Local expression of tumor necrosis factor-alpha and interleukin-10 on wound healing of intestinal anastomosis during endotoxemia in mice

A clinical nomogram for predicting small bowel obstruction after extubation after radical resection of esophageal cancer and jejunostomy

BACKGROUND

Small bowel obstruction after extubation is among the most serious complications of radical esophageal cancer and jejunostomy resection. This study aimed to explore the risk factors and treatment methods for small bowel obstruction after extubation and construct a predictive model to guide its clinical management.

METHODS

Clinical data for 514 patients who underwent esophagectomy with jejunostomy for esophageal cancer were collected. A nomogram was constructed using the independent risk factors for small bowel obstruction after extubation determined on multivariable logistic regression analysis, and a subgroup analysis was performed of the treatment methods for the 61 patients with small bowel obstruction after extubation.

RESULTS

The nomogram incorporated the independent risk factors for small bowel obstruction after extubation (gastrointestinal function recovery [P < .001], postoperative albumin reduction ratio [P = .009], and serious postoperative complications [P < .001]) in the multivariable logistic regression analysis. The final model had an area under the curve of 0.829 (95% confidence interval, 0.775-0.883). The calibration plots demonstrated high concordance between the predicted and actual probabilities. The model demonstrated excellent discriminatory power for internal and time validation, with adjusted C-statistics of 0.821 and 0.810 (95% confidence interval, 0.686-0.933), respectively. In the subgroup analysis, an abnormal anion gap (P = .016) and low serum albumin level (P = .005) were associated with recurrent small bowel obstruction. The model's area under the curve was 0.815 (95% confidence interval, 0.683-0.948). The probability of recurrence among patients with small bowel obstruction after extubation was 78.3% when the 2 risk factors were present.

CONCLUSION

The clinical nomogram based on small bowel obstruction after extubation predictors recommends aggressive surgical intervention for patients with small bowel obstruction after extubation and an abnormal anion gap and low serum albumin level at admission.

Chyme Reinfusion Reducing the Postoperative Complications After Definitive Surgery for Small Intestinal Enteroatmospheric Fistula: A Cohort Study

Purpose

This study is aimed to reveal the role of preoperative chyme reinfusion (CR) in reducing the complications occurring after definitive surgery (DS) for small intestinal enteroatmospheric fistula (EAF).

Methods

In this study, from January 2012 to December 2019, the patients with small intestinal EAF and receiving a definitive surgery were recruited. Depending on whether the CR has been performed, these patients were divided into either the CR group or the non-CR group. Then, propensity scores matching (PSM) was used to further divide these patients into the PSM CR group or the PSM none-CR group. The clinical characteristics exhibited by the groups were analyzed, and the effect of preoperative CR was investigated.

Result

A total of 159 patients were finally recruited with 72 patients in the CR group and 87 patients in the non-CR group. The postoperative complications were manifested in a total of 126 cases (79.3%). There were 49 cases in the CR group, and 77 cases in the non-CR group. CR was associated with the occurrence of postoperative complications (multivariate odds ratio [OR] = 0.289; 95% CI: 0.123-0.733; p = 0.006). After 1:1 PSM, there were 92 patients included. The postoperative complications were observed in 67 out of these 92 patients. There were 26 patients in the PSM CR group, and 41 patients in the PSM non-CR group. CR was associated with postoperative complications (multivariate OR = 0.161; 95% CI: 0.040-0.591; p = 0.002). In addition, CR played a role in reducing the recurrence of fistula both before (multivariate OR = 0.382; 95% CI: 0.174-0.839; p = 0.017) and after (multivariate OR = 0.223; 95% CI: 0.064-0.983; p = 0.034) PSM. In addition, there is a protective factor at play for those patients with postoperative ileus before (multivariate OR = 0.209; 95% CI: 0.095-0.437; p < 0.001) and after (multivariate OR = 0.222; 95% CI: 0.089-0.524; p < 0.001) PSM. However, the relationship between CR and incision-related complications was not observed in this study.

