Characterization of the distal esophagus high-pressure zone with manometry, ultrasound and micro-computed tomography

Immunohistochemical characterization of interstitial cells and their spatial relationship to motor neurons within the mouse esophagus

Interstitial cells of Cajal (ICC) and PDGFRα+ cells regulate smooth muscle motility in the gastrointestinal (GI) tract, yet their function in the esophagus remains unknown. The mouse esophagus has been described as primarily skeletal muscle; however, ICC  have been identified in this region. This study characterizes the distribution of skeletal and smooth muscle cells (SMCs) and their spatial relationship to ICC, PDGFRα+ cells, and intramuscular motor neurons in the mouse esophagus. SMCs occupied approximately 30% of the distal esophagus, but their density declined in more proximal regions. Similarly, ANO1+ intramuscular ICC (ICC-IM) were distributed along the esophagus, with density decreasing proximally. While ICC-IM were closely associated with SMCs, they were also present in regions of skeletal muscle. Intramuscular, submucosal, and myenteric PDGFRα+ cells were densely distributed throughout the esophagus, yet only intramuscular PDGFRα+ cells in the lower esophageal sphincter (LES) and distal esophagus expressed SK3. ICC-IM and PDGFRα+ cells were closely associated with intramuscular nNOS+, VIP+, VAChT+, and TH+ neurons and GFAP+ cells resembling intramuscular enteric glia. These findings suggest that ICC-IM and PDGFRα+ cells may have roles in regulating esophageal motility due to their close proximity to each other and to skeletal muscle and SMCs, although further functional studies are needed to explore their role in this region. The mixed muscular composition and presence of interstitial cells in the mouse distal esophagus is anatomically similar to the transitional zone found in the human esophagus, and therefore, motility studies in the mouse may be translatable to humans.

Immunohistochemical characterization of interstitial cells and their relationship to motor neurons within the mouse esophagus

Interstitial cells of Cajal (ICC) and PDGFRα+ cells regulate smooth muscle motility in the gastrointestinal (GI) tract. However, their role(s) in esophageal motility are still unclear. The mouse esophagus has traditionally been described as almost entirely skeletal muscle in nature though ICC have been identified along its entire length. The current study evaluated the distribution of skeletal and smooth muscle within the esophagus using a mouse selectively expressing eGFP in smooth muscle cells (SMCs). The relationship of SMCs to ICC and PDGFRα+ cells was also examined. SMCs declined in density in the oral direction however SMCs represented ~ 25% of the area in the distal esophagus suggesting a likeness to the transition zone observed in humans. ANO1+ intramuscular ICC (ICC-IM) were distributed along the length of the esophagus though like SMCs, declined proximally. ICC-IM were closely associated with SMCs but were also found in regions devoid of SMCs. Intramuscular and submucosal PDGFRα+ cells were densely distributed throughout the esophagus though only intramuscular PDGFRα+ cells within the LES and distal esophagus highly expressed SK3. ICC-IM and PDGFRα+ cells were closely associated with nNOS+, VIP+, VAChT+ and TH+ neurons throughout the LES and distal esophagus. GFAP+ cells resembling intramuscular enteric glia were observed within the muscle and were closely associated with ICC-IM and PDGFRα+ cells, occupying a similar location to c. These data suggest that the mouse esophagus is more similar to the human than thought previously and thus set the foundation for future functional and molecular studies using transgenic mice.

Reconstruction of the human lower esophageal sphincter based on ultra-mill imaging for biomechanical analysis

