A novel laparoscopic device for measuring gastrointestinal slow-wave activity

[A New Paradigm in Diagnosing Functional Gastroduodenal Disorders: High-Resolution Electrogastrography]

High-resolution electrogastrography (HR-EGG) presents a new paradigm in diagnosing and treating functional gastroduodenal disorders. Unlike traditional electrogastrography, HR-EGG allows for a more precise analysis of the gastric electrical activity, offering improved diagnostic accuracy. Recent studies have revealed the clinical potential of HR-EGG, particularly in detecting abnormal electrical patterns in patients with functional dyspepsia and gastroparesis, supporting the development of novel therapeutic strategies. The non-invasive HR-EGG method has shown promise in identifying new biomarkers. Moreover, further integration of artificial intelligence, is expected to enhance diagnostic efficiency and develop more refined treatment models for functional gastrointestinal disorders.

Clinical application and research progress of extracellular slow wave recording in the gastrointestinal tract

The physiological function of the gastrointestinal (GI) tract is based on the slow wave generated and transmitted by the interstitial cells of Cajal. Extracellular myoelectric recording techniques are often used to record the characteristics and propagation of slow wave and analyze the models of slow wave transmission under physiological and pathological conditions to further explore the mechanism of GI dysfunction. This article reviews the application and research progress of electromyography, bioelectromagnetic technology, and high-resolution mapping in animal and clinical experiments, summarizes the clinical application of GI electrical stimulation therapy, and reviews the electrophysiological research in the biliary system.

Analysis of Intestinal Movements with Spatiotemporal Maps: Beyond Anatomy and Physiology

Over 150 years ago, methods for quantitative analysis of gastrointestinal motor patterns first appeared. Graphic representations of physiological variables were recorded with the kymograph after the mid-1800s. Changes in force or length of intestinal muscles could be quantified, however most recordings were limited to a single point along the digestive tract.In parallel, photography and cinematography with X-Rays visualised changes in intestinal shape, but were hard to quantify. More recently, the ability to record physiological events at many sites along the gut in combination with computer processing allowed construction of spatiotemporal maps. These included diameter maps (DMaps), constructed from video recordings of intestinal movements and pressure maps (PMaps), constructed using data from high-resolution manometry catheters. Combining different kinds of spatiotemporal maps revealed additional details about gut wall status, including compliance, which relates forces to changes in length. Plotting compliance values along the intestine enabled combined DPMaps to be constructed, which can distinguish active contractions and relaxations from passive changes. From combinations of spatiotemporal maps, it is possible to deduce the role of enteric circuits and pacemaker cells in the generation of complex motor patterns. Development and application of spatiotemporal methods to normal and abnormal motor patterns in animals and humans is ongoing, with further technical improvements arising from their combination with impedance manometry, magnetic resonance imaging, electrophysiology, and ultrasonography.

Body surface mapping of the stomach: New directions for clinically evaluating gastric electrical activity

BACKGROUND

Gastric motility disorders, which include both functional and organic etiologies, are highly prevalent. However, there remains a critical lack of objective biomarkers to guide efficient diagnostics and personalized therapies. Bioelectrical activity plays a fundamental role in coordinating gastric function and has been investigated as a contributing mechanism to gastric dysmotility and sensory dysfunction for a century. However, conventional electrogastrography (EGG) has not achieved common clinical adoption due to its perceived limited diagnostic capability and inability to impact clinical care. The last decade has seen the emergence of novel high-resolution methods for invasively mapping human gastric electrical activity in health and disease, providing important new insights into gastric physiology. The limitations of EGG have also now become clearer, including the finding that slow-wave frequency alone is not a reliable discriminator of gastric dysrhythmia, shifting focus instead toward altered spatial patterns. Recently, advances in bioinstrumentation, signal processing, and computational modeling have aligned to allow non-invasive body surface mapping of the stomach to detect spatiotemporal gastric dysrhythmias. The clinical relevance of this emerging strategy to improve diagnostics now awaits determination.

PURPOSE

This review evaluates these recent advances in clinical gastric electrophysiology, together with promising emerging data suggesting that novel gastric electrical signatures recorded at the body surface (termed "body surface mapping") may correlate with symptoms. Further technological progress and validation data are now awaited to determine whether these advances will deliver on the promise of clinical gastric electrophysiology diagnostics.

