Evaluation of a biodegradable PLA–PEG–PLA internal biliary stent for liver transplantation: in vitro degradation and mechanical properties

Engineering Shape to Overcome Contraction: The Role of Polymer-Collagen Hybrids in Advanced Dermal Substitutes

Collagen gels are the standard dermal equivalents par excellence, however the problem of rapid cell-mediated contraction remains unresolved. Therefore, the development of hybrid constructs (HCs) based on collagen and polymeric scaffolds is proposed to address the mechanical instability that usually limits the formation of new, functional tissue. Equally important, these synthetic structures should be temporary (degradable) while ensuring that cells are well-adapted to the new extracellular environment. In this study, we screened a library of scaffolds made of various polymers, including homopolymers of polycaprolactone (PCL) and poly D,L-lactide (PLA50), their blends (PCL/PLA50), and copolymers (poly(D,L-lactide-co-caprolactone), PCLLA50) to prepare HCs in a layer-by-layer fashion. The properties of polymers and copolymers along with their processability by electrospinning and 3D-printing were evaluated. Then, we assessed the HCs resistance toward cell-mediated contraction as well as the degradation of the polymeric scaffolds. Our results indicate that scaffolds with higher PLA50 content (e.g., PLA50 100%, PCL/PLA50 or PCLLA50, both at 50/50 caprolactone-to-D,L-lactide molar ratio) presented more drawbacks in terms of handleability and processing, while those with greater PCL presence showed structural steadiness and ease to use. All the scaffolds integrated well with the collagen gel to form the corresponding HCs. With few exceptions, the HCs demonstrated good resistance to cell-derived contraction over 3 weeks. Notably, HCs based on PCLLA50 90/10 (both versions, electrospun or 3D-printed) performed best, showing only a 5%-17% area reduction compared to the 93% observed in collagen-only gels. This copolymer displayed hydrolytic degradation depending on its shape, with up to 45% and 65% loss of molecular weight for the electrospun and 3D-printed forms, respectively, correlating with their progressive change in mechanical features. HCs containing PCLLA50 90/10 also exhibited a better fibroblast distribution, enhanced myofibroblastic differentiation, and a three-fold increase in cell proliferation (when the electrospun type was used) compared to collagen controls. These findings were instrumental in selecting a potential HC that might be used for future experiments in vivo.

Biliary stents for active materials and surface modification: Recent advances and future perspectives

Demand for biliary stents has expanded with the increasing incidence of biliary disease. The implantation of plastic or self-expandable metal stents can be an effective treatment for biliary strictures. However, these stents are nondegradable and prone to restenosis. Surgical removal or replacement of the nondegradable stents is necessary in cases of disease resolution or restenosis. To overcome these shortcomings, improvements were made to the materials and surfaces used for the stents. First, this paper reviews the advantages and limitations of nondegradable stents. Second, emphasis is placed on biodegradable polymer and biodegradable metal stents, along with functional coatings. This also encompasses tissue engineering & 3D-printed stents were highlighted. Finally, the future perspectives of biliary stents, including pro-epithelialization coatings, multifunctional coated stents, biodegradable shape memory stents, and 4D bioprinting, were discussed.

Mechanical Enhancement of the Gelatin/Poly(zinc acrylate) Hydrogel Stent in Bile

Hydrogels with the features of softness, biocompatibility, and modifiability have emerged as excellent materials in the biomedical field. However, the poor mechanical properties of the hydrogels limit their further practical applications. Double-network and metal ion coordination, such as Cu2+ and Zn2+, have achieved a significant reinforcement of the mechanical strength of the hydrogels. Herein, we report a Zn2+-enhanced polyelectrolyte double-network hydrogel stent with a mechanical enhancement phenomenon in bile. The gelatin/poly(zinc acrylate) (PZA) stent was constructed by dip-coating and UV irradiation. Although the mechanical strength of the as-prepared stent was quite weak, it was discovered to be mechanically enhanced by the natural bile. After exploring the effect of different components on the stents according to the components of bile, we found that Ca2+ in bile made a contribution to the mechanical enhancement of the stent. It is envisioned that this bile-enhanced gelatin/PZA stent provides a train of thought for the potential application of hydrogels in the biliary environment.