Introduction: The lower esophageal sphincter (LES) controls the passage into the stomach and prevents reflex of contents into the esophagus. Dysfunctions of this region typically involves impairment of muscular function, leading to diseases including gastro-esophageal reflux disease and achalasia. The main objective of this study was to develop a finite element model from a unique human LES dataset reconstructed from an ultra-mill imaging setup, and then to investigate the effect of anatomical characteristics on intraluminal pressures. Methods: A pipeline was developed to generate a mesh from a set of input images, which were extracted from a unique ultra-mill sectioned human LES. A total of 216 nodal points with cubic Hermite basis function was allocated to reconstruct the LES, including the longitudinal and circumferential muscles. The resultant LES mesh was used in biomechanical simulations, utilizing a previously developed LES mathematical model based on the Visible Human data to calculate intraluminal pressures. Anatomical and functional comparisons were made between the Ultra-mill and Visible human models. Results: Overall, the Ultra-mill model contained lower cavity (1,796 vs. 5,400 mm3) and muscle (1,548 vs. 15,700 mm3) volumes than the Visible Human model. The Ultra-mill model also developed a higher basal pressure (13.8 vs. 14.7 mmHg) and magnitude of pressure (19.8 vs. 18.9 mmHg) during contraction. Out of all the geometric transformations (i.e., uniform enlargement of volume, lengthening along the center-axis, dilation of the diameter, and increasing muscle thickness), the muscle volume was found to be the main contributor of basal and magnitude of pressures. Increases in length also caused proportional increases to pressures, while dilation of diameter had a less influential reverse effect. Discussion: The findings provide information on interindividual variability in LES pressure and demonstrates that anatomy has a large influence on pressures. This model forms the basis of more complex simulations involving food bolus transport and predicting LES dysfunctions.

Atrous spatial pyramid pooling and multi-image data fusion for smooth muscle segmentation in upper gastrointestinal sphincters

Gastrointestinal (GI) sphincters provide critical roles in regulating the transport of contents along the GI tract. Dysfunctions of GI sphincters are associated with a range of major digestive disorders. Despite their importance, the microstructures of GI sphincters are not well investigated. While micro-computed tomography (μ-CT) provides detailed 3D images, conventional segmentation methods rely on manual correction, which is both time-consuming and prone to human error. This study proposes a segmentation method using atrous spatial pyramid pooling (ASPP), which helps in capturing different effective fields of view from a given input feature map, thereof providing finer local and global information for a given pixel. Additionally, we explored the use of multi-species data fusion to make the model more generalized. The proposed segmentation network incorporating ASPP and multi-species data fusion improved the segmentation of sphincter muscle images. Specifically, it increased the dice score and Jaccard index by 3.7% and 5.8%, respectively, while reducing the variance compared to conventional methods.Clinical relevance- Techniques developed in this study will inform μ-CT segmentation of human upper GI sphincters for detailed structural analysis of muscular dysfunction.

Volumetric Tissue Imaging of Surgical Tissue Specimens Using Micro-Computed Tomography: An Emerging Digital Pathology Modality for Nondestructive, Slide-Free Microscopy-Clinical Applications of Digital Pathology in 3 Dimensions

OBJECTIVES

Micro-computed tomography (micro-CT) is a novel, nondestructive, slide-free digital imaging modality that enables the acquisition of high-resolution, volumetric images of intact surgical tissue specimens. The aim of this systematic mapping review is to provide a comprehensive overview of the available literature on clinical applications of micro-CT tissue imaging and to assess its relevance and readiness for pathology practice.

METHODS

A computerized literature search was performed in the PubMed, Scopus, Web of Science, and CENTRAL databases. To gain insight into regulatory and financial considerations for performing and examining micro-CT imaging procedures in a clinical setting, additional searches were performed in medical device databases.

RESULTS

Our search identified 141 scientific articles published between 2000 and 2021 that described clinical applications of micro-CT tissue imaging. The number of relevant publications is progressively increasing, with the specialties of pulmonology, cardiology, otolaryngology, and oncology being most commonly concerned. The included studies were mostly performed in pathology departments. Current micro-CT devices have already been cleared for clinical use, and a Current Procedural Terminology (CPT) code exists for reimbursement of micro-CT imaging procedures.

CONCLUSIONS

Micro-CT tissue imaging enables accurate volumetric measurements and evaluations of entire surgical specimens at microscopic resolution across a wide range of clinical applications.