Conclusion

Preoperative CR is effective in reducing postoperative complications after definitive surgery was performed for EAF.

Early Enteral Nutrition Could Reduce Risk of Recurrent Leakage After Definitive Resection of Anastomotic Leakage After Colorectal Cancer Surgery

BACKGROUND

The present study aimed to evaluate the effect of early enteral nutrition (EEN) after definitive resection of anastomotic leakage (DRAL) resulting from a sigmoid colon or rectal cancer radical resection.

METHODS

This was a prospective cohort study performed at our center. From January 2014 to May 2016, every patient received a standard postoperative nutritional protocol (SPNP) after DRAL and was included into SPNP group. From June 2016 to December 2018, all patients received an EEN after DRAL and were included into EEN group. The effect of postoperative EEN was evaluated.

RESULTS

There were a final total of 133 patients enrolled in our study. There were 70 patients in the SPNP group, and 63 patients in the EEN group. There were 12 cases (19.05%) with a recurrent leakage in the EEN group, and 28 cases (40%) in the SPNP group. The recurrent rate was associated with EEN (HR = 0.417, 95% CI 0.196-0.890, p = 0.024). The median defecation time in the EEN group was 5(4-7) days, while in the SPNP group was 7(6-8.25) days. The defecation was associated with EEN (HR = 1.588, 95% CI 1.080-2.336, p = 0.019), as well.

CONCLUSION

EEN could reduce the recurrent leakage rate and defecation time after definitive resection of anastomotic leakage resulting from sigmoid colon or rectal cancer radical resection.

Comparison of platelet rich plasma versus fibrin glue on colonic anastomoses in rats

PURPOSE

To compare platelet rich plasma (PRP) and fibrin glue about the effect of anastomotic healing.

METHODS

Thirty six Wistar-Albino male rats diveded into 3 groups according to control(Group1), PRP (Group 2) and fibrin glue(Tisseel VH) (Group 3). The colon was transected with scissor and subsequently an end to end anastomosis was performed using continuous one layer 6/0 vicryl sutures. Postoperative 7th day effect of anastomotic healing measuring with tissue hydroxyproline(TH) level and anastomotic bursting pressure(ABP); moreover comparison of cytokine (IL-6 and IL-10) and procalcitonin levels on 1st,3rd and 7th days.

RESULTS

There was no statistically significant difference of the ABP and hydroxyproline levels between PRP and fibrin glue on the 7th day. There was no statistically significant difference between levels of proinflammatory cytokine (IL-6) (P=0.41), anti-inflammatory cytokine (IL-10) (P=0.35), and procalcitonin levels (P=0.63) on 1, 3 and 7 days.

CONCLUSION

Fibrin glue and platelet rich plasma are shown to be effective in healing intestinal anastomoses without superior to each other.

Perioperative lipid-enriched enteral nutrition versus standard care in patients undergoing elective colorectal surgery (SANICS II): a multicentre, double-blind, randomised controlled trial

BACKGROUND

Postoperative ileus and anastomotic leakage severely impair recovery after colorectal resection. We investigated the effect of perioperative lipid-enriched enteral nutrition versus standard care on the risk of postoperative ileus, anastomotic leakage, and other clinical outcomes.

METHODS

We did an international, multicentre, double-blind, randomised, controlled trial of patients (≥18 years) undergoing elective colorectal surgery with primary anastomosis at six clinical centres in the Netherlands and Denmark. Patients were randomly assigned (1:1), stratified by location (colonic and rectal) and type of surgery (laparoscopic and open), via online randomisation software, with block sizes of six, to receive either continuous lipid-enriched enteral tube feeding from 3 h before until 6 h after surgery (intervention) or no perioperative nutrition (control). Surgeons, patients, and researchers were masked to treatment allocation for the entire study period. The primary outcome was postoperative ileus. Secondary outcomes included anastomotic leakage, pneumonia, preoperative gastric volumes, time to functional recovery, length of hospital stay, the need for additional interventions, intensive care unit admission, postoperative inflammatory response, and surgical complications. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02175979, and trialregister.nl, number NTR4670.

