Autologous implantation of bilayered tissue-engineered respiratory epithelium for tracheal mucosal regenesis in a sheep model

Tissue Engineering for Tracheal Replacement: Strategies and Challenges

The critical feature in trachea replacement is to provide a hollow cylindrical framework that is laterally stable and longitudinally flexible, facilitating cartilage and epithelial tissue formation. Despite advanced techniques and sources of materials used, most inherent challenges are related to the complexity of its anatomy. Limited blood supply leads to insufficient regenerative capacity for cartilage and epithelium. Natural and synthetic scaffolds, different types of cells, and growth factors are part of tissue engineering approaches with varying outcomes. Pre-vascularization remains one of the crucial factors to expedite the regenerative process in tracheal reconstruction. This review discusses the challenges and strategies used in tracheal tissue engineering, focusing on scaffold implantation in clinical and preclinical studies conducted in recent decades.

Evaluating Feasibility of Human Tissue Engineered Respiratory Epithelium Construct as a Potential Model for Tracheal Mucosal Reconstruction

The normal function of the airway epithelium is vital for the host’s well-being. Conditions that might compromise the structure and functionality of the airway epithelium include congenital tracheal anomalies, infection, trauma and post-intubation injuries. Recently, the onset of COVID-19 and its complications in managing respiratory failure further intensified the need for tracheal tissue replacement. Thus far, plenty of naturally derived, synthetic or allogeneic materials have been studied for their applicability in tracheal tissue replacement. However, a reliable tracheal replacement material is missing. Therefore, this study used a tissue engineering approach for constructing tracheal tissue. Human respiratory epithelial cells (RECs) were isolated from nasal turbinate, and the cells were incorporated into a calcium chloride-polymerized human blood plasma to form a human tissue respiratory epithelial construct (HTREC). The quality of HTREC in vitro, focusing on the cellular proliferation, differentiation and distribution of the RECs, was examined using histological, gene expression and immunocytochemical analysis. Histological analysis showed a homogenous distribution of RECs within the HTREC, with increased proliferation of the residing RECs within 4 days of investigation. Gene expression analysis revealed a significant increase (p < 0.05) in gene expression level of proliferative and respiratory epithelial-specific markers Ki67 and MUC5B, respectively, within 4 days of investigation. Immunohistochemical analysis also confirmed the expression of Ki67 and MUC5AC markers in residing RECs within the HTREC. The findings show that calcium chloride-polymerized human blood plasma is a suitable material, which supports viability, proliferation and mucin secreting phenotype of RECs, and this suggests that HTREC can be a potential candidate for respiratory epithelial tissue reconstruction.

Preliminary Study on the Development of In Vitro Human Respiratory Epithelium Using Collagen Type I Scaffold as a Potential Model for Future Tracheal Tissue Engineering

Pathological conditions of the tracheal epithelium, such as postoperative injuries and chronic conditions, often compromise the functionality of the respiratory epithelium. Although replacement of the respiratory epithelium using various types of tracheal transplantation has been attempted, there is no predictable and dependable replacement method that holds for safe and practicable long-term use. Therefore, we used a tissue engineering approach for ex vivo regeneration of the respiratory epithelium (RE) construct. Collagen type I was isolated from sheep tendon and it was fabricated in a three-dimensional (3D) scaffold format. Isolated human respiratory epithelial cells (RECs) and fibroblasts from nasal turbinate were co-cultured on the 3D scaffold for 48 h, and epithelium maturation was allowed for another 14 days in an air–liquid interface culture system. The scanning electron microscope results revealed a fabricated porous-structure 3D collagen scaffold. The scaffold was found to be biocompatible with RECs and fibroblasts and allows cells attachment, proliferation, and migration. Immunohistochemical analysis showed that the seeded RECs and fibroblasts were positive for expression of cytokeratin 14 and collagen type I markers, respectively, indicating that the scaffold supports the native phenotype of seeded cells over a period of 14 days. Although a longer maturation period is needed for ciliogenesis to occur in RECs, the findings suggest that the tissue-engineered RE construct is a potential candidate for direct use in tracheal epithelium replacement or tracheal tube reengineering.