Evaluation of the extent of damage to the esophageal wall caused by press-through package ingestion

Press-through package (PTP) is the most common accidentally ingested foreign body in Japan. Accidental ingestion of PTP can result in esophageal damage. An approach for evaluating the risk of esophageal injury has not been established. Therefore, we used porcine esophageal tissue and silicone sheets to establish a method for assessing the risk of esophageal damage on accidental PTP ingestion. We pathologically evaluated porcine lower esophageal tissue using a scratch tester. Using porcine esophageal tissue, scratch tests were performed with 4 test objects and pathological damage was compared. It was assumed that each object was accidentally ingested. The objects were polyvinylidene chloride (PVDC)-coated polyvinyl chloride (PVC) PTP, soft PThPa, round PTP, and a disposable scalpel. The porcine esophagus was replaced with a silicon sheet, and an automatic friction machine was used for quantitative evaluation. The silicon sheet was scratched using HHS 2000 with 750-g load at 50 mm/min. We investigated the frictional force exerted on the surface for each of the objects. The degree of damage (depth) was the highest for the disposable scalpel, followed by PVDC-coated PVC PTP, while the degree of damage (depth) was the lowest for soft PThPa and round PTP. The mean frictional forces on the silicon sheet were 524.0 gf with PVDC-coated PTP, 323.5 gf with soft PThPa, 288.7 gf with round PTP, and 922.7 gf with the disposable scalpel. We developed approaches to qualitatively and quantitatively evaluate the risk of esophageal damage after accidental PTP ingestion. Our findings indicate that the risk of gastrointestinal damage after accidental PTP ingestion is low with soft PTP and round PTP.

Studies of abnormalities of the lower esophageal sphincter during esophageal emptying based on a fully coupled bolus-esophageal-gastric model

The aim of this work was to develop a fully coupled bolus-esophageal-gastric model based on the immersed boundary-finite element method to study the process of esophageal emptying across the esophagogastric junction (EGJ). The model included an esophageal segment, an ellipsoid-shaped stomach, a bolus, and a simple model of the passive and active sphincteric functions of the lower esophageal sphincter (LES). We conducted three sets of case studies: (1) the effect of a non-relaxing LES; (2) the influence of the tissue anisotropy in the form of asymmetrical right- and left-sided compliance of the LES segment; and (3) the influence of LES and gastric wall stiffness on bulge formation of the distal esophageal wall. We found that a non-relaxing LES caused sustained high wall stress along the LES segment and obstruction of bolus emptying. From the simulations of tissue anisotropy, we found that the weaker side (i.e., more compliant) of the LES segment sustained greater deformation, greater wall shear stress, and a greater high-pressure load during bolus transit. In the third set of studies, we found that a right-sided bulge in the esophageal wall tends to develop during esophageal emptying when LES stiffness was decreased or gastric wall stiffness was increased. Hence, the bulge may be partly due to the asymmetric configuration of the gastric wall with respect to the esophageal tube. Together, the observations from these simulations provide insight into the genesis of epiphrenic diverticula, a complication observed with esophageal motility disorders. Future work, with additional layers of complexity to the model, will delve into the mechanics of gastroesophageal reflux and the effects of hiatus hernia on EGJ function.

Three-Dimensional Myoarchitecture of the Lower Esophageal Sphincter and Esophageal Hiatus Using Optical Sectioning Microscopy

Studies to date have failed to reveal the anatomical counterpart of the lower esophageal sphincter (LES). We assessed the LES and esophageal hiatus morphology using a block containing the human LES and crural diaphragm, serially sectioned at 50 μm intervals and imaged at 8.2 μm/pixel resolution. A 3D reconstruction of the tissue block was reconstructed in which each of the 652 cross sectional images were also segmented to identify the boundaries of longitudinal (LM) and circular muscle (CM) layers. The CM fascicles on the ventral surface of LES are arranged in a helical/spiral fashion. On the other hand, the CM fascicles from the two sides cross midline on dorsal surface and continue as sling/oblique muscle on the stomach. Some of the LM fascicles of the esophagus leave the esophagus to enter into the crural diaphragm and the remainder terminate into the sling fibers of the stomach. The muscle fascicles of the right crus of diaphragm which form the esophageal hiatus are arranged like a “noose” around the esophagus. We propose that circumferential squeeze of the LES and crural diaphragm is generated by a unique myo-architectural design, each of which forms a “noose” around the esophagus.