FINDINGS

Between July 28, 2014, and February 20, 2017, 280 patients were randomly assigned, 15 of whom were excluded after random allocation because they fulfilled one or more exclusion criteria. 265 patients received perioperative nutrition (n=132) or standard care (n=133) and were included in the analyses. A postoperative ileus occurred in 37 (28%) patients in the intervention group versus 29 (22%) in the control group (risk ratio [RR] 1·09, 95% CI 0·95-1·25; p=0·24). Anastomotic leakage occurred in 12 (9%) patients in the intervention group versus 11 (8%) in the control group (RR 1·01, 95% CI 0·94-1·09; p=0·81). Pneumonia occurred in ten (8%) patients in the intervention group versus three (2%) in the control group (RR 1·06, 95% CI 1·00-1·12; p=0·051). All other secondary outcomes were similar between groups (all p>0·05).

INTERPRETATION

Perioperative lipid-enriched enteral nutrition in patients undergoing elective colorectal surgery has no advantage over standard care in terms of postoperative complications.

FUNDING

Netherlands Organisation for Health Research and Development (ZonMW), Fonds NutsOhra, and Danone Research.

Relation between postoperative ileus and anastomotic leakage after colorectal resection: a post hoc analysis of a prospective randomized controlled trial

AIM

Anastomotic leakage (AL) following abdominal surgery is a critical determinant of postoperative recovery, of which the aetiology is largely unknown. Interestingly, interventions aimed at reducing the inflammatory response and postoperative ileus (POI) have an unexpected effect on AL. The aim of this study was to investigate the relation of POI with inflammation and AL after colorectal resection.

METHOD

A post hoc analysis of a prospective randomized controlled trial in which patients underwent a colorectal resection was performed. Patients undergoing a colorectal resection were stratified into having or not having POI. The incidence of AL and other clinical parameters was registered prospectively. Intestinal fatty acid binding protein (I-FABP, a marker for tissue damage) and the inflammatory response in plasma and colon tissue were determined.

RESULTS

AL was present in nine of 43 patients in the POI group, and in one of 65 in the group without POI (P < 0.001). There was a significant association between POI and AL (OR 12.57, 95% CI: 2.73-120.65; P = 0.0005). Patients with POI had significantly higher plasma levels of soluble tumour necrosis factor receptor 1 (TNFRSF1A) at 4 h postoperatively (0.89 ng/l, interquartile range 0.56) than patients without POI (0.80 ng/l, interquartile range 0.37; P = 0.04) and higher plasma levels of C-reactive protein on the second day postoperatively (234 ± 77 vs 163 ± 86 mg/l; P = 0.001). Patients who developed AL had significantly higher plasma levels of I-FABP compared with patients without AL at 24 h after onset of surgery.

CONCLUSION

POI is associated with a higher prevalence of AL and an increased inflammatory response.

Impact of hypertonic saline on postoperative complications for patients undergoing upper gastrointestinal surgery

