Cystic fibrosis (CF) is a condition arising from a genetic disorder of the cystic fibrosis transmembrane conductance regulator (CFTR) protein traversing luminal organ epithelial lining. Nasal potential difference (NPD) measurement can be used to study CF through evaluation of CFTR channel activity. Salt-bridge-based probes in combination with calomel electrodes have been used to provide discriminative information between normal and CF patients. This setup is bulky and less convenient for use in a clinical setting. Thus, we have developed a small caliber NPD probe and validated it in 3 normal subjects, providing results consisted to those reported in literature.
OCT-based tethered capsule endomicroscopy (TCE) is an emerging tool for unsedated Barrett’s Esophagus (BE) screening. Cancer progression risk is best determined by acquiring and analyzing a BE tissue sample. We report a TCE device with a biopsy channel capable of extracting tissue samples in an unsedated platform. We show in swine studies (n=2) the biopsy capsule can locate simulated targets and visualize the extraction of biopsies. Owing to its capacity to be utilized in patients without requiring sedation, this new technology could be useful for screening for BE subjects who have an elevated risk of developing cancer.
Our lab has developed a 2-mm-diameter transnasal introduction tube (TNIT) that enables safe and rapid optical coherence tomography (OCT) imaging of the upper gastrointestinal tract in unsedated pregnant women. Here, we report our clinical experience with TNIT-based OCT imaging in unsedated pregnant women (n=5) at Mass General Hospital (MGH). Results show that OCT imaging of the esophagus, stomach, and duodenum can be safely and effectively conducted in pregnant women with this device.
We have developed a new self-propelled OCT imaging technology called retrograde Tethered Capsule Endomicroscopy
(R-TCE) for colonic disease screening. We successfully demonstrated that the R-TCE device can be advanced over 1 meter in 5 swine colons in vivo. R-TCE with balloon pullback imaging enabled full circumferential OCT visualization of 95.94 % ± 0.13% of the colon wall. 3D reconstructed colon OCT images and 3D rendered flythroughs showed that R-TCE is feasible for OCT microscopic imaging of the entire colon in vivo. When translated to humans, this R-TCE
technology may provide a less invasive and more efficient alternative to colonoscopy.
We have previously demonstrated a miniaturized transnasal introduction tube (TNIT) for transnasal endomicroscopy (TNEM) with optical coherence tomography (OCT) for clinical imaging of the small intestine of infants and adults in vivo. Although the TNIT is a convenient and effective way to implement TNEM, OCT probes for imaging through the TNIT had long manufacturing times and low yields, and its multiple cylindrical surfaces caused severe optical aberrations, degrading OCT image quality. Here we introduce a new optical design for 3D-printed microoptics that correct TNIT-induced astigmatism. Preliminary results show that the lens improves resolution and can be reliably manufactured.
We developed OCT-TCE devices with either guidewire or propylene glycol infusion tethers and tested pullback force and tissue damage over different distances of the small intestine in living swine. For all devices, the maximum force was below our safety threshold of 2N across intestinal lengths of 4m or less. At lengths > 4m, the force was > 4N for the infusion tube devices and > 5N for the guidewire devices, and the proximal intestine showed visible damage matching the tether shape. In conclusion, TCE may be safe for jejunal imaging but likely needs further improvement for ileum imaging in humans.
Endoscopic biopsies play a vital role in the diagnosis of many diseases of the gastrointestinal (GI) tract. The standard means of biopsy capture using forceps presents challenges in obtaining adequate tissue samples, especially for unsedated transnasal endoscopy (uTNE). Cryobiopsy is an emerging minimally-invasive alternative where the distal tip of a dual-lumen uTNE probe is cooled momentarily, freezing and adhering the tissue in contact, which is collected for histology. OCT image guidance during cryobiopsy can enable pre-biopsy lesion examination; however, dimensional constraints make this challenging. Here, we demonstrate a microscale 3D-printed device capable of minimally-invasive side-viewing OCT image-guided cryobiopsy though uTNE scopes.
Celiac disease (CD) is an autoimmune disease that damages the small intestine's villi upon gluten ingestion. Intestinal biopsy via esophagogastroduodenoscopy is the current diagnostic gold standard for CD, but this procedure requires sedation and suffers from sampling error. Here, we conducted a clinical study to test whether image biomarkers derived from duodenal OCT tethered capsule endomicroscopy (TCE) can be used to diagnose CD. Results showed a statistically significant difference in OCT image metrics (villus height & width, contrast, and homogeneity with p<0.0001) among active CD, inactive CD and healthy subjects, demonstrating the potential of TCE for the diagnosis of CD.
