Muscularis Propria Layer Research Articles

Improving Endotherapy - A New Concept for Intraluminal Endoscopic Suturing

Advances in intraluminal endoscopic suturing may lead to new minimally invasive treatments for gastrointestinal disorders. However, unlike the serosa, the mucosal surface is challenging to induce tissue fusion. This study demonstrates a technique to create permanent intraluminal partitioning of the stomach that could be adapted for endoluminal surgery through gastrointestinal endoscopes. M&M: Six pigs underwent an open gastrostomy to access the gastric lumen. The aim was to suture opposing walls of the stomach using only intraluminal manipulation to induce a permanent partition. Gastric partitioning was performed at different levels and lengths for each animal. Initially, a one-cm wide mucosal resection of the walls to be sutured was performed. The exposed areas of muscularis propria were joined by suturing the two edges of the mucosectomy with Vicryl 3-0. Each animal had one gastric partitioning extending from 5 to 10 cm. The gastrostomy and the abdominal wall were closed. Animals were allowed to recover and had a liquid diet during the survival period. Endoscopy was performed after 3, 7 and 14 days to assess the sutured areas. Animals were sacrificed and areas fused by healing sent to histopathology. Results: A permanent fusion was observed endoscopically and histologically in 2/6 of the suture sites at day 14. Histopathology showed collagen deposition between the two layers of muscularis propria, characteristic of the maturation phase of healing, leading to a stable attachment between the walls. Dehiscence with re-epithelization of the mucosectomy sites was observed in 4/6 of the suture sites at days 3 and 7. Conclusions: 1) Intraluminal gastric partitioning can be obtained using mucosectomy followed by apposition of the muscularis propria with sutures. 2) Risk factors for dehiscence are still undetermined. 3) Novel endoscopic sewing devices could potentially reproduce this technique.

Characteristic images of deeply infiltrating rectosigmoid endometriosis on transvaginal and transrectal ultrasonography.

To evaluate the usefulness of transvaginal and transrectal ultrasonography for diagnosis and management of deeply infiltrating rectosigmoid endometriosis. A series of six patients (aged 32-39 years) with rectosigmoid endometriosis underwent transvaginal and transrectal ultrasonography. In three patients undergoing surgical resection of the intestine, the ultrasonographic findings were compared with macroscopic and microscopic findings. In one patient, sequential observations of the lesion using ultrasonography were conducted before and after medical treatment and following childbirth. In all cases, the lesion was detected as a hypoechoic irregular-shaped area surrounded by a hyperechoic rim located posterior to the uterus, with size ranging from 18 x 17 to 29 x 28 mm in diameter. The comparison of the ultrasonographical findings with histology revealed that the hypoechoic irregular-shaped area corresponded to a layer of hypertrophic muscularis propria of the lesion, while the hyperechoic rim represented the layer including the mucosa, submucosa and serosa. In one patient, the lesion decreased in size and lost its central hypoechoic area after childbirth in association with pain relief. Transvaginal and transrectal ultrasonography provides characteristic appearances for rectosigmoid endometriosis that correlate well with its histological findings. The procedures would be useful in the management of rectosigmoid endometriosis.

Experimental endoscopic repair of gastric perforations with an omental patch and clips

Background: The omental patch is a standard surgical treatment of gastroduodenal ulcer perforation. This is a report of an experimental method for endoscopic repair of anterior gastric perforations with an omental patch developed by using a porcine model. Methods: A standardized gastric perforation was created in 10 pigs. The omentum was pulled into the gastric lumen and fixed endoscopically to the muscularis propria layer of the stomach with metallic clips. Results: The postoperative course was normal in 9 animals. An ulcer was evident at the site of repair at follow-up endoscopy. At autopsy, the omentum was adherent to the external side of gastric wall. One animal died with peritonitis, presumably because the muscularis propria layer could not be seen during the procedure, and the clips attached the omentum only to the mucosa. Conclusions: Endoscopic repair with an omental patch appears to be an effective procedure for closure of gastric perforations.

3437 Dynamic holographic endoscopy - pilot investigations using an in-vitro model.

The combination of holographic interferometric metrology and endoscopic imaging can be applied to assess disturbances of gastrointestinal wall elasticity. Connecting an Electronic Speckle Pattern Interferometry (ESPI) camera system with a continuous wave Argon-ion laser (λ=514,5 nm) as its light source to a standard fiber glass gastroscope, we performed in-vitro experiments on porcine stomachs to detect areas characterized by altered tissue elasticity. Linking the endoscopic ESPI camera system to a fast image processing system, we were able to apply the method of double pulse exposure image subtraction at a video frame rate of 12,5 Hz. In a series of experiments, we analysed the speckle correlation patterns resulting from gastric wall deformation induced by gentle touch with a guidewire. Interferograms of gastric wall areas without structural abnormalities showed concentric fringes, the center of which corresponding to the point of stimulation. In contrast to that, fringe patterns that corresponded to areas of reduced tissue elasticity, as produced by implanting foreign materials (e.g., tissue glue) into the muscularis propria layer, were characterized by parallel lines, indicating that stimulation primarily led to tilting. We conclude that gastric wall abnormalities leading to altered tissue elasticity (but not necessarily producing visible changes on the mucosal surface) can be demonstrated by applying the method of dynamic holographic endoscopy.