The aim of this study was to explore the impact of 3% hypertonic saline (HS) intragastric administration for patients who underwent upper gastrointestinal surgery.During the postoperative period, 3% HS has been suggested as a means to improve the intestinal edema and reduce gastrointestinal complications.The medical records of 111 patients with HS intragastric administration following upper gastrointestinal surgery and 268 patients, served as control, were reviewed retrospectively. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including early gastrointestinal function recovery, postoperative complications, and length of hospital stay, were compared according to the HS intragastric administration or not.HS intragastric administration was associated with prompt postoperative gastrointestinal function recovery, including first flatus (risk ratio [RR], 1.32; 95% confidence interval [CI], 0.89-1.65; P = 0.048) and feeding within 3 postoperative days (RR (95% CI), 0.57 (0.49-0.77); P = 0.036). Early ileus occurred in 25 of 108 patients with HS treatment versus 36 of 108 patients without HS treatment (RR (95% CI), 1.43 (0.63-2.15); P = 0.065). The patients with HS experienced a lower overall postoperative complication (odds ratio [OD] 0.57; 95% CI, 0.33-1.09; P = 0.063), including trend toward a decrease for infectious complications (15[13.9] vs 23[21.3]; P = 0.11; OD, 0.59; 95% CI, 0.29-1.22). There was a decreased incidence of anastomotic leakage (1[0.9] vs 7[6.5]; P = 0.033) and postoperative ileuas (5[4.6%] vs 11[10.2%]; P = 0.096) in the HS administration patients.Our study demonstrated beneficial postoperative clinical effects of HS intragastric administration in patients who had undergone upper gastrointestinal surgery, such as prompt postoperative gastrointestinal function recovery and reduced overall postoperative complications, which may be attributed to a reduced intestinal edema.

Effects of metoclopramide on the expression of metalloproteinases and interleukins in left colonic anastomoses. An experimental study

PURPOSE

To evaluate the effects of metoclopramide on metalloproteinases (MMP) and interleukins (IL) gene expression in colonic anastomoses in rats.

METHODS

Eighty rats were divided into two groups for euthanasia on the 3rd or 7th postoperative day (POD), then into two subgroups for sepsis induction or not, and then into subgroups to receive either metoclopramide or saline solution. Left colonic anastomosis were performed and then analyzed.

RESULTS

On the 3rd POD, metoclopramide was associated with increased expression of MMP-1a, MMP-13, and TNF-α. On the 7th POD, the transcripts of all MMPs, TNF-α, IL-1β, IFN-γ, and IL-10 of the treated animals became negatively modulated. In the presence of sepsis, metoclopramide did not change MMPs and decreased IL-6, IL-1β, IFN-γ and IL-10 gene expression on the 3rd POD. On the 7th POD, increased expression of all MMPs, IFN-γ and IL-10 and negative modulated TNF-α and IL-6 gene expression.

CONCLUSION

Administration of metoclopramide increased metalloproteinases and interleukins gene expression on the 3rd postoperative day and negatively modulated them on the 7th POD. In the presence of abdominal sepsis, metoclopramide did not change MMPs and decreased ILs gene expression on the 3rd POD. On the 7th POD, the drug increased expression of all MMPs.

The effects of stimulation of the autonomic nervous system via perioperative nutrition on postoperative ileus and anastomotic leakage following colorectal surgery (SANICS II trial): a study protocol for a double-blind randomized controlled trial

BACKGROUND

Postoperative ileus and anastomotic leakage are important complications following colorectal surgery associated with short-term morbidity and mortality. Previous experimental and preclinical studies have shown that a short intervention with enriched enteral nutrition dampens inflammation via stimulation of the autonomic nervous system and thereby reduces postoperative ileus. Furthermore, early administration of enteral nutrition reduced anastomotic leakage. This study will investigate the effect of nutritional stimulation of the autonomic nervous system just before, during and early after colorectal surgery on inflammation, postoperative ileus and anastomotic leakage.

METHODS/DESIGN

This multicenter, prospective, double-blind, randomized controlled trial will include 280 patients undergoing colorectal surgery. All patients will receive a selfmigrating nasojejunal tube that will be connected to a specially designed blinded tubing system. Patients will be allocated either to the intervention group, receiving perioperative nutrition, or to the control group, receiving no nutrition. The primary endpoint is postoperative ileus. Secondary endpoints include anastomotic leakage, local and systemic inflammation, (aspiration) pneumonia, surgical complications classified according to Clavien-Dindo, quality of life, gut barrier integrity and time until functional recovery. Furthermore, a cost-effectiveness analysis will be performed.