Effect of submucosal tunneling endoscopic resection for submucosal tumors at esophagogastric junction and risk factors for failure of en bloc resection

BACKGROUND AND AIMS

Most submucosal tumors (SMTs) in the esophagogastric junction (EGJ) are irregularly shaped and different from those in the esophagus, where submucosal tunneling endoscopic resection (STER) has been proven effective and safe. However, few reports paid attention to STER for SMTs in the EGJ. The aim of the study was not only to evaluate the effect of STER in patients with SMTs in the EGJ but to analyze the risk factors for failure of en bloc resection.

METHODS

A consecutive of 47 patients with SMTs originating from the muscularis propria (MP) layer in the EGJ underwent STER were retrospectively included between September 2012 and December 2016. Thirty-five tumors underwent en bloc resection, and the other 12 tumors received piecemeal resection. The tumor size, operation time, en bloc resection rate, complications, residual, and local recurrence were achieved and compared between the two groups.

RESULTS

Forty-six of 47 lesions (97.9%) were successfully resected. The mean lesion size was 29.7 ± 16.3 mm. Both the en bloc resection rate and complete resection rate were 74.5% (35/47). No severe complications occurred in the 47 patients. Patients in the piecemeal resection group had more irregularly shaped lesions, longer tumor diameter, larger tumor size (≥40 mm), longer operation time, and longer hospital stay after procedure (P < 0.05), and there were no statistically differences between the two groups in in-operative complications, post-operative complications, and residual rate (P > 0.05). By univariate analysis and stepwise logistic regression analysis, irregular shape and tumor diameter ≥20 mm were two risk factors for failure of en bloc resection.

CONCLUSIONS

STER is an effective and safe technique for the treatment of SMTs arising from the MP layer in the EGJ. Irregular shape and tumor diameter ≥20 mm are the reliable risk factors for en bloc resection failure.

Microscopic dual-energy CT (microDECT): a flexible tool for multichannel ex vivo 3D imaging of biological specimens

Dual-energy computed tomography (DECT) uses two different x-ray energy spectra in order to differentiate between tissues, materials or elements in a single sample or patient. DECT is becoming increasingly popular in clinical imaging and preclinical in vivo imaging of small animal models, but there have been only very few reports on ex vivo DECT of biological samples at microscopic resolutions. The present study has three main aims. First, we explore the potential of microscopic DECT (microDECT) for delivering isotropic multichannel 3D images of fixed biological samples with standard commercial laboratory-based microCT setups at spatial resolutions reaching below 10 μm. Second, we aim for retaining the maximum image resolution and quality during the material decomposition. Third, we want to test the suitability for microDECT imaging of different contrast agents currently used for ex vivo staining of biological samples. To address these aims, we used microCT scans of four different samples stained with x-ray dense contrast agents. MicroDECT scans were acquired with five different commercial microCT scanners from four companies. We present a detailed description of the microDECT workflow, including sample preparation, image acquisition, image processing and postreconstruction material decomposition, which may serve as practical guide for applying microDECT. The MATLAB script (The Mathworks Inc., Natick, MA, USA) used for material decomposition (including a graphical user interface) is provided as a supplement to this paper (https://github.com/microDECT/DECTDec). In general, the presented microDECT workflow yielded satisfactory results for all tested specimens. Original scan resolutions have been mostly retained in the separate material fractions after basis material decomposition. In addition to decomposition of mineralized tissues (inherent sample contrast) and stained soft tissues, we present a case of double labelling of different soft tissues with subsequent material decomposition. We conclude that, in contrast to in vivo DECT examinations, small ex vivo specimens offer some clear advantages regarding technical parameters of the microCT setup and the use of contrast agents. These include a higher flexibility in source peak voltages and x-ray filters, a lower degree of beam hardening due to small sample size, the lack of restriction to nontoxic contrast agents and the lack of a limit in exposure time and radiation dose. We argue that microDECT, because of its flexibility combined with already established contrast agents and the vast number of currently unexploited stains, will in future represent an important technique for various applications in biological research.

