Peter Kunwald

A new technique for evaluating sphincter function in visceral organs: application of the functional lumen imaging probe (FLIP) for the evaluation of the oesophago–gastric junction

No quantitative method has been implemented routinely in clinical practice to assess the oesophago-gastric junction (OGJ). Using impedance planimetry a functional lumen imaging probe (FLIP) was constructed to measure eight cross-sectional areas (CSA) at 4 mm intervals inside a saline-filled bag. To validate the FLIP technique for profiling the OGJ, polymethylmethacrylate (Perspex) cylinders with different CSAs were measured ten times by the FLIP to assess reproducibility and accuracy. A geometric sphincter phantom was constructed and its geometry was measured with a 360 degrees radial ultrasound (US) mini-probe pulled through it at a rate of 1 mm s(-1). The measurements were compared with FLIP measurements. Safety and technique reproducibility were tested on a volunteer. Reproducibility and accuracy between the ten samples were good. The probe performed well with and without a balloon mounted on it except for the smallest CSA (38.5 mm(2)) where there was a difference of 22% from the actual value at one CSA measurement point. The FLIP imaged the phantom geometry as well as the radial scanning US mini-probe. Pilot studies on a volunteer showed that the probe could be placed in the OGJ and the balloon distensions revealed the geometry of the sphincter at various levels of distension. The technique may be useful in accessing the role of the OGJ in diseases such as gastroesophageal reflux disease (GORD) and achalasia and their treatments with surgical and endoscopic therapies.

Functional lumen imaging of the gastrointestinal tract.

This nonsystematic review aims to describe recent developments in the use of functional lumen imaging in the gastrointestinal tract stimulated by the introduction of the functional lumen imaging probe. When ingested food in liquid and solid form is transported along the gastrointestinal tract, sphincters provide an important role in the flow and control of these contents. Inadequate function of sphincters is the basis of many gastrointestinal diseases. Despite this, traditional methods of sphincter diagnosis and measurement such as fluoroscopy, manometry, and the barostat are limited in what they can tell us. It has long been thought that measurement of sphincter function through resistance to distension is a better approach, now more commonly known as distensibility testing. The functional lumen imaging probe is the first medical measurement device that purports in a practical way to provide geometric profiling and measurement of distensibility in sphincters. With use of impedance planimetry, an axial series of cross-sectional areas and pressure in a catheter-mounted allantoid bag are used for the calculation of distensibility parameters. The technique has been trialed in many valvular areas of the gastrointestinal tract, including the upper esophageal sphincter, the esophagogastric junction, and the anorectal region. It has shown potential in the biomechanical assessment of sphincter function and characterization of swallowing disorders, gastroesophageal reflux disease, eosinophilic esophagitis, achalasia, and fecal incontinence. From this early work, the functional lumen imaging technique has the potential to contribute to a better and more physiological understanding of narrowing regions in the gastrointestinal tract in general and sphincters in particular.

Tissue softening of guinea pig oesophagus tested by the tri-axial test machine

Tissue softening is commonly reported during mechanical testing of biological tissues in vitro. The loss of stiffness may be due to viscoelasticity-induced softening (the time-history of load-caused softening) and strain-induced stress softening (the maximum previous load-caused softening). However, the knowledge about tissue softening behaviour is presently poor. The aims of this study were to distinguish whether the loss of the stiffness during preconditioning was due to strain softening or viscoelasticity and to test the tissue softening in circumferential and longitudinal direction in the guinea pig oesophagus. Eight repeated pressure controlled ramp distensions and eight uniaxial tensile-release ramp stretches in three series were done on eight guinea pig oesophagi. The stress-strain curves were used to display the time-dependency (viscoelasticity) and the maximum previous load-caused softening (strain softening) in circumferential and longitudinal directions. For both the longitudinal and the circumferential softening, the peak stress and stiffness produced during the first loading were bigger than those produced in the remaining loadings. The stress loss due to strain softening was about three times more than that due to viscoelasticity in the longitudinal direction. The strain increased more than two times between the strain softening and viscoelastic softening in the circumferential direction. With a stress level of 20 kPa, the stiffness in the circumferential direction lost more than that in the longitudinal direction (P<0.05), indicating the anisotropic softening properties in the oesophagus. In conclusion, the stiffness loss during preconditioning is mainly attributed to strain softening, appears irreversible and is anisotropic.

