower esophageal sphincter.