Three-dimensional reconstruction of neovasculature in solid tumors and basement membrane matrix using ex vivo X-ray microcomputed tomography

OBJECTIVE

To create accurate, high-resolution 3D reconstructions of neovasculature structures in xenografted tumors and Matrigel plugs for quantitative analyses in angiogenesis studies in animal models.

METHODS

The competent neovasculature within xenografted solid tumors or Matrigel plugs in mice was perfused with Microfil, a radioopaque, hydrophilic polymerizing contrast agent, by systemic perfusion of the blood circulation via the heart. The perfused tumors and plugs were resected and scanned by X-ray micro-CT to generate stacks of 2D images showing the radioopaque material. A nonbiased, precise postprocessing scheme was employed to eliminate background X-ray absorbance from the extravascular tissue. The revised binary image stacks were compiled to reveal the Microfil-casted neovasculature as 3D reconstructions. Vascular structural parameters were calculated from the refined 3D reconstructions using the scanner software.

RESULTS

Clarified 3D reconstructions were sufficiently precise to allow measurements of vascular architecture to a diametric limit of resolution of 3 μm in tumors and plugs.

CONCLUSIONS

Ex vivo micro-CT can be used for 3D reconstruction and quantitative analysis of neovasculature including microcirculation in solid tumors and Matrigel plugs. This method can be generally applied for reconstructing and measuring vascular structures in three dimensions.

Respiratory physiotherapy in gastroesophageal reflux disease: A review article

Gastroesophageal reflux disease (GERD) is a frequent disorder which is expensive to diagnose and treat. Initiating therapy with empiric trial of proton-pump inhibitor is a well established strategy; however, symptoms of GERD do often persist regardless of effective medication. Nowadays, increasing interest concerning the efficacy and safety of chronic acid suppression with proton-pump inhibitors (PPIs), prompts a consideration for GERD treatment strategies related to the basic physiology of the lower esophageal sphincter, including modulation of its tone and ending of spontaneous transient lower esophageal sphincter relaxation, which contributes to reflux. Together, the lower esophageal sphincter and the crural diaphragm represent the major antireflux barrier, protecting the esophagus from reflux of gastric content. In order to prevent the need for enduring PPIs therapy or surgical procedures, substitute therapeutics approaches are being researched. Recently, studies have focused on the response of the respiratory muscles to inspiratory muscle training. As a result, inspiratory muscle training has emerged as a potential alternative for treatment of gastroesophageal reflux. The present report reviews the physiologic factors contributing to GERD, and presents the newly developed therapies that can be applied either alone or in association with available efficient GERD therapy.

Myelomeningocele: How we can improve the assessment of the most severe form of spina bifida

Myelomeningocele (MMC) is a devastating spinal cord birth defect, which results in significant life-long disabilities, impaired quality of life, and difficult medical management. The pathological progression of MMC involves failure in neural tube and vertebral arch closure at early gestational ages, followed by subsequent impairment in spinal cord and vertebral growth during fetal development. MMC is irreversible at term. Thus, prenatal therapeutic strategies that interrupt progressive pathological processes offer an appealing approach for treatment of MMC. However, a thorough understanding of pathological progression of MMC is mandatory for appropriate treatment to be rendered. This article is part of a Special Issue entitled SI: Spinal cord injury.

Physiology of the upper segment, body, and lower segment of the esophagus

The following discussion on the physiology of the esophagus includes commentaries on the function of the muscularis mucosa and submucosa as a mechanical antireflux barrier in the esophagus; the different mechanisms of neurological control in the esophageal striated and smooth muscle; new insights from animal models into the neurotransmitters mediating lower esophageal sphincter (LES) relaxation, peristalsis in the esophageal body (EB), and motility of esophageal smooth muscle; differentiation between in vitro properties of the lower esophageal circular muscle, clasp muscle, and sling fibers; alterations in the relationship between pharyngeal contraction and relaxation of the upper esophageal sphincter (UES) in patients with dysphagia; the mechanical relationships between anterior hyoid movement, the extent of upper esophageal opening, and aspiration; the application of fluoroscopy and manometry with biomechanics to define the stages of UES opening; and nonpharmacological approaches to alter the gastroesophageal junction (GEJ).