7022 One uniform endosonographic layer reflects a thin subserosal adipose tissue of the normal gallbladder wall.

Introduction and aim: Endoscopic ultrasonography (EUS) plays a major role in diagnosis of the gallbladder lesions. The normal gallbladder wall has been demonstrated to consist of 3 layers on EUS images. It is generally accepted that the 2nd and the 3rd layers include the muscularis propria and subserosal fibrous tissue, and the subserosal adipose tissue, respectively. However these 3 layers cannot be seen in some normal gallbladder by EUS images. Therefore this study was aimed to clarify the cause of these 2 different EUS images seen normal gallbladder by histological study of the gallbladder wall performed simultaneously. Materials and methods: Gallbladder specimens from 12 autopsy cases without biliary tract disorders, 6 with the three EUS layers (goup A) and 6 with one uniform layer (group B), were enrolled in this study. Two needles were stabbed into the gallbladder wall from the mucosa to perform EUS and histological study for the same area of the specimen. For this study an Olympus GFUMQ 240 with a frequency of 7.5MHz was used. Results: Histology of the specimens were summarized in the table. The thickness of the muscularis propria and fibrous layer showed no significant differences between group A and B. While the thickness of the adipose layer of group B was determined to be one half of group A. Conclusions: This study indicates that the one uniform layer seen in normal gallbladder on EUS images reflects a thin subserosal adipose layer.

Endoscopic ultrasound

Achalasia is a relatively infrequent disorder of oesophageal motility, and is most often easily diagnosed by stationary manometry showing absence of peristalsis and incomplete lower oesophageal sphincter (LOS) relaxation. In rare cases manometric findings may be inconclusive or a malignant underlying disease is suspected. In such cases direct visualization of the LOS by endoscopic ultrasound (EUS) could contribute to securing the diagnosis and possibly lead to earlier diagnosis and treatment. With lower frequency EUS, increased thickness of the inner circular layer of the muscularis propria may be difficult to detect. Available data suggest that high frequency (20 MHz) and 3-D EUS has a potential to reliably discriminate between achalasia patients and normal subjects, and thereby be of diagnostic value.

Intraductal ultrasonography in diagnosing tumor extension of cancer of the papilla of Vater

Background: Intraductal ultrasonography is clinically useful in assessing various pancreatobiliary diseases. This study was carried out to evaluate the usefulness of intraductal ultrasonography in diagnosing tumor extension of cancer of the papilla of Vater. Methods: Thirty-two patients with cancer underwent intraductal ultrasonography. According to the spatial relationship between the tumor echo and the hypoechoic layers representing Oddi's muscle layer or the duodenal muscularis propria layer, the images were classified into four grades. We attempted to diagnose tumor extension using this grading system. Lymph nodes measuring over 10 mm were evaluated as involved. Findings were compared with postoperative histopathologic findings classified as follows: d0, tumor limited to Oddi's muscle layer; d1, tumor invading the duodenal submucosal layer; d2, tumor invading the duodenal muscularis propria layer; and panc(+), tumor invading the pancreas. Results: Diagnostic accuracy rate was 100% (6 of 6) in d0 cases, 92.3% (12 of 13) in d1 cases, 100% (1 of 1) in a d2 case, and 75% (9 of 12) in panc(+) cases. Overall accuracy rate was 87.5% (28 of 32). In assessing lymph node metastases, sensitivity was 66.7% (6 of 9) and specificity was 91.3% (21 of 23). Conclusion: Intraductal ultrasonography examination is useful in diagnosing tumor extension of cancer of the papilla of Vater. (Gastrointest Endosc 1997;45:251-60.)

Short communication: detection of early scirrhous carcinoma of the stomach by endoscopic ultrasonography.

The endoscopic ultrasonography (US) characteristics of early scirrhous carcinoma of the stomach (ESS) were evaluated in four patients. ESS was defined as the presence of poorly differentiated carcinoma cells spreading through the submucosa and muscularis propria in association with a marked desmoplastic reaction without serosal invasion. ESS was characterized by localized irregular hypoechoic enlargement of the third (submucosal) and the fourth (muscularis propria) layers. The fifth (serosal) layer was normal. The third and fourth layers showed a threefold increase in thickness compared with the thickness of these layers in healthy subjects. Our results suggest that endoscopic US is useful for diagnosis of ESS.