3D bioprinting of in situ vascularized tissue engineered bone for repairing large segmental bone defects

Large bone defects remain an unsolved clinical challenge because of the lack of effective vascularization in newly formed bone tissue. 3D bioprinting is a fabrication technology with the potential to create vascularized bone grafts with biological activity for repairing bone defects. In this study, vascular endothelial cells laden with thermosensitive bio-ink were bioprinted in situ on the inner surfaces of interconnected tubular channels of bone mesenchymal stem cell-laden 3D-bioprinted scaffolds. Endothelial cells exhibited a more uniform distribution and greater seeding efficiency throughout the channels. In vitro, the in situ bioprinted endothelial cells can form a vascular network through proliferation and migration. The in situ vascularized tissue-engineered bone also resulted in a coupling effect between angiogenesis and osteogenesis. Moreover, RNA sequencing analysis revealed that the expression of genes related to osteogenesis and angiogenesis is upregulated in biological processes. The in vivo 3D-bioprinted in situ vascularized scaffolds exhibited excellent performance in promoting new bone formation in rat calvarial critical-sized defect models. Consequently, in situ vascularized tissue-engineered bones constructed using 3D bioprinting technology have a potential of being used as bone grafts for repairing large bone defects, with a possible clinical application in the future.

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3D bioprinting was used to fabricate in situ vascularized tissue engineered bone.

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In situ bioprinted endothelial cells exhibited uniform distribution and greater seeding efficiency.

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3D-bioprinted scaffold produced coupling between angiogenesis and osteogenesis.

Biocompatibility and biocidal effects of modified polylactide composites

Polylactide (PLA) materials treated with antimicrobial fillers represent a suitable alternative to the production of medical devices. Their advantage is that they can prevent the growth of microorganisms and the formation of microbial biofilms on the surface and around composites. The work is focused on the evaluation of biocompatibility and biocide effect of PLA composite films filled with vermiculite and graphene oxide modified with silver (Ag⁺ and Ag nanoparticles), hexadecylpyridinium (HDP) and hexadecyltrimethylammonium (HDTMA) cations and their degradation leachates monitored at 1-3-6-month intervals. The antimicrobial effect of the leachates was detected by microdilution methods on gram-negative (Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis), gram-positive (Staphylococcus aureus, Streptococcus salivarius) bacteria and yeast (Candida albicans). The biocidal effect of composites on biofilm formation on the surface of composites was monitored by Christensen method and autoaggregation and motility tests. The biocompatibility of the composite and the leachates was assessed by 3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide (MTT) cytotoxicity assay. The evaluation of the antimicrobial effect of the leachates demonstrated that leachates of PLA composite filled with graphene oxide and Ag⁺ showed a stronger antimicrobial effect than leachates of PLA composite filled with vermiculite and Ag⁺ and Ag nanoparticles. The leachates of PLA composites containing vermiculite with HDP and HDTMA cations had a higher antimicrobial effect on G⁺ bacteria and yeast than G^- bacteria. Bacterial growth, biofilm formation, autoaggregation and motility of the tested bacteria were most inhibited by the composite with vermiculite and Ag⁺ and Ag nanoparticles. Even after a 6-month degradation of this composite, bacterial growth and biofilm formation continued to be strongly inhibited up to 42 and 91%, respectively. The cytotoxic effect was proved only in the leachate of the composite with vermiculite containing HDP after 6 months of its degradation. Tests evaluating the biocompatibility of materials have shown that the vermiculite is the most preferred carrier and can be used in the future to bind other compounds. The study confirmed that PLA composite filled with vermiculite and Ag⁺ and Ag nanoparticles was the most stable and effective composite with the best biocompatible and biocidal properties.

The effect of polyethylene glycol on printability, physical and mechanical properties and osteogenic potential of 3D-printed poly (l-lactic acid)/polyethylene glycol scaffold for bone tissue engineering