Bioelectrical Signals for the Diagnosis and Therapy of Functional Gastrointestinal Disorders

Coordinated contractions and motility patterns unique to each gastrointestinal organ facilitate the digestive process. These motor activities are coordinated by bioelectrical events, sensory and motor nerves, and hormones. The motility problems in the gastrointestinal tract known as functional gastrointestinal disorders (FGIDs) are generally caused by impaired neuromuscular activity and are highly prevalent. Their diagnosis is challenging as symptoms are often vague and difficult to localize. Therefore, the underlying pathophysiological factors remain unknown. However, there is an increasing level of research and clinical evidence suggesting a link between FGIDs and altered bioelectrical activity. In addition, electroceuticals (bioelectrical therapies to treat diseases) have recently gained significant interest. This paper gives an overview of bioelectrical signatures of gastrointestinal organs with normal and/or impaired motility patterns and bioelectrical therapies that have been developed for treating FGIDs. The existing research evidence suggests that bioelectrical activities could potentially help to identify the diverse etiologies of FGIDs and overcome the drawbacks of the current clinically adapted methods. Moreover, electroceuticals could potentially be effective in the treatment of FGIDs and replace the limited existing conventional therapies which often attempt to treat the symptoms rather than the underlying condition.

Methods for High-Resolution Electrical Mapping in the Gastrointestinal Tract

Over the last two decades, high-resolution (HR) mapping has emerged as a powerful technique to study normal and abnormal bioelectrical events in the gastrointestinal (GI) tract. This technique, adapted from cardiology, involves the use of dense arrays of electrodes to track bioelectrical sequences in fine spatiotemporal detail. HR mapping has now been applied in many significant GI experimental studies informing and clarifying both normal physiology and arrhythmic behaviors in disease states. This review provides a comprehensive and critical analysis of current methodologies for HR electrical mapping in the GI tract, including extracellular measurement principles, electrode design and mapping devices, signal processing and visualization techniques, and translational research strategies. The scope of the review encompasses the broad application of GI HR methods from in vitro tissue studies to in vivo experimental studies, including in humans. Controversies and future directions for GI mapping methodologies are addressed, including emerging opportunities to better inform diagnostics and care in patients with functional gut disorders of diverse etiologies.

A novel retractable laparoscopic device for mapping gastrointestinal slow wave propagation patterns

BACKGROUND

Gastric slow waves regulate peristalsis, and gastric dysrhythmias have been implicated in functional motility disorders. To accurately define slow wave patterns, it is currently necessary to collect high-resolution serosal recordings during open surgery. We therefore developed a novel gastric slow wave mapping device for use during laparoscopic procedures.

METHODS

The device consists of a retractable catheter constructed of a flexible nitinol core coated with Pebax. Once deployed through a 5-mm laparoscopic port, the spiral head is revealed with 32 electrodes at 5 mm intervals. Recordings were validated against a reference electrode array in pigs and tested in a human patient.

RESULTS

Recordings from the device and a reference array in pigs were identical in frequency (2.6 cycles per minute; p = 0.91), and activation patterns and velocities were consistent (8.9 ± 0.2 vs 8.7 ± 0.1 mm s^-1; p = 0.2). Device and reference amplitudes were comparable (1.3 ± 0.1 vs 1.4 ± 0.1 mV; p = 0.4), though the device signal-to-noise ratio was higher (17.5 ± 0.6 vs 12.8 ± 0.6 dB; P < 0.0001). In the human patient, corpus slow waves were recorded and mapped (frequency 2.7 ± 0.03 cycles per minute, amplitude 0.8 ± 0.4 mV, velocity 2.3 ± 0.9 mm s^-1).

CONCLUSION

In conclusion, the novel laparoscopic device achieves high-quality serosal slow wave recordings. It can be used for laparoscopic diagnostic studies to document slow wave patterns in patients with gastric motility disorders.

Time-Delay Mapping of High-Resolution Gastric Slow-Wave Activity

GOAL

Analytic monitoring of electrophysiological data has become an essential component of efficient and accurate clinical care. In the gastrointestinal (GI) field, recent advances in high-resolution (HR) mapping are now providing critical information about spatiotemporal profiles of slow-wave activity in normal and disease (dysrhythmic) states. The current approach to analyze GI HR electrophysiology data involves the identification of individual slow-wave events in the electrode array, followed by tracking and clustering of events to create a spatiotemporal map. This method is labor and computationally intensive and is not well suited for real-time clinical use or chronic monitoring.

METHODS

In this study, an automated novel technique to assess propagation patterns was developed. The method utilized time delays of the slow-wave signals which was computed through cross correlations to calculate velocity. Validation was performed with both synthetic and human and porcine experimental data.

RESULTS

The slow-wave profiles computed via the time-delay method compared closely with those computed using the traditional method (speed difference: 7.2% ± 2.6%; amplitude difference: 8.6% ± 3.5%, and negligible angle difference).

CONCLUSION

This novel method provides rapid and intuitive analysis and visualization of slow-wave activity.