Biomimetic Hybrid Systems for Tissue Engineering

Tissue engineering approaches appear nowadays highly promising for the regeneration of injured/diseased tissues. Biomimetic scaffolds are continuously been developed to act as structural support for cell growth and proliferation as well as for the delivery of cells able to be differentiated, and also of bioactive molecules like growth factors and even signaling cues. The current research concerns materials employed to develop biological scaffolds with improved features as well as complex preparation techniques. In this work, hybrid systems based on natural polymers are discussed and the efforts focused to provide new polymers able to mimic proteins and DNA are extensively explained. Progress on the scaffold fabrication technique is mentioned, those processes based on solution and melt electrospinning or even on their combination being mainly discussed. Selection of the appropriate hybrid technology becomes vital to get optimal architecture to reasonably accomplish the final applications. Representative examples of the recent possibilities on tissue regeneration are finally given.

Biomedical grafts for tracheal tissue repairing and regeneration "Tracheal tissue engineering: an overview"

Airway system is a vital part of the living being body. Trachea is the upper respiratory portion that connects nostril and lungs and has multiple functions such as breathing and entrapment of dust/pathogen particles. Tracheal reconstruction by artificial prosthesis, stents, and grafts are performed clinically for the repairing of damaged tissue. Although these (above-mentioned) methods repair the damaged parts, they have limited applicability like small area wounds and lack of functional tissue regeneration. Tissue engineering helps to overcome the above-mentioned problems by modifying the traditional used stents and grafts, not only repair but also regenerate the damaged area to functional tissue. Bioengineered tracheal replacements are biocompatible, nontoxic, porous, and having 3D biomimetic ultrastructure with good mechanical strength, which results in faster and better tissue regeneration. Till date, the bioengineered tracheal replacements studies have been going on preclinical and clinical levels. Besides that, still many researchers are working at advance level to make extracellular matrix-based acellular, 3D printed, cell-seeded grafts including living cells to overcome the demand of tissue or organ and making the ready to use tracheal reconstructs for clinical application. Thus, in this review, we summarized the tracheal tissue engineering aspects and their outcomes.

Ex vivo ovine model for teaching open laryngotracheal surgery

Objective

To develop an animal model for teaching open laryngotracheal surgical procedures.

Methods

The heads and necks from 5 pre-pubescent sheep were harvested after humane anesthesia. After 2–5 days to allow for rigor mortis to resolve, a specimen was supported with sandbags on an operating table. Operative procedures including tracheotomy, medialization laryngoplasty, anterior cartilage grafting, tracheal resection with primary anastomosis, and laryngectomy with closure of the pharynx were attempted.

Results

The ovine head and neck provided an accurate model for simulation of all attempted procedures. Ovine tissue resembled that of humans in mechanical properties and handling. Postsurgical endoscopy confirmed graft alignment.

Conclusions

The sheep head and neck provides an inexpensive, realistic, and safe model for surgical training for a variety of open laryngotracheal procedures. This is particularly relevant given the recent emphasis on surgical simulation and the relative rarity of some of these procedures in residency training.

The Effect of Human Adipose Tissue-Derived Mesenchymal Stem Cells in Rat's Subglottic Stenosis Model

OBJECTIVE

Subglottic stenosis remains a clinical challenge. The aim of this study was to evaluate the effect of human adipose tissue-derived mesenchymal stem cells (hAMSCs) in rat model of subglottic stenosis.

SUBJECTS AND METHODS

Ninety-six 13-week-old male rats were enrolled in this study. They were divided into 3 groups as normal control (NC) group, a subglottic injury and media injection (SM) group, and a subglottic injury and media-stem cell injection (SMSC) group. The hAMSCs were immediately injected into subglottis after injury. Histologic characteristics of subglottis; the mRNA expressions of interleukin-1β, cyclooxygenase-2, tumor growth factor-β and basic fibroblast growth factor; and hAMSCs' survival were evaluated.

RESULTS

The hAMSCs survived in the subglottis of the rat until 10 days after implantation. The NC and SMSC groups had a significantly wider subglottic lumen and thinner lamina propria than the SM group at 56 days after injury. Collagen intensity of subglottis was significantly higher in the SM group than in the NC and SMSC groups at 28 days after injury. Gene expression didn't show significant difference between the SM group and the SMSC group.

CONCLUSIONS

The hAMSCs injection was found to be helpful for preventing subglottic stenosis in a rat model.

Autologous Cell Seeding in Tracheal Tissue Engineering

Purpose of Review

There is no consensus on the best technology to be employed for tracheal replacement. One particularly promising approach is based upon tissue engineering and involves applying autologous cells to transplantable scaffolds. Here, we present the reported pre-clinical and clinical data exploring the various options for achieving such seeding.