Use of air enema radiography to assess depth of ulceration during acute attacks of ulcerative colitis

Summary Background Acute colitis is usually assessed by means of plain abdominal radiographs, the diagnostic utility of which can be enhanced by barium enema. Colonoscopy can also be useful. The latter methods may be laborious and carry risk. We describe a radiographic technique using air as the contrast medium to show mucosal or deeper ulceration. Methods Of 60 patients undergoing colectomy for acute ulcerative colitis, 35 had air enema radiography and 14 had plain films with sufficient amount of spontaneously occurring gas to allow visualisation of the mucosa, during the 10 days before surgery. The degree of inflammation on air enema films and the extent of histopathological ulceration in colectomy specimens were independently graded and compared with each other. Depth of ulceration was compared with clinical data including a preoperative risk stratification, the APACHE II score. Findings The degree of inflammation on air enema radiography correlated significantly with depth of ulceration at histopathological examination (rs 0·61, p<0·001). Presence of mucosal changes had a close association with deep ulceration extending into the muscularis propria layer or beyond (p<0·001). Air enema radiography had a high sensitivity (0·91) for presence of and specificity (0·75) in the exclusion of deep ulceration, with positive and negative predictive values of 0·88 and 0·80. 42 of 49 patients were correctly classified as regards deep ulcers. The correlation between higher preoperative APACHE II scores and severity of histopathological colitis was weak (rs 0·30, p<0·05). Interpretation Air enema radiography reliably assesses the presence of colonic ulceration in patients with an acute attack of ulcerative colitis. It is a first-line investigation to assess the presence of deeper ulceration in acute colitis.

大腸癌における発育進展の検討

The early stage of colorectal cancer is divided into two morphological types ; polypoid and superficial. What percentage of advanced cancer is derived from the polypoid or superficial type is a matter of concern. We designated superficial type tumors from the both morphological and histological viewpoints. Histological designation of superficial type tumor was that there was horizontal growth of cancer in the residual mucosa. The existence of horizontal growing mucosal cancer at the marginal area of cancer is a biomarker showing the lesion being of superficial origin. The rates of arise from superficial tumor of submucosal cancer in the residual mucosa was 29/98 (29.6%) . The cancer with invasion deeper than the muscularis propria layer usually loose cancer in the mucosa, therefore, the rates may not reflect actual incidence. The rate of submucosal cancer (29.6%) may be close to the actual rate at present. It may be useful to focus on the horizontal growing tumor of the colorectum for understanding the advance and development of colorectal tumors.

Peritoneal dissemination after a curative gastrectomy in patients with undifferentiated adenocarcinoma of the stomach.

Peritoneal dissemination is the major pattern of recurrence in patients with gastric cancer. Among the 1,337 patients with gastric cancer who underwent a curative resection, a multivariate analysis showed that the independent risk factors for the occurrence of peritoneal dissemination were an undifferentiated tissue type and serosal invasion. We focus our attention on 477 patients with undifferentiated type tumor, in which the postoperative prognosis and the pattern of recurrence after curative resection were evaluated with regard to the depth of the cancerous invasion in the gastric wall. Patients with tumors limiting to the subserosal layer had a satisfactory post-operative course, with five-year survival rates of 98.5%, 97.4%, and 82.5% in patients with tumors limiting to the submucosal layer, the muscularis propria and subserosal layer, respectively. In 179 patients with tumors invading to the subserosal layer, however, the five year survival rate was only 48.2%. Seventy-one died of peritoneal dissemination, while 24 and 15 were due to hematogenous and local recurrences, respectively. Only 50 (27.9%) survived over 5 years without any recurrence.

Transrectal ultrasound study of the pathogenesis of solitary rectal ulcer syndrome.

Transrectal ultrasonography is of clinical value in anorectal carcinoma and in inflammatory diseases of the anorectum. In this study a rigid linear endorectal probe was used to examine 15 patients with endoscopically and biopsy proved diagnosis of solitary rectal ulcer syndrome. In 13 of the 15 patients the rectal wall was thicker (mean (SEM) 5.7 (0.4) mm; normal values: 2.8 (0.1) mm) near the rectal ulcer. In all these cases the muscularis propria layer exceeded the maximum normal diameter of 2 mm. In nine of the 15 patients the normal rectal wall echo-structure, with five distinct layers, was disturbed and there was fading of the borders between the mucosa and the muscularis propria. Poor relaxation of the puborectalis muscle during straining was seen on ultrasound in 11 patients, as was intussusception of the rectal wall. The obvious enlargement of the muscularis propria points to a chronic mechanical load on the rectal wall. The ulcerative lesions are formed in this area of overloaded rectal wall. The direct visualisation of the puborectalis muscle during dynamic transrectal ultrasonography indicates that the fact that it does not relax is an important element in the pathogenesis of solitary rectal ulcer syndrome.