SIGNIFICANCE

This techniques will find major applications in the clinical translation of acute and chronic HR electrical mapping for motility disorders, and act as a screening tool for detailed detection and tracking of individual propagating wavefronts, without the need for comprehensive standard event-detection analysis.

A physiome interoperability roadmap for personalized drug development

The goal of developing therapies and dosage regimes for characterized subgroups of the general population can be facilitated by the use of simulation models able to incorporate information about inter-individual variability in drug disposition (pharmacokinetics), toxicity and response effect (pharmacodynamics). Such observed variability can have multiple causes at various scales, ranging from gross anatomical differences to differences in genome sequence. Relevant data for many of these aspects, particularly related to molecular assays (known as '-omics'), are available in online resources, but identification and assignment to appropriate model variables and parameters is a significant bottleneck in the model development process. Through its efforts to standardize annotation with consequent increase in data usability, the human physiome project has a vital role in improving productivity in model development and, thus, the development of personalized therapy regimes. Here, we review the current status of personalized medicine in clinical practice, outline some of the challenges that must be overcome in order to expand its applicability, and discuss the relevance of personalized medicine to the more widespread challenges being faced in drug discovery and development. We then review some of (i) the key data resources available for use in model development and (ii) the potential areas where advances made within the physiome modelling community could contribute to physiologically based pharmacokinetic and physiologically based pharmacokinetic/pharmacodynamic modelling in support of personalized drug development. We conclude by proposing a roadmap to further guide the physiome community in its on-going efforts to improve data usability, and integration with modelling efforts in the support of personalized medicine development.

Use of electrogastrography in preclinical studies of cholinergic and anticholinergic agents in experimental pigs

Electrogastrography (EGG) is a non-invasive method for the assessment of gastric myoelectrical activity. Porcine EGG is comparable with human one. The purpose of this study was to evaluate the effect of atropine and neostigmine on the EGG in experimental pigs. Adult female pigs were administrated atropine (1.5 mg i.m., n=6) and neostigmine (0.5 mg i.m., n=6) after the baseline EGG, followed by a 90-min trial recording (MMS, Enschede, the Netherlands). Running spectral analysis was used for the evaluation. The results were expressed as dominant frequency of slow waves and EGG power (areas of amplitudes). Neostigmine increased continuously the dominant frequency and decreased significantly the EGG power. Atropine did not change the dominant frequency significantly. However, atropine increased significantly the EGG power (areas of amplitudes) from basal values to the maximum at the 10-20-min interval. After that period, the areas of amplitudes decreased significantly to the lowest values at the 60-90-min interval. In conclusion, cholinergic and anticholinergic agents affect differently EGG in experimental pigs.

Noninvasive biomagnetic detection of intestinal slow wave dysrhythmias in chronic mesenteric ischemia

Chronic mesenteric ischemia (CMI) is a challenging clinical problem that is difficult to diagnose noninvasively. Diagnosis early in the disease process would enable life-saving early surgical intervention. Previous studies established that superconducting quantum interference device (SQUID) magnetometers detect the slow wave changes in the magnetoenterogram (MENG) noninvasively following induction of mesenteric ischemia in animal models. The purpose of this study was to assess functional physiological changes in the intestinal slow wave MENG of patients with chronic mesenteric ischemia. Pre- and postoperative studies were conducted on CMI patients using MENG and intraoperative recordings using invasive serosal electromyograms (EMG). Our preoperative MENG recordings showed that patients with CMI exhibited a significant decrease in intestinal slow wave frequency from 8.9 ± 0.3 cpm preprandial to 7.4 ± 0.1 cpm postprandial (P < 0.01) that was not observed in postoperative recordings (9.3 ± 0.2 cpm preprandial and 9.4 ± 0.4 cpm postprandial, P = 0.86). Intraoperative recording detected multiple frequencies from the ischemic portion of jejunum before revascularization, whereas normal serosal intestinal slow wave frequencies were observed after revascularization. The preoperative MENG data also showed signals with multiple frequencies suggestive of uncoupling and intestinal ischemia similar to intraoperative serosal EMG. Our results showed that multichannel MENG can identify intestinal slow wave dysrhythmias in CMI patients.