Recent Findings

Various cell combinations, delivery strategies, and outcome measures are described. Mesenchymal stem cells (MSCs) are the most widely employed cell type in tracheal bioengineering. Airway epithelial cell luminal seeding is also widely employed, alone or in combination with other cell types. Combinations have thus far shown the greatest promise. Chondrocytes may improve mechanical outcomes in pre-clinical models, but have not been clinically tested. Rapid or pre-vascularization of scaffolds is an important consideration. Overall, there are few published objective measures of post-seeding cell viability, survival, or overall efficacy.

Summary

There is no clear consensus on the optimal cell-scaffold combination and mechanisms for seeding. Systematic in vivo work is required to assess differences between tracheal grafts seeded with combinations of clinically deliverable cell types using objective outcome measures, including those for functionality and host immune response.

Electronic supplementary material

The online version of this article (10.1007/s40778-017-0108-2) contains supplementary material, which is available to authorized users.

Tissue-engineered trachea: A review

Tracheal replacement is performed after resection of a portion of the trachea that was impossible to reconnect via direct anastomosis. A tissue-engineered trachea is one of the available options that offer many advantages compared to other types of graft. Fabrication of a functional tissue-engineered trachea for grafting is very challenging, as it is a complex organ with important components, including cartilage, epithelium and vasculature. A number of studies have been reported on the preparation of a graftable trachea. A laterally rigid but longitudinally flexible hollow cylindrical scaffold which supports cartilage and epithelial tissue formation is the key element. The scaffold can be prepared via decellularization of an allograft or fabricated using biodegradable or non-biodegradable biomaterials. Commonly, the scaffold is seeded with chondrocytes and epithelial cells at the outer and luminal surfaces, respectively, to hasten tissue formation and improve functionality. To date, several clinical trials of tracheal replacement with tissue-engineered trachea have been performed. This article reviews the formation of cartilage tissue, epithelium and neovascularization of tissue-engineered trachea, together with the obstacles, possible solutions and future. Furthermore, the role of the bioreactor for in vitro tracheal graft formation and recently reported clinical applications of tracheal graft were also discussed. Generally, although encouraging results have been achieved, however, some obstacles remain to be resolved before the tissue-engineered trachea can be widely used in clinical settings.

Clinical Translation of Tissue Engineered Trachea Grafts

OBJECTIVE

To provide a state-of-the-art review discussing recent achievements in tissue engineered tracheal reconstruction.

DATA SOURCES AND REVIEW METHODS

A structured PubMed search of the current literature up to and including October 2015. Representative articles that discuss the translation of tissue engineered tracheal grafts (TETG) were reviewed.

CONCLUSIONS

The integration of a biologically compatible support with autologous cells has resulted in successful regeneration of respiratory epithelium, cartilage, and vascularization with graft patency, although the optimal construct composition has yet to be defined. Segmental TETG constructs are more commonly complicated by stenosis and delayed epithelialization when compared to patch tracheoplasty.

IMPLICATIONS FOR PRACTICE

The recent history of human TETG recipients represents revolutionary proof of principle studies in regenerative medicine. Application of TETG remains limited to a compassionate use basis; however, defining the mechanisms of cartilage formation, epithelialization, and refinement of in vivo regeneration will advance the translation of TETG from the bench to the bedside.

Tubular organ epithelialisation

Hollow, tubular organs including oesophagus, trachea, stomach, intestine, bladder and urethra may require repair or replacement due to disease. Current treatment is considered an unmet clinical need, and tissue engineering strategies aim to overcome these by fabricating synthetic constructs as tissue replacements. Smart, functionalised synthetic materials can act as a scaffold base of an organ and multiple cell types, including stem cells can be used to repopulate these scaffolds to replace or repair the damaged or diseased organs. Epithelial cells have not yet completely shown to have efficacious cell-scaffold interactions or good functionality in artificial organs, thus limiting the success of tissue-engineered grafts. Epithelial cells play an essential part of respective organs to maintain their function. Without successful epithelialisation, hollow organs are liable to stenosis, collapse, extensive fibrosis and infection that limit patency. It is clear that the source of cells and physicochemical properties of scaffolds determine the successful epithelialisation. This article presents a review of tissue engineering studies on oesophagus, trachea, stomach, small intestine, bladder and urethral constructs conducted to actualise epithelialised grafts.