DISCUSSION

Activation of the autonomic nervous system via perioperative enteral feeding is expected to dampen the local and systemic inflammatory response. Consequently, postoperative ileus will be reduced as well as anastomotic leakage. The present study is the first to investigate the effects of enriched nutrition given shortly before, during and after surgery in a clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02175979 - date of registration: 25 June 2014. Dutch Trial Registry: NTR4670 - date of registration: 1 August 2014.

The time course of cytokine expressions plays a determining role in faster healing of intestinal and colonic anastomatic wounds

OBJECTIVES

Inflammation is critical in the early phases of wound healing. It has been reported previously that small intestinal and colonic wounds display a more rapid healing than those of other organs. However, the underlying mechanism has not yet been elucidated. Here we examined whether differences in the time course of specified cytokine expression, in colonic and small intestinal anastomotic lesions, might play a major role in this observation in comparison to lesions effecting skin and muscle tissue.

MATERIALS AND METHODS

Tissue lesions were applied to 36 male Sprague-Dawley rats. Tissue samples were harvested at 1, 3, 5, 7, and 14 days postoperatively with the levels of TNF-α, IL-6, and IFN-α determined by ELISA-derived methods.

RESULTS

The characteristics of TNF-α, IL-6, and IFN-α expression during the healing process for intestinal and colonic lesions were comparable. However, data differed significantly with that observed during healing of skin and muscle lesions. Intestinal and colonic lesions exhibited a significant and sustained increase in specified cytokine levels on day 5 to day 14 as compared with day 1 and 3. Skin and muscle lesions had random or unaltered cytokine levels throughout the study period.

CONCLUSION

Differences in expression of cytokines TNF-α, IL-6, and IFN-α indicate that these play an important role underlying the more rapid healing processes observed in small intestinal and colonic lesions.

Randomized clinical trial of the effect of gum chewing on postoperative ileus and inflammation in colorectal surgery

BACKGROUND

Postoperative ileus (POI) is a common complication following colorectal surgery that delays recovery and increases length of hospital stay. Gum chewing may reduce POI and therefore enhance recovery after surgery. The aim of the study was to evaluate the effect of gum chewing on POI, length of hospital stay and inflammatory parameters.

METHODS

Patients undergoing elective colorectal surgery in one of two centres were randomized to either chewing gum or a dermal patch (control). Chewing gum was started before surgery and stopped when oral intake was resumed. Primary endpoints were POI and length of stay. Secondary endpoints were systemic and local inflammation, and surgical complications. Gastric emptying was measured by ultrasonography. Soluble tumour necrosis factor receptor 1 (TNFRSF1A) and interleukin (IL) 8 levels were measured by enzyme-linked immunosorbent assay.

RESULTS

Between May 2009 and September 2012, 120 patients were randomized to chewing gum (58) or dermal patch (control group; 62). Mean(s.d.) length of hospital stay was shorter in the chewing gum group than in controls, but this difference was not significant: 9·5(4·9) versus 14·0(14·5) days respectively. Some 14 (27 per cent) of 52 analysed patients allocated to chewing gum developed POI compared with 29 (48 per cent) of 60 patients in the control group (P = 0·020). More patients in the chewing gum group first defaecated within 4 days of surgery (85 versus 57 per cent; P = 0·006) and passed first flatus within 48 h (65 versus 50 per cent; P = 0·044). The decrease in antral area measured by ultrasonography following a standard meal was significantly greater among patients who chewed gum: median 25 (range -36 to 54) per cent compared with 10 (range -152 to 54) per cent in controls (P = 0·004). Levels of IL-8 (133 versus 288 pg/ml; P = 0·045) and TNFRSF1A (0·74 versus 0·92 ng/ml; P = 0·043) were lower among patients in the chewing gum group. Fewer patients in this group developed a grade IIIb complication (2 of 58 versus 10 of 62; P = 0·031).

CONCLUSION

Gum chewing is a safe and simple treatment to reduce POI, and is associated with a reduction in systemic inflammatory markers and complications.