Recent progress in gastric arrhythmia: pathophysiology, clinical significance and future horizons

Gastric arrhythmia continues to be of uncertain diagnostic and therapeutic significance. However, recent progress has been substantial, with technical advances, theoretical insights and experimental discoveries offering new translational opportunities. The discoveries that interstitial cells of Cajal (ICC) generate slow waves and that ICC defects are associated with dysmotility have reinvigorated gastric arrhythmia research. Increasing evidence now suggests that ICC depletion and damage, network disruption and channelopathies may lead to aberrant slow wave initiation and conduction. Histological and high-resolution (HR) electrical mapping studies have now redefined the human 'gastric conduction system', providing an improved baseline for arrhythmia research. The application of HR mapping to arrhythmia has also generated important new insights into the spatiotemporal dynamics of arrhythmia onset and maintenance, resulting in the emergence of new provisional classification schemes. Meanwhile, the strong associations between gastric functional disorders and electrogastrography (EGG) abnormalities (e.g. in gastroparesis, unexplained nausea and vomiting and functional dyspepsia) continue to motivate deeper inquiries into the nature and causes of gastrointestinal arrhythmias. In future, technical progress in EGG methods, new HR mapping devices and software, wireless slow wave acquisition systems and improved gastric pacing devices may achieve validated applications in clinical practice. Neurohormonal factors in arrhythmogenesis also continue to be elucidated and a deepening understanding of these mechanisms may open opportunities for drug design for treating arrhythmias. However, for all translational goals, it remains to be seen whether arrhythmia can be corrected in a way that meaningfully improves organ function and symptoms in patients.

Gastric arrhythmias in gastroparesis: low- and high-resolution mapping of gastric electrical activity

Gastric arrhythmias occur in gastroparesis but their significance is debated. An improved understanding is currently emerging, including newly-defined histopathologic abnormalities in gastroparesis. In particular, the observation that interstitial cells of Cajal are depleted and injured provides mechanisms for arrhythmogenesis in gastroparesis. Electrogastrography has been the dominant clinical method of arrhythmia analysis, but is limited by summative nature, low signal quality, and incomplete sensitivity and specificity. Recently, high-resolution (HR; multi-electrode) mapping has emerged, providing superior spatial data on arrhythmic patterns and mechanisms. However, HR mapping is invasive, and low-resolution approaches are being assessed as bridging techniques until endoscopic mapping is achieved.

Normal and abnormal electrical propagation in the small intestine

As in other muscular organs, small intestinal motility is determined to a large degree by the electrical activities that occur in the smooth muscle layers of the small intestine. In recent decades, the interstitial cells of Cajal, located in the myenteric plexus, have been shown to be responsible for the generation and propagation of the electrical impulse: the slow wave. It was also known that the slow waves as such do not cause contraction, but that the action potentials ('spikes') that are generated by the slow waves are responsible for the contractions. Recording from large number of extracellular electrodes simultaneously is one method to determine origin and pattern of propagation of these electrical signals. This review reports the characteristics of slow wave propagation through the intestinal tube, the occurrence of propagation blocks along its length, which explains the well-known decrease in frequency, and the specific propagation pattern of the spikes that follow the slow waves. But the value of high-resolution mapping is highest in discovering and analysing mechanisms of arrhythmias in the gut. Most recently, circus movements (also called 're-entries') have been described in the small intestine in several species. Moreover, several types of re-entries have now been described, some similar to what may occur in the heart, such as functional re-entries, but others more unique to the small intestine, such as circumferential re-entry. These findings seem to suggest the possibilities of hitherto unknown pathologies that may be present in the small intestine.

Slow wave conduction patterns in the stomach: from Waller's foundations to current challenges

This review provides an overview of our understanding of motility and slow wave propagation in the stomach. It begins by reviewing seminal studies conducted by Walter Cannon and Augustus Waller on in vivo motility and slow wave patterns. Then our current understanding of slow wave patterns in common laboratory animals and humans is presented. The implications of slow wave arrhythmic patterns that have been recorded in animals and patients suffering from gastroparesis are discussed. Finally, current challenges in experimental methods and techniques, slow wave modulation and the use of mathematical models are discussed.

A theoretical analysis of the electrogastrogram (EGG)

In this study, a boundary element model was developed to investigate the relationship between the gastric electrical activity, also known as slow waves, and the electrogastrogram (EGG). A dipole was calculated to represent the equivalent net activity of gastric slow waves. The dipole was then placed in an anatomically-realistic torso model to simulate EGG. The torso model was constructed from a laser-scanned geometry of an adult male torso phantom with 190 electrode sites equally distributed around the torso so that simulated EGG could be directly compared between the physical model and the mathematical model. The results were analyzed using the Fast Fourier Transforms (FFT), spatial distribution of EGG potential and a resultant EGG based on a 3-lead configuration. The FFT results showed both the dipole and EGG contained identical dominant frequency component of 3 cycles per minute (cpm), with this result matching known physiological phenomenon. The -3 dB point of the EGG was 110 mm from the region directly above the dipole source. Finally, the results indicated that electrode coupling could theoretically be used in a similar fashion to ECG coupling to gain greater understanding of how EGG correlate to gastric slow waves.