A screening test for early detection of pancreatic cancer (PC) is a critical unmet need as PC is usually detected late when mortality is unavoidable. Pancreatic fluid (PF), excreted to the duodenum by the Ampulla of Vater (AoV), offers a promising sample for early stage pancreatic cancer screening as it is the richest source of PC bioanalytes. The successful identification of the AoV is critical to develop a minimally invasive and inexpensive capsule-based PC screening test. With our recently developed tether capsule endomicroscopy (TCE) technique, we imaged 27 subjects and analyzed 353 duodenal OCT-TCE datasets. Using relative positions of the major and minor ampulla, and influx of bile into the duodenum, we distinguished the major from the minor. At least one ampulla was identified in 100%, major ampulla identified in 85%, and minor ampulla identified in 67% of all subjects. The measured mean max. diameter of the major ampulla was 6.49 ± 2.23 mm, and 6.09 ± 2.05 mm for the minor.
For OCT-tethered capsule endomicroscopy (TCE) to be a useful minimally invasive tool for evaluating Crohn’s disease, the capsule must be able to be localized within the terminal ileum where the disease often manifests. Here, we developed a machine learning algorithm to assign OCT images of the small intestine into their corresponding anatomical regions. We selected a convolutional neural network and trained it on a set of 2108 cross-sectional images obtained from four swine ex vivo imaging studies to classify images into duodenum, jejunum, or terminal ileum. The model achieved 93±1.72% (95% confidence interval) accuracy on a separate test set of 846 images. These results suggest machine learning may be used to automatically determine when the capsule is in the terminal ileum, enabling microscopic evaluation of this anatomical segment that exhibits pathology in Crohn’s disease.
Significance: While spectral-domain optical coherence tomography (SD-OCT) is a preferred form of OCT imaging, sensitivity roll-off limits its applicability for certain biomedical imaging applications.
Aim: The aim of this work is to extend the imaging range of conventional SD-OCT systems for imaging large luminal organs such as the gastrointestinal tract.
Approach: We present an SD-OCT system operating at a center wavelength of 1300 nm that uses two delayed reference arms to reduce sensitivity roll-off and an optical switch and a fiber optic delay line to ensure that the interference spectra are acquired from the same sample time window.
Result: The proposed system was used to image swine colon ex vivo and duodenum in vivo, demonstrating improved image quality due to a ∼14 dB increase in sensitivity at the edges of the ranging depth.
Conclusion: The proposed system requires modest hardware implementation and is compatible with catheter-based endoscopic helical scanning with enhanced sensitivity for the samples at a distance of ∼6 mm from the zero delay point.
Environmental enteric dysfunction (EED) is a pathological condition of the small intestine that is endemic to low- and middle-income countries (LMICs). EED is thought to interfere with nutrient absorption and enteropathogen exclusion, resulting in altered immune response, increased infection, and limited neurological and physical development. Biopsy of the small intestine is the current diagnostic gold standard for diagnosis yet is untenable due to lack of availability in these countries. Endoscopic biopsy is further problematic since EED-related stunting can only be reversed if diagnosed in the first two years of life when endoscopy must be conducted under anesthesia in advanced medical care settings. Thus, there is an unmet need for a minimally invasive technology for obtaining small intestinal biopsies in unsedated infants in LMICs. To address this need, we have developed an OCT image-guided trans-nasal cryobiopsy device. The device comprises a dual-lumen 1.2 mm outer diameter (OD) probe, terminated by a metal tip, through which Freon is injected. The device is introduced through the lumen of a novel liquid-metal transnasal imaging tube that passively transits to the small intestine. M-mode OCT image guidance is used to determine when the metal tip is in contact with the mucosa so that cryobiopsies may be efficiently acquired. We have conducted feasibility experiments using this device in 10 swine in vivo, demonstrating residual bleeding that is comparable to conventional excisional biopsy, tissue sampling volumes that are greater than or equal to those of conventional biopsy, and high-quality histopathology. These results suggest that this transnasal cryobiopsy technique may be suitable for infants in low-resource settings where EED is prevalent, due to its simplicity and its ability to be used in unsedated subjects.
Upper endoscopy is a standard technique for imaging, sampling, and treating gastrointestinal tissue. Endoscopy is frequently requiring the subjects who undergo the procedure be consciously sedated. Sedation necessitates that the endoscopy procedure be conducted in a specialized setting to mitigate complications should they arise. Endoscopy is further problematic for infants and young children (aged 0-24 months) who sometimes need to be anesthetized. These issues motivate alternative methods for upper gastrointestinal tract visualization and biopsy that do not require conscious sedation/anesthesia. To address this need, we have developed a double lumen 6.5 Fr transnasal introduction catheter (TNIC). During transnasal insertion, real-time OCT imaging provides confirmation of the anatomical location of the device. Once in the stomach, a safe and high-density liquid metal fills a balloon at the distal tip of the TNIC, allowing it to passively transit through stomach into the small intestine. Once properly positioned, OCT-guided instruments for imaging and biopsy can be inserted through main lumen of the TNIC, performing many of the functions of conventional endoscopy and advanced endomicroscopy. To test the feasibility of the TNIC, we conducted a clinical study using the first version of the device in 4 unsedated normal volunteers. Results showed detailed OCT endomicroscopy images of the esophagi and duodena. These results suggest that TNIC may be an effective, less invasive method for the diagnosis of upper GI tract conditions.