Re-epithelialization: a key element in tracheal tissue engineering

Trachea-tissue engineering is a thriving new field in regenerative medicine that is reaching maturity and yielding numerous promising results. In view of the crucial role that the epithelium plays in the trachea, re-epithelialization of tracheal substitutes has gradually emerged as the focus of studies in tissue-engineered trachea. Recent progress in our understanding of stem cell biology, growth factor interactions and transplantation immunobiology offer the prospect of optimization of a tissue-engineered tracheal epithelium. In addition, advances in cell culture technology and successful applications of clinical transplantation are opening up new avenues for the construction of a tissue-engineered tracheal epithelium. Therefore, this review summarizes current advances, unresolved obstacles and future directions in the reconstruction of a tissue-engineered tracheal epithelium.

Tissue engineering airway mucosa: a systematic review

OBJECTIVES/HYPOTHESIS

Effective treatments for hollow organ stenosis, scarring, or agenesis are suboptimal or lacking. Tissue-engineered implants may provide a solution, but those performed to date are limited by poor mucosalization after transplantation. We aimed to perform a systematic review of the literature on tissue-engineered airway mucosa. Our objectives were to assess the success of this technology and its potential application to airway regenerative medicine and to determine the direction of future research to maximize its therapeutic and commercial potential.

DATA SOURCES AND REVIEW METHODS

A systematic review of the literature was performed searching Medline (January 1996) and Embase (January 1980) using search terms "tissue engineering" or "tissue" and "engineering" or "tissue engineered" and "mucous membrane" or "mucous" and "membrane" or "mucosa." Original studies utilizing tissue engineering to regenerate airway mucosa within the trachea or the main bronchi in animal models or human studies were included.

RESULTS

A total of 719 papers matched the search criteria, with 17 fulfilling the entry criteria. Of these 17, four investigated mucosal engineering in humans, with the remaining 13 studies investigating mucosal engineering in animal models. The review demonstrated how an intact mucosal layer protects against infection and suggests a role for fibroblasts in facilitating epithelial regeneration in vitro. A range of scaffold materials were used, but no single material was clearly superior to the others.

CONCLUSION

The review highlights gaps in the literature and recommends key directions for future research such as epithelial tracking and the role of the extracellular environment.

Cell sources for trachea tissue engineering: past, present and future

Trachea tissue engineering has been one of the most promising approaches to providing a potential clinical application for the treatment of long-segment tracheal stenosis. The sources of the cells are particularly important as the primary factor for tissue engineering. The use of appropriate cells seeded onto scaffolds holds huge promise as a means of engineering the trachea. Furthermore, appropriate cells would accelerate the regeneration of the tissue even without scaffolds. Besides autologous mature cells, various stem cells, including bone marrow-derived mesenchymal stem cells, adipose tissue-derived stem cells, umbilical cord blood-derived mesenchymal stem cells, amniotic fluid stem cells, embryonic stem cells and induced pluripotent stem cells, have received extensive attention in the field of trachea tissue engineering. Therefore, this article reviews the progress on different cell sources for engineering tracheal cartilage and epithelium, which can lead to a better selection and strategy for engineering the trachea.

What can regenerative medicine offer for infants with laryngotracheal agenesis?

BACKGROUND

Laryngotracheal agenesis is a rare congenital disorder but has devastating consequences. Recent achievements in regenerative medicine have opened up new vistas in therapeutic strategies for these infants.

OBJECTIVE

To provide a state-of-the-art review concerning recent achievements in tissue engineering as applied to fetal airway reconstruction and to discuss the use of autologous human amniotic stem cells to prepare organs in advance for babies with laryngotracheal agenesis.

DATA SOURCES AND REVIEW METHODS

A structured search of the current literature (up to and including June 2011). The authors searched PubMed, EMBASE, CINAHL, Web of Science, BIOSIS Previews, Cambridge Scientific Abstracts, ICTRP, and additional sources for published and unpublished trials.

RESULTS

Over the past 15 years, progress has been made in advancing the boundaries of regenerative medicine from the laboratory to the clinical setting through translational research. Most experience has been gained with adult stem cells and synthetic materials or decellularized scaffolds. The optimal cell source for fetal tissue engineering remains to be determined, but a combination of decellularized scaffolds and amniotic fluid stem cells holds great promise for fetal tissue engineering.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Current treatment strategies for laryngotracheal agenesis are suboptimal, and fetal tissue engineering offers an alternative to conventional treatments. Use of human amniotic fluid stem cells for preparing autologous tissue-engineered organ constructs prenatally is an attractive concept. Although this approach is still in its experimental stages, further preclinical and clinical studies are encouraged to define its exact role in the pediatric laryngological setting.