Automated classification and identification of slow wave propagation patterns in gastric dysrhythmia

The advent of high-resolution (HR) electrical mapping of slow wave activity has significantly improved the understanding of gastric slow wave activity in normal and dysrhythmic states. One of the current limitations of this technique is it generates a vast amount of data, making manual analysis a tedious task for research and clinical development. In this study we present new automated methods to classify, identify, and locate patterns of interest in gastric slow wave propagation. The classification method uses a similarity metric to classify slow wave propagations, while the identification algorithm uses the divergence and mean curvature of the slow wave propagation to identify and regionalize patterns of interest. The methods were applied to synthetic and experimental datasets and were also compared to manual analysis. The methods classified and identified patterns of slow wave propagation in less than 1 s, compared to manual analysis which took up to 40 min. The automated methods achieved 96% accuracy in classifying AT maps, and 95% accuracy in identifying the propagation pattern with a mean spatial error of 1.5 mm in comparison to manual methods. These new methods will facilitate the efficient translation of gastrointestinal HR mapping techniques to clinical practice.

Mapping and modeling gastrointestinal bioelectricity: from engineering bench to bedside

A key discovery in gastrointestinal motility has been the central role played by interstitial cells of Cajal (ICC) in generating electrical slow waves that coordinate contractions. Multielectrode mapping and multiscale modeling are two emerging interdisciplinary strategies now showing translational promise to investigate ICC function, electrophysiology, and contractions in the human gut.

Arrhythmias in the gut

In recent years, it has become possible to record, from a large number of extracellular electrodes, the electrical activities of smooth muscle organs. These recordings, after proper processing and analysis, may reveal origin and propagation of normal and abnormal electrical activities in these organs. Several publications have appeared in the past 5 years describing origin and propagation of slow waves in the stomach of experimental animals and in humans. Furthermore, publications are now starting to appear that describe pathophysiological patterns of propagation and these studies provide us with novel concepts regarding potential mechanisms of arrhythmias in the gut, crucial information if we are ever going to successfully treat patients suffering from such arrhythmias. In this issue of Neurogastroenterology & Motility, Angeli et al. have mapped the slow wave propagation in the porcine small intestine and discovered two types of reentry; functional reentry and circumferential reentry. Next to the descriptions of arrhythmias in the stomach, the fact that reentrant arrhythmias may also occur in the small intestine further extends this new emerging field of gastrointestinal (GI) arrhythmias. In this viewpoint, the relevance of these arrhythmias is further discussed and a few ideas for future research in this field, not necessarily constrained to the GI system, proposed.

A miniature bidirectional telemetry system for in vivo gastric slow wave recordings

Stomach contractions are initiated and coordinated by an underlying electrical activity (slow waves), and electrical dysrhythmias accompany motility diseases. Electrical recordings taken directly from the stomach provide the most valuable data, but face technical constraints. Serosal or mucosal electrodes have cables that traverse the abdominal wall, or a natural orifice, causing discomfort and possible infection, and restricting mobility. These problems motivated the development of a wireless system. The bidirectional telemetric system constitutes a front-end transponder, a back-end receiver and a graphical userinter face. The front-end module conditions the analogue signals, then digitizes and loads the data into a radio for transmission. Data receipt at the backend is acknowledged via a transceiver function. The system was validated in a bench-top study, then validated in vivo using serosal electrodes connected simultaneously to a commercial wired system. The front-end module was 35 × 35 × 27 mm3 and weighed 20 g. Bench-top tests demonstrated reliable communication within a distance range of 30 m, power consumption of 13.5 mW, and 124 h operation when utilizing a 560 mAh, 3 V battery. In vivo,slow wave frequencies were recorded identically with the wireless and wired reference systems (2.4 cycles min−1), automated activation time detection was modestly better for the wireless system (5% versus 14% FP rate), and signal amplitudes were modestly higher via the wireless system (462 versus 3 86μV; p<0.001). This telemetric system for slow wave acquisition is reliable,power efficient, readily portable and potentially implantable. The device will enable chronic monitoring and evaluation of slow wave patterns in animals and patients.0967-3334/

Abnormal initiation and conduction of slow-wave activity in gastroparesis, defined by high-resolution electrical mapping

BACKGROUND & AIMS

Interstitial cells of Cajal (ICC) generate slow waves. Disrupted ICC networks and gastric dysrhythmias are each associated with gastroparesis. However, there are no data on the initiation and propagation of slow waves in gastroparesis because research tools have lacked spatial resolution. We applied high-resolution electrical mapping to quantify and classify gastroparesis slow-wave abnormalities in spatiotemporal detail.