KEYWORDS: Optical coherence tomography, Endomicroscopy, Intestine, Endoscopy, Inflammation, Biopsy, 3D image processing, Visualization, Control systems
Environmental Enteric Dysfunction (EED) is a poorly understood condition of the small intestine that is prevalent in regions of the world with inadequate sanitation and hygiene. EED affects 25% of all children globally and causes over a million deaths each year. The condition is associated with increased intestinal permeability, bacterial translocation, inflammation and villous blunting. The loss of absorptive area and intestinal function leads to nutrient malabsorption, with long term outcomes characterized by stunted growth and neurocognitive development. Currently, the only way to directly evaluate the morphology of the intestine is endoscopy with mucosal biopsy. Yet because EED is endemic in low and middle-income countries, endoscopy is untenable for studying EED. As a result, the diagnosis of EED and the assessment of the efficacy of EED interventions is hampered by an inability to evaluate the intestinal mucosa.
Our lab has previously developed a technology termed tethered capsule OCT endomicroscopy (TCE). The method involves swallowing an optomechanically-engineered pill that generates 3D images of the GI tract as it traverses the lumen of the organ via peristalsis, assisted by gravity. In order to study the potential of using TCE to investigate EED, we initiated and conducted a TCE study in adolescents at Aga Khan Medical Center in Pakistan. To make swallowing easier, the tethered capsule’s size was reduced from 11x25 mm to 8x22 mm. Villous morphologic visualization was enhanced by building a notch (x mm deep, y mm wide) in the capsule’s imaging window. To date, 26 Pakistani subjects with ages ranging from 14 to 18 y/o (16.4 +/- 1.0) have been enrolled and imaged. A total of 19 subjects were able to swallow the capsule. Of those, 9 successfully passed through the pylorus, allowing successful microscopic imaging of the entire duodenum. There were no adverse events in any of the cases. Maximum villous height and width were measured from 3 randomly chosen, representative frames from each Pakistan subject as well as a matching number from US controls. Preliminary results, comparing Pakistani vs US villous morphology, indicated that subjects from Pakistan have shorter (628.6 +/- 22.0 um and 492.3 +/- 13.2 um, respectively, p< 0.0001) and wider duodenal villi (244.9 +/- 8.8 um and 293.4 +/- 13.2 um, respectively, p< 0.0001). These findings suggest that OCT TCE of the duodenum may be a useful tool for evaluating villous morphology in EED.
Environmental enteric dysfunction (EED) is a poorly understood condition of the small intestine prevalent in low and middle income countries. This disease is believed to cause nutrient malabsorption and poor oral vaccine uptake, resulting in arrested neurological development and growth stunting in children that persists as they grow into adulthood. Optical coherence tomography (OCT) imaging of the small intestine can potentially capture some of the microstructural changes, such as villous blunting, in the small gut that accompany EED, and hence could potentially improve the understanding of EED and help in determining and monitoring the effectiveness of EED interventions. Notably, EED must be studied and diagnosed in infants, aged 0-24 months as this is the only window in which interventional strategies can reverse the disease. In order to address this need, we propose a trans-nasal OCT imaging technique for imaging the small intestine that may be suitable for low-resource settings owing to its simplicity, ease of administration, and implementation in unsedated infants. To demonstrate the potential of transnasal OCT intestinal imaging, we have created a 10 Fr transnasal OCT imaging probe and have submitted an IRB application for a first-in-human study using this probe to image the adult small intestine. We anticipate that the results from this pilot study will justify the development of a transnasal OCT intestinal imaging device for infants.
Environmental enteric dysfunction (EED) is a poorly understood disease of the small intestine that causes nutrient malabsorption in children, predominantly from low and middle income countries. The clinical importance of EED is neurological and growth stunting that remains as the child grows into adulthood. Tethered capsule endomicroscopy (TCE) has the potential to improve the understanding of EED and could be used to determine the effectiveness of EED interventions. TCE in the adult esophagus and the duodenum has been demonstrated for Barrett`s esophagus and celiac disease diagnosis, respectively. While adult subjects can independently swallow these capsules, it is likely that infants will not, and, as a result, new strategies for introducing these devices in young children aged 0.5-2 years need to be investigated. Our first approach will be to introduce the TCE devices in infants under the aid of endoscopic guidance. To determine the most effective method, we have tested endoscopic approaches for introducing TCE devices into the small intestine of living swine. These methods will be compared and contrasted to discuss the most effective means for endoscopic tethered capsule introduction into the small intestine.
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