One of the challenges in critical size bone defect repairing is the use of a porous degradable scaffold with appropriate properties to the host tissue. Nowadays, the three-dimensional (3D) printing method can produce custom and personalized scaffolds and overcome the problems of traditional methods by controlling the porosity and dimensions of biomaterial scaffolds. In this study, polylactic acid/polyethylene glycol (PLA/PEG) scaffolds were prepared with different PEG percentages (0, 5, 10, 15 and 20 wt%) by fused deposition modeling (FDM) to optimize printability and achieve suitable physico-mechanical properties and also enhance cellular behavior for bone tissue engineering and actually, this study complements previous studies. Fourier transform infrared spectroscopy (FTIR), Scanning electron microscopy (SEM) and differential scanning calorimetry (DSC) were employed for chemical, morphological and thermal evaluations, respectively. It was shown that the adding of 20 wt% PEG to PLA 3D printed scaffolds reduced water contact angle (from 78.16 ± 3.27 to 60.00 ± 2.16), and increased surface wettability. The results also showed that the mechanical properties of the printed scaffolds were not significantly reduced by adding 5 and 10 wt% of PEG. The addition of PEG increased the degradability of scaffolds during immersion in phosphate buffer saline (PBS) solution for 8 weeks and PLA/PEG20 scaffold with 50.96 % had the highest rate of degradation. MTT assay showed that none of the studied scaffolds had cytotoxicity against MG-63 cells and increasing the PEG levels to 20 wt%, increased cell viability and adhesion and osteogenic differentiation. According to the obtained physical, mechanical and biological results, PLA/PEG scaffold printed by the FDM method can be an appropriate candidate for use in bone repair applications.

Duct-to-duct biliary reconstruction with or without an Intraductal Removable Stent in Liver Transplantation: The BILIDRAIN-T Multicentric Randomized Trial

Background & Aims

Biliary complications (BC) following liver transplantation (LT) are responsible for significant morbidity. No technical procedure during reconstruction has been associated with a risk reduction of BC. The placement of an intraductal removable stent (IRS) during reconstruction followed by its endoscopic removal showed feasibility and safety in a preliminary study. This multicentric randomised controlled trial aimed at evaluating the impact of an IRS on BC following LT.

Methods

This multicentric randomised controlled trial was conducted in 7 centres from April 2015 to February 2019. Randomisation was done during LT when a duct-to-duct anastomosis was confirmed with at least 1 of the stump diameters ≤7 mm. In the IRS group, a custom-made segment of a T-tube was placed into the bile duct to act as a stake during healing and was removed endoscopically 4 to 6 months post LT. The primary endpoint was the incidence of BC (fistulae and strictures) within 6 months post LT. The secondary criteria were complications related to the IRS placement or extraction, including endoscopic retrograde cholangio-pancreatography (ERCP)-related complications.

Results

In total, 235 patients were randomised: 117 in the IRS group and 118 in the control group. BC occurred in 31 patients (26.5%) in the IRS group vs. 24 (20.3%) in the control group (p = 0.27), including 16 (13.8%) and 15 (12.8%) strictures, respectively. IRS migration occurred in 24 patients (20.5%), cholangitis in 1 (0.9%), acute pancreatitis in 2 (1.8%), and difficulty during endoscopic extraction in 19 (19.4%). No predictive factor for BC was identified.

Conclusions

IRS does not prevent BC after LT and may require specific endoscopic expertise for removal.

Trial registration number (ClinicalTrials.gov)

NCT02356939 (https://clinicaltrials.gov/ct2/show/NCT02356939?term=NCT02356939&draw=2&rank=1).

Lay summary

Liver transplantation is a life-saving treatment for many patients with end-stage liver disease. However, it can be associated with complications involving the bile duct reconstruction. Herein, the placement of a specific stent called an intraductal removable stent was trialled as a way of reducing bile duct complications in patients undergoing liver transplantation. Unfortunately, it did not help preventing such complications.

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An IRS was placed during biliary reconstruction in bile ducts ≤7 mm; ERCP removal was 4–6 months post LT.

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The primary endpoint was the incidence of biliary complications (fistulae and strictures) within 6 months post LT.

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Biliary complications occurred in 31 patients (26.5%) in the IRS vs. 24 (20.3%) in the control group (p = 0.27).

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IRS migrated in 24 (20.5%) patients, and extraction was difficult in 19 (19.4%).

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No predictive factor for biliary complications was identified.

Emerging Trends in Biliary Stents: A Materials and Manufacturing Perspective

Biliary stent technology has come a long way since its inception. There have been significant advancements in materials used, designs, and deployment strategies. Options have expanded from thermoplastic and metallic...

Pediatric T-tube in adult liver transplantation: Technical refinements of insertion and removal

BACKGROUND

With the increasing use of extended-criteria donor organs, the interest around T-tubes in liver transplantation (LT) was restored whilst concerns regarding T-tube-related complications persist.

AIM

To describe insertion and removal protocols implemented at our institution to safely use pediatric rubber 5-French T-tubes and subsequent outcomes in a consecutive series of adult patients.