METHODS

Serosal high-resolution mapping was performed using flexible arrays (256 electrodes; 36 cm(2)) at stimulator implantation in 12 patients with diabetic or idiopathic gastroparesis. Data were analyzed by isochronal mapping, velocity and amplitude field mapping, and propagation animation. ICC numbers were determined from gastric biopsy specimens.

RESULTS

Mean ICC counts were reduced in patients with gastroparesis (2.3 vs 5.4 bodies/field; P < .001). Slow-wave abnormalities were detected by high-resolution mapping in 11 of 12 patients. Several new patterns were observed and classified as abnormal initiation (10/12; stable ectopic pacemakers or diffuse focal events; median, 3.3 cycles/min; range, 2.1-5.7 cycles/min) or abnormal conduction (7/10; reduced velocities or conduction blocks; median, 2.9 cycles/min; range, 2.1-3.6 cycles/min). Circumferential conduction emerged during aberrant initiation or incomplete block and was associated with velocity elevation (7.3 vs 2.9 mm s(-1); P = .002) and increased amplitudes beyond a low base value (415 vs 170 μV; P = .002).

CONCLUSIONS

High-resolution mapping revealed new categories of abnormal human slow-wave activity. Abnormalities of slow-wave initiation and conduction occur in gastroparesis, often at normal frequency, which could be missed by tests that lack spatial resolution. Irregular initiation, aberrant conduction, and low amplitude activity could contribute to the pathogenesis of gastroparesis.

High-resolution spatial analysis of slow wave initiation and conduction in porcine gastric dysrhythmia

BACKGROUND

The significance of gastric dysrhythmias remains uncertain. Progress requires a better understanding of dysrhythmic behaviors, including the slow wave patterns that accompany or promote them. The aim of this study was to use high-resolution spatiotemporal mapping to characterize and quantify the initiation and conduction of porcine gastric dysrhythmias.

METHODS

High-resolution mapping was performed on healthy fasted weaner pigs under general anesthesia. Recordings were made from the gastric serosa using flexible arrays (160-192 electrodes; 7.6mm spacing). Dysrhythmias were observed to occur in 14 of 97 individual recordings (from 8 of 16 pigs), and these events were characterized, quantified and classified using isochronal mapping and animation.

KEY RESULTS

All observed dysrhythmias originated in the corpus and fundus. The range of dysrhythmias included incomplete conduction block (n=3 pigs; 3.9±0.5cpm; normal range: 3.2±0.2cpm) complete conduction block (n=3; 3.7±0.4cpm), escape rhythm (n=5; 2.0±0.3cpm), competing ectopic pacemakers (n=5, 3.7±0.1cpm) and functional re-entry (n=3, 4.1±0.4cpm). Incomplete conduction block was observed to self-perpetuate due to retrograde propagation of wave fragments. Functional re-entry occurred in the corpus around a line of unidirectional block. 'Double potentials' were observed in electrograms at sites of re-entry and at wave collisions.

CONCLUSIONS & INFERENCES

Intraoperative multi-electrode mapping of fasted weaner healthy pigs detected dysrhythmias in 15% of recordings (from 50% of animals), including patterns not previously reported. The techniques and findings described here offer new opportunities to understand the nature of human gastric dysrhythmias.

A comparison of gold versus silver electrode contacts for high-resolution gastric electrical mapping using flexible printed circuit board arrays

Stomach contractions are initiated and coordinated by electrical events termed slow waves, and slow wave abnormalities contribute to gastric motility disorders. Recently, flexible printed circuit board (PCB) multi-electrode arrays were introduced, facilitating high-resolution mapping of slow wave activity in humans. However PCBs with gold contacts have shown a moderately inferior signal quality to previous custom-built silver-wire platforms, potentially limiting analyses. This study determined if using silver instead of gold contacts improved flexible PCB performance. In a salt-bath test, modestly higher stimulus amplitudes were recorded from silver PCBs (mean 312, s.d. 89 µV) than those from gold (mean 281, s.d. 85 µV) (p < 0.001); however, the signal-to-noise ratio (SNR) was similar (p = 0.26). In eight in vivo experimental studies, involving gastric serosal recordings from five pigs, no silver versus gold differences were found in terms of slow wave amplitudes (mean 677 versus 682 µV; p = 0.91), SNR (mean 8.8 versus 8.8 dB; p = 0.94) or baseline drift (NRMS; mean 12.0 versus 12.1; p = 0.97). Under the prescribed conditions, flexible PCBs with silver or gold contacts provide comparable results in vivo, and contact material difference does not explain the performance difference between current-generation slow wave mapping platforms. Alternative explanations for this difference and the implications for electrode design are discussed.