Stomach stress and strain depend on location, direction and the layered structure

The stomach is as other parts of the gastrointestinal tract functionally subjected to dimensional change. Hence, the biomechanical properties are of functional importance. Our group has previously demonstrated that the stress-strain properties of the rat and rabbit stomach wall were species-, location- and direction-dependent. We further wanted to study the anisotropic biomechanical properties of the stomach wall in pigs. Furthermore, we made an in-depth biomechanical test on the layered wall of the stomach in different regions. Two stomach strips were cut both in longitudinal direction (parallel with the greater curvature) and circumferential direction (perpendicular to the greater curvature) from the gastric fundus, corpus and antrum. One strip was used for the non-separated (intact) wall test and the other one was separated for the test on the mucosa-submucosa and muscle layers individually. The length, thickness and width of each strip were measured from digital images. The uni-axial stress and strain were computed from the force generation and the tissue strip deformation during stretching. The muscle layer was the thickest in the antrum whereas the mucosal-submucosal layer was the thickest in the corpus of the stomach (P<0.01). The strips from the corpus were stiffest among the three regions in both longitudinal and circumferential directions (P<0.001). The longitudinal strips was stiffer than the circumferential strips in all three regions (P<0.001) and the mucosa-submucosa strips was stiffer than the intact wall and the muscle layer in both directions for the fundus and the corpus (P<0.001). The constant a of the intact wall and mucosa-submucosa layer was in both directions linearly associated with the mucosa-submucosa thickness. In conclusion, the uni-axial stress-strain curves of pig stomach were location-, direction- and layer-dependent. The stiffer wall in the corpus is likely due to its thicker mucosa, i.e., the stiffness of the mucosa-submucosa layer seems can explain the intact wall stiffness. Since the structure and function of the pig stomach are similar to the human stomach, we believe that the data obtained from this study can be extended to humans. Detailed biomechanical mapping of the stomach will likely help us to understand physiological functions of the different parts of the human stomach, such as gastric accommodation and mechanosensation.

A new distensibility technique to measure sphincter of Oddi function

Background  Evaluation of the biliary tract is important in physiological, pathophysiological, and clinical studies. Although the sphincter of Oddi (SO) can be evaluated with manometry, this technique has several limitations. This may explain the difficulties in identifying pathophysiological mechanisms for dysfunction of the SO and in identifying patients who may benefit from certain therapies. To encompass problems with manometry, methods such as the functional lumen imaging probe (FLIP) technique have been developed to study GI sphincters. This study set about miniaturising the FLIP probe and validating it for measurements in the SO. In order to get a better physiological understanding of the SO the aims were to show the sphincter profile in vivo and motility patterns of SO in pilot studies using volunteers that were experiencing biliary type pain but had normal SO manometry.

Neurogenic adaptation contributes to the afferent response to mechanical stimulation.

This study aimed to characterize the effect of mechanical stimuli on mesenteric afferent nerve signaling in the isolated rat jejunum in vitro. This was done to determine the effect of mechanical stresses and strains relative to nonmechanical parameters (neurogenic adaptation). Mechanical stimulations were applied to a segment of jejunum from 15 rats using ramp distension with water at three rates of distension, a relaxation test (volume maintained constant from initial pressure of 20 or 40 mmHg), and a creep test (pressure maintained constant). Circumferential stress and strain and the spike rate increase ratio were calculated for evaluation of afferent nerve activity during the mechanical stimulations. Ramp distension evoked two distinct phases of afferent nerve signaling as a function of circumferential stress or strain. Changing the volume distension rate did not change the stress-strain relationship, but faster distension rate increased the afferent firing rate (P < 0.05). In the stress relaxation test, the spike rate declined faster and to a greater extent than the stress. In the creep test, the spike rate declined, despite a small increase in the strain. Three classes of mechanosensitive single-afferent units (low, wide dynamic range, and high threshold units) showed different response profiles against stress and strain. Low-threshold units exhibited a near linear relationship against the strain (R(2) = 0.8095), whereas high-threshold units exhibited a linear profile against the stress (R(2) = 0.9642). The afferent response is sensitive to the distension speed and to the stress and strain level during distension. However, the afferent nerve response is not a simple function of either stress or strain. Nonmechanical time-dependent adaptive responses other than those related to viscoelasticity also play a role.

Model for electrical field distribution in the human esophagus during stimulation with patch and ring electrodes

Introduction. Electrical stimulation is used in experimental human pain models. The aim was to develop a model that visualizes the distribution of electrical field in the esophagus close to ring and patch electrodes mounted on an esophageal catheter and to explain the obtained sensory responses. Methods. Electrical field distribution in esophageal layers (mucosa, muscle layers, and surrounding tissue) was computed using a finite element model based on a 3D model. Each layer was assigned different electrical properties. An electrical field exceeding 20 V/m was considered to activate the esophageal afferents. Results. The model output showed homogeneous and symmetrical field surrounding ring electrodes compared to a saddle-shaped field around patch electrodes. Increasing interelectrode distance enlarged the electrical field in muscle layer. Conclusion. Ring electrodes with 10 mm interelectrode distance seem optimal for future catheter designs. Though the model needs further validation, the results seem useful for electrode designs and understanding of electrical stimulation patterns.

Design of a static pressure stimulation system for neurophysiological investigation of human middle ear function

In this work, we describe a rapid, safe and accurate airflow injection method for neurophysiological investigations of the middle ear pressure regulation. The need for such a system arises from new knowledge about a variety of middle ear disorders that could have neurophysiological origins as well as a new understanding about human atmospheric pressure sensitivity. The performance of the system was investigated to confirm its reliability under a set of designated tasks.