METHODS

Data of consecutive adult LT patients from brain-dead donors, treated from March 2017 to December 2019, were collected (i.e., biliary complications, adverse events, treatment after T-Tube removal). Patients with upfront hepatico-jejunostomy, endoscopically removed T-tubes, those who died or received retransplantation before T-tube removal were excluded.

RESULTS

Seventy-two patients were included in this study; T-tubes were removed 158 d (median; IQR 128-206 d) after LT. In four (5.6%) patients accidental T-tube removal occurred requiring monitoring only; in 68 (94.4%) patients Nelaton drain insertion was performed according to our protocol, resulting in 18 (25%) patients with a biliary output, subsequently removed after 2 d (median; IQR 1-4 d). Three (4%) patients required endoscopic retrograde cholangiopancreatography (ERCP) due to persistent Nelaton drain output. Three (4%) patients developed suspected biliary peritonitis, requiring ERCP with sphincterotomy and nasobiliary drain insertion (only one revealing contrast extravasation); no patient required percutaneous drainage or emergency surgery.

CONCLUSION

The use of pediatric rubber 5-French T-tubes in LT proved safe in our series after insertion and removal procedure refinements.

Electrospun microstructured PLA-based scaffolds featuring relevant anisotropic, mechanical and degradation characteristics for soft tissue engineering

Electrospun scaffolds combine suitable structural characteristics that make them strong candidates for their use in tissue engineering. These features can be tailored to optimize other physiologically relevant attributes (e.g. mechanical anisotropy and cellular affinity) while ensuring adequate degradation rates of the biomaterial. Here, we present the fabrication of microstructured scaffolds by using a combination of micropatterned electrospinning collectors (honeycomb- or square-patterned) and poly(lactic acid) (PLA)-based copolymers (linear or star-shaped). The resulting materials showed appropriate macropore size and fiber alignment that were key parameters to enhance their anisotropic properties in protraction. Moreover, their elastic modulus, which was initially similar to that of soft tissues, gradually changed in hydrolytic conditions, matching the degradation profile in a 2- to 3-month period. Finally, honeycomb-structured scaffolds exhibited enhanced cellular proliferation compared to standard electrospun mats, while cell colonization was shown to be guided by the macropore contour. Taking together, these results provide new insight into the rational design of microstructured materials that can mimic the progressive evolution of properties in soft tissue regeneration.

Photopolymerization strategy for the preparation of small-diameter artificial blood vessels with micro-nano structures on the inner wall

Although large diameter vessels made of polyurethane materials have been widely used in clinical practice, the biocompatibility and long-term patency of small diameter artificial vessels have not been well addressed. Any technological innovation and advancement in small-diameter artificial blood vessels is of great interest to the biomedical field. Here a novel technique is used to produce artificial blood vessels with a caliber of less than 6 mm and a wall thickness of less than 0.5 mm by rotational exposure, and to form a bionic inner wall with a periodically micro-nano structure inside the tube by laser double-beam interference. The polyethylene glycol diacrylate used is a widely recognized versatile biomaterial with good hydrophilicity, biocompatibility and low cytotoxicity. The effect of the bionic structure on the growth of hepatocellular carcinoma cells and human umbilical vein endothelial cells was investigated, and it was demonstrated that the prepared vessels with the bionic structure could largely promote the endothelialization process of the cells inside them.

Preparation, characterization and primary evaluation of trilayered biliary stent films for anti-cholangiocarcinoma and anti-biofilm formation

Excessive growth of tumor within biliary wall and formation of biofilm on inner surface of stent can cause restenosis or even obstruction after stent implantation. Therefore, it is important and valuable to develop a new biliary stent for anti-cholangiocarcinoma and anti-biofilm formation. Herein, we designed, prepared and primarily evaluated a new trilayered film for biliary stents consisting of one poly (lactic acid) (PLA) layer loaded with anti-tumor paclitaxel (PTX layer), one middle PLA isolation layer (isolation layer) and one PLA layer loaded with antimicrobial ofloxacin (OFLX layer). It is postulated that the PTX layer releases drug towards biliary wall with tumor, the OFLX layer releases drug towards lumen of bile duct and the isolation layer is used to separate from the PTX layer and the OFLX layer and facilitate drug release in unidirectional way. The prepared trilayered films were characterized in terms of morphology, microstructure, crystallinity and biodegradability. It was found that the films could effectively tune drug release by addition of different amounts of drug or PEG, release PTX and OFLX in opposite directions, effectively inhibit the proliferation of human cholangiocarcinoma RBE cells, the adherence of E. coli and S. aureus and the formation of biofilm in vitro. It is potential that the trilayered films can be used to fabricate a new biliary stent with a dual function of anti-cholangiocarcinoma and anti-biofilm formation.