Origin, propagation and regional characteristics of porcine gastric slow wave activity determined by high-resolution mapping

BACKGROUND

The pig is a popular model for gastric electrophysiology studies. However, its normal baseline gastric activity has not been well characterized. High-resolution (HR) mapping has recently enabled an accurate description of human and canine gastric slow wave activity, and was employed here to define porcine gastric slow wave activity.

METHODS

Fasted pigs underwent HR mapping following anesthesia and laparotomy. Flexible printed-circuit-board arrays were used (160-192 electrodes; spacing 7.62 mm). Anterior and posterior surfaces were mapped simultaneously. Activation times, velocities, amplitudes and frequencies were calculated, and regional differences evaluated.

KEY RESULTS

Mean slow wave frequency was 3.22 ± 0.23 cpm. Slow waves propagated isotropically from the pacemaker site (greater curvature, mid-fundus). Pacemaker activity was of higher velocity (13.3 ± 1.0 mm s(-1)) and greater amplitude (1.3 ± 0.2 mV) than distal fundal activity (9.0 ± 0.6 mm s(-1), 0.9 ± 0.1 mV; P < 0.05). Velocities and amplitudes were similar in the distal fundus, proximal corpus (8.4 ± 0.8 mm s(-1), 1.0 ± 0.1 mV), distal corpus (8.3 ± 0.8 mm s(-1), 0.9 ± 0.2 mV) and antrum (6.8 ± 0.6 mm s(-1), 1.1 ± 0.2 mV). Activity was continuous across the anterior and posterior gastric surfaces.

CONCLUSIONS & INFERENCES

This study has quantified normal porcine gastric slow wave activity at HR during anesthesia and laparotomy. The pacemaker region was associated with high-amplitude, high-velocity slow wave activity compared to the activity in the rest of the stomach. The increase in distal antral slow wave velocity and amplitude previously described in canines and humans is not observed in the pig. Investigators should be aware of these inter-species differences.

Detailed measurements of gastric electrical activity and their implications on inverse solutions

Significant research effort has been expended on investigating methods to non-invasively characterize gastrointestinal electrical activity. Despite the clinical success of the 12-lead electrocardiograms (ECG) and the emerging success of inverse methods for characterizing electrical activity of the heart and brain, similar methods have not been successfully transferred to the gastrointestinal field. The normal human stomach generates rhythmic electrical impulses, known as slow waves, that propagate within the stomach at a frequency of 3 cycles per minute. Disturbances in this activity are known to result in disorders in the motility patterns of the stomach. However, there is still limited understanding regarding the basic characteristics of the electrical propagation in the stomach. Contrary to existing beliefs, recent results from high resolution recordings of gastric electrical activity have shown that multiple waves, complete with depolarization and repolarization fronts, can be simultaneously present at any given time in the human stomach. In addition, it has been shown that there are marked variations in the amplitude and velocities in different regions in the stomach. In human recordings, the antrum had slow waves with significantly higher amplitudes and velocities than the corpus. Due to the presence of multiple slow wave events, single and multiple dipole-type inverse methods are not appropriate and distributed source models must therefore be considered. Furthermore, gastric electrical waves move significantly slower than electrical waves in the heart, and it is currently difficult to obtain structural images of the stomach at the same time as surface electrical or magnetic gastric recordings are made. This further complicates the application of inverse procedures for gastric electrical imaging.

Technical advances in monitoring human motility patterns

Abnormal motor patterns are implicated in many motility disorders. However, for many regions of the gut, our knowledge of normal and abnormal motility behaviors and mechanisms remains incomplete. There have been many recent advances in the development of techniques to increase our knowledge of gastrointestinal motility, some readily available while others remain confined to research centers. This review highlights a range of these recent developments and examines their potential to help diagnose and guide treatment for motility disorders.