Evaluation of acetic acid-induced gastric ulcers in dogs by endoscopic ultrasonography.

To clarify the ability of endoscopic ultrasonography (EUS) to diagnose gastric ulcer, we induced gastric ulcer (19 open ulcers and 11 ulcer scars) by injecting acetic acid into the stomach via an endoscope in 15 dogs. The stomachs were resected and scanned by EUS in a water bath, and the findings were compared with the histologic observations. The ulcer depth was correctly diagnosed in 29 of 30 instances (96.7%). In active, open ulcers the width and depth of the ulcer crater and the thickness of the gastric wall around the crater measured in the photographs obtained by EUS corresponded with those observed in histologic photographs. In the ulcers disrupting the muscularis propria layer the distance between the disrupted muscularis propria layer in EUS also corresponded to the histologic observations. In all ulcer lesions the low-echoic area below the ulcer in EUS corresponded to the histologic area of granulation or fibrosis. However, it was difficult to distinguish granulation from fibrosis by EUS. EUS is thus considered useful for evaluating gastric ulcers quantitatively in the clinical setting.

Heterogeneity in gastric carcinoma with special reference to DNA content and mitotic activity: histopathologic differentiation.

DNA ploidy and mitotic activity were microspectrophotometrically investigated in 46 patients with gastric carcinoma. Measurements of DNA content and mitotic index (M.I.) were examined in the mucosal, submucosal, muscularis propria, and serosal layers of tumors, respectively. The frequency of cells with values exceeding hexaploid chromosome (6c) and mitotic counting analysis revealed a significant higher value in serosa, compared with findings in the mucosa. This tendency was not evident in cases of a differentiated type adenocarcinoma but was noted in those with the undifferentiated type. There were 37 tumors (80.0%) with the same DNA distribution patterns in every layer of the stomach (homogeneous DNA ploidy). Heterogeneity of DNA ploidy was observed in nine tumors (20.0%). Carcinoma with a heterogeneous DNA ploidy manifested a significantly higher incidence of metastasis to the lymph nodes than did those with homogeneous type. Characteristically, there was venous permeation preponderance in the differentiated type and peritoneal dissemination preponderance in the undifferentiated type. This evidence of DNA heterogeneity in gastric carcinoma tissues suggests a possible correlation with the metastatic behavior.

Intramural nerves and interstitial cells revealed by the Champy Maillet stain in the opossum esophagus

The 3 layers of smooth muscle of the opossum esophagus exhibit distinctly different and characteristic functions in response to nerve stimulation. These behaviors might be related to differences in patterns of innervation. Serial sections, stained with osmic acid and zinc iodide, were examined from all parts of the esophagus to describe in full the innervation of opossum esophageal smooth muscle. Linear beaded structures identified as terminal nerves were abundant in all 3 layers of smooth muscle. They were aligned with muscle bundles in bundles of 1–5 in mucosal muscle and up to about 10 in the longitudinal layer of muscularis propria. In the circular layer of muscularis propria they were less dense and more arborized and they crossed the muscle obliquely to also innervate bipolar interstitial cells; these cells resembled type III interstitial cells of Cajal, were specific for the circular muscle layer and were uniformly distributed throughout the thickness of that layer. Their distribution density in the circular muscle was slightly greater, 8777/cm 2 in the most caudad 1.5 cm of the esophagus (which encompasses the sphincter) than in the 6 cm above that level. Terminal nerves also innervated submucosal glands, vessels and the epithelium. Ganglion cells and nerve bundles in the submucous and myenteric plexuses were variably stained. Ganglia of the latter plexus contained intraganglionic laminar endings as described previously in other species. In the striated muscle there were nerves terminating in motor end-plates. Other leafy stellate cells resembling interstitial cells of Cajal of other types were stained, as were oval interstitial cells.

Surgical treatment and adjuvant chemotherapy of gastric cancer on the basis of pathological findings.

Gastrectomy was performed in 626 outo 692 operated cases of gastric cancer. Histologic examination of the resected specimens revealed that the cancer was confined to the mucosal (m) or submucosal layer (sm) in 256 cases, advanced to the muscularis propria (pm) or subserosal layer (ss) in 110, and to the serosa (se) or the surrounding organs (si, sei) in 260. 238 (93%) of m and sm cases were free from lymphnode metastasis. Lymphnode metastasis was noted in 51 (46%) of pm and ss cases, 177 (77%) were positive in lymphnode metastasis and 108 (47%) showed metastasis in n2 and n3 degree. Adjuvant chemotherapy fairly improved the psotoperative survival rate of the advanced cases with lymphnode metastasis, serosal involvement, or lymph and blood vessel involement of gastric cancer.