The Exploration of a Novel Biodegradable Drug-Eluting Biliary Stent: Preliminary Work

PURPOSE

To explore the degradation, drug release, and mechanical properties of drug-incorporated films made of different ratios of poly(lactic-co-glycolic acid) (PLGA) and different amounts of paclitaxel (PTX), which may serve as the material platform for the manufacturing of biodegradable drug-eluting biliary stents.

MATERIALS AND METHODS

PLGA of different lactic acid/glycolic acid ratios (50/50, 70/30, and 80/20) and 0%, 10, 20, and 30% weight by weight (w/w) PTX was mixed to make PLGA films, which were then cut into small pieces for further testing. Films were immersed in phosphate-buffered saline (pH 7.4) for a maximum of 11 weeks. Samples were taken randomly at Day 2, 4, 6, 8, 10, 12, 14, and weekly thereafter until Week 11 to test tensile strength, weight loss, pH value of the soaking solution, and drug release. The morphology of films was observed using scanning electron microscope (SEM).

RESULTS

At Week 10 of degradation, PLGA 80/20 still withstood a tensile strength of 9.7 newton (N), while PLGA 50/50 and 70/30 cracked spontaneously since Day 4. At Week 11, weight loss of PLGA 50/50, 70/30, and 80/20 was 95.15, 82.32, and 16.17%, respectively; and the lowest pH value of soaking solution was 1.87, 1.95, and 6.58, respectively. Drug release of 10, 20, and 30% PTX groups was 3.52-4.48%, 1.90-2.26%, and 1.44-2.06%, respectively. SEM proved smooth films before degradation; however, after the tensile strength was lost, cracks could be seen.

CONCLUSION

The degradation rate of PLGA can be controlled by altering lactic acid/glycolic acid ratio. Overall, PLGA 50/50 and 70/30 degrade significantly faster than 80/20. PLGA can serve as an effective drug carrier for PTX while being the stent strut, and PTX can be slowly released as PLGA degrades.

Biodegradable polylactic acid (PLA)

Polylactic acid (PLA) is a biodegradable material that can be processed using the common processing techniques, such as injection molding, extrusion, and blow molding. PLA has widely been researched and tested due to its biodegradable nature. As a biodegradable material, PLA can be subject to some inherently poor qualities, such as its brittleness, weak mechanical properties, small processing windows, or poor electrical and thermal properties. In order to nullify some of these issues, nanofiller composites have been added to the polymer matrix, such as nanocellulose, nanoclays, carbon nanotubes, and graphene. Dye-clay hybrid nanopigments (DCNP) have been used to explore potential applications in the food packaging industry with promising results. Several different compatibilizers have been studied as well, with the goal of increasing the mechanical properties of blends. A key application for PLA is in wound healing and surgical work, with a few studies described in the present chapter. Finally, the superwettability of dopamine modified PLA is examined, with promising results for separation of oily wastewater.

Case report: Trans-papillary free stenting of the cystic duct and of the common bile duct in a double biliary ducts anastomoses of a right lobe living donor transplantation

Background

One of the major issues related to the living donor liver transplantation recipient outcome is still the high rate of biliary complication, especially when multiple biliary ducts are present and multiple anastomoses have to be performed.

Case presentation and conclusion

We report a case of adult-to-adult right lobe living donor liver transplantation performed for a recipient affected by alcohol-related cirrhosis with MELD score of 17. End-stage liver disease was complicated by refractory ascites, portal hypertension, small esophageal varices and portal gastropathy, hypersplenism, and abundant right pleural effusion. Here in the attached video we described the adult-to-adult LDLT procedures, where a right lobe with two biliary ducts draining respectively the right anterior and the right posterior segments has been transplanted. LDLT required a biliary reconstruction using the native cystic and common bile ducts stented trans-papillary with two 5- French 6 cm long soft silastic catheter. None major complications were detected during post-operative clinical courses. Actually, the donor and the recipient are alive and well. The technique we describe in the video, allow to keep the biliary anastomoses protected and patent without having the risk of creating cholestasis and the need of invasive additional procedure. No living donor right lobe transplantation should be refused because of the presence of multiple biliary ducts.