High-resolution entrainment mapping of gastric pacing: a new analytical tool

Gastric pacing has been investigated as a potential treatment for gastroparesis. New pacing protocols are required to improve symptom and motility outcomes; however, research progress has been constrained by a limited understanding of the effects of electrical stimulation on slow-wave activity. This study introduces high-resolution (HR) "entrainment mapping" for the analysis of gastric pacing and presents four demonstrations. Gastric pacing was initiated in a porcine model (typical amplitude 4 mA, pulse width 400 ms, period 17 s). Entrainment mapping was performed using flexible multielectrode arrays (</=192 electrodes; 92 cm(2)) and was analyzed using novel software methods. In the first demonstration, entrainment onset was quantified over successive waves in spatiotemporal detail. In the second demonstration, slow-wave velocity was accurately determined with HR field analysis, and paced propagation was found to be anisotropic (longitudinal 2.6 +/- 1.7 vs. circumferential 4.5 +/- 0.6 mm/s; P < 0.001). In the third demonstration, a dysrhythmic episode that occurred during pacing was mapped in HR, revealing an ectopic slow-wave focus and uncoupled propagations. In the fourth demonstration, differences were observed between paced and native slow-wave amplitudes (0.24 +/- 0.08 vs. 0.38 +/- 0.14 mV; P < 0.001), velocities (6.2 +/- 2.8 vs. 11.5 +/- 4.7 mm/s; P < 0.001), and activated areas (20.6 +/- 1.9 vs. 32.8 +/- 2.6 cm(2); P < 0.001). Entrainment mapping enables an accurate quantification of the effects of gastric pacing on slow-wave activity, offering an improved method to assess whether pacing protocols are likely to achieve physiologically and clinically useful outcomes.

Multiscale modeling of gastrointestinal electrophysiology and experimental validation

Normal gastrointestinal (GI) motility results from the coordinated interplay of multiple cooperating mechanisms, both intrinsic and extrinsic to the GI tract. A fundamental component of this activity is an omnipresent electrical activity termed slow waves, which is generated and propagated by the interstitial cells of Cajal (ICCs). The role of ICC loss and network degradation in GI motility disorders is a significant area of ongoing research. This review examines recent progress in the multiscale modeling framework for effectively integrating a vast range of experimental data in GI electrophysiology, and outlines the prospect of how modeling can provide new insights into GI function in health and disease. The review begins with an overview of the GI tract and its electrophysiology, and then focuses on recent work on modeling GI electrical activity, spanning from cell to body biophysical scales. Mathematical cell models of the ICCs and smooth muscle cell are presented. The continuum framework of monodomain and bidomain models for tissue and organ models are then considered, and the forward techniques used to model the resultant body surface potential and magnetic field are discussed. The review then outlines recent progress in experimental support and validation of modeling, and concludes with a discussion on potential future research directions in this field.

Falling-edge, variable threshold (FEVT) method for the automated detection of gastric slow wave events in high-resolution serosal electrode recordings

High resolution (HR) multi-electrode mapping is increasingly being used to evaluate gastrointestinal slow wave behaviors. To create the HR activation time (AT) maps from gastric serosal electrode recordings that quantify slow wave propagation, it is first necessary to identify the AT of each individual slow wave event. Identifying these ATs has been a time consuming task, because there has previously been no reliable automated detection method. We have developed an automated AT detection method termed falling-edge, variable threshold (FEVT) detection. It computes a detection signal transform to accentuate the high 'energy' content of the falling edges in the serosal recording, and uses a running median estimator of the noise to set the time-varying detection threshold. The FEVT method was optimized, validated, and compared to other potential algorithms using in vivo HR recordings from a porcine model. FEVT properly detects ATs in a wide range of waveforms, making its performance substantially superior to the other methods, especially for low signal-to-noise ratio (SNR) recordings. The algorithm offered a substantial time savings (>100 times) over manual-marking whilst achieving a highly satisfactory sensitivity (0.92) and positive-prediction value (0.89).

Effects of electrical stimulation on isolated rodent gastric smooth muscle cells evaluated via a joint computational simulation and experimental approach

Gastric electrical stimulation (GES) involves the delivery of electrical impulses to the stomach for therapeutic purposes. New GES protocols are needed that are optimized for improved motility outcomes and energy efficiency. In this study, a biophysically based smooth muscle cell (SMC) model was modified on the basis of experimental data and employed in conjunction with experimental studies to define the effects of a large range of GES protocols on individual SMCs. For the validation studies, rat gastric SMCs were isolated and subjected to patch-clamp analysis during stimulation. Experimental results were in satisfactory agreement with simulation results. The results define the effects of a wide range of GES parameters (pulse width, amplitude, and pulse-train frequency) on isolated SMCs. The minimum pulse width required to invoke a supramechanical threshold response from SMCs (defined at -30 mV) was 65 ms (at 250-pA amplitude). The minimum amplitude required to invoke this threshold was 75 pA (at 1,000-ms pulse width). The amplitude of the invoked response beyond this threshold was proportional to the stimulation amplitude. A high-frequency train of stimuli (40 Hz; 10 ms, 150 pA) could invoke and maintain the SMC plateau phase while requiring 60% less power and accruing approximately 30% less intracellular Ca(2+) concentration during the plateau phase than a comparable single-pulse protocol could in a demonstrated example. Validated computational simulations are an effective strategy for efficiently identifying effective minimum-energy GES protocols, and pulse-train protocols may also help to reduce the power consumption of future GES devices.