REGISTRATION NUMBER

NTR2867 (http://www.trialregister.nl).

Reduction of postoperative ileus by early enteral nutrition in patients undergoing major rectal surgery: prospective, randomized, controlled trial

BACKGROUND

The current trend in postoperative nutrition is to promote a normal oral diet as early as possible. However, postoperative ileus is a frequent and common problem after major abdominal surgery. This study was designed to investigate whether early enteral nutrition (EEN), as a bridge to a normal diet, can reduce postoperative ileus.

METHODS

Patients undergoing major rectal surgery for locally advanced primary or recurrent rectal carcinoma (after neoadjuvant (chemo)-radiation, with or without intraoperative radiotherapy) were randomly assigned to EEN (n = 61) or early parenteral nutrition (EPN, n = 62) in addition to an oral diet. Early nutrition was started 8 hours after surgery. Early parenteral nutrition was given as control nutrition to obtain caloric equivalence and minimize confounding. The primary endpoint was time to first defecation; secondary outcomes were morbidity, other ileus symptoms, and length of hospital stay.

RESULTS

Baseline characteristics were similar for both groups. In intention-to-treat analysis, the time to first defecation was significantly shorter in the enteral nutrition arm than in the control arm (P = 0.04). Moreover, anastomotic leakage occurred significantly less frequently in the enteral group (1 patient) compared with parenteral supplementation (9 patients, P = 0.009). Mean length of stay in the enteral group was 13.4 ± 2.2 days versus 16.7 ± 2.3 days in the parenteral group (P = 0.007).

CONCLUSIONS

Early enteral nutrition is safe and associated with significantly less ileus. Early enteral nutrition is associated with less anastomotic leakage in patients undergoing extensive rectal surgery.

Comparison of the effects of Mg-6Zn and Ti-3Al-2.5V alloys on TGF-β/TNF-α/VEGF/b-FGF in the healing of the intestinal tract in vivo

To evaluate the different effects of Mg-6Zn alloy and Ti-3Al-2.5V alloy implants in intestinal tract healing, we compared these two different alloys with respect to their effect on a rat's intestinal tract, using serum magnesium, radiology, pathology and immunohistochemistry in vivo. It was found using the scanning electron microscope that the Mg-6Zn alloy began to degrade during the first week and that the Ti-3Al-2.5V alloy was non-degradable throughout the process. The Mg-6Zn alloy did not have an impact on serum magnesium. Superior to the Ti-3Al-2.5V alloy, the Mg-6Zn alloy enhanced the expression of transforming growth factor-β1 in healing tissue, and promoted the expression of both the vascular endothelial growth factor and the basic fibroblast growth factor, which helped angiogenesis and healing. The Mg-6Zn alloy reduced the expression of the tumor necrosis factor (TNF-α) at different stages and decreased inflammatory response, which may have been related to the zinc inhibiting TNF-α. In general, the Mg-6Zn alloy performed better than Ti-3Al-2.5V at promoting healing and reducing inflammation. The Mg-6Zn alloy may be a promising candidate for use in the pins of circular staplers for gastrointestinal reconstruction in medicine.

The impact of the myeloid response to radiation therapy

Radiation therapy is showing potential as a partner for immunotherapies in preclinical cancer models and early clinical studies. As has been discussed elsewhere, radiation provides debulking, antigen and adjuvant release, and inflammatory targeting of effector cells to the treatment site, thereby assisting multiple critical checkpoints in antitumor adaptive immunity. Adaptive immunity is terminated by inflammatory resolution, an active process which ensures that inflammatory damage is repaired and tissue function is restored. We discuss how radiation therapy similarly triggers inflammation followed by repair, the consequences to adaptive immune responses in the treatment site, and how the myeloid response to radiation may impact immunotherapies designed to improve control of residual cancer cells.

Expression of metalloproteinases and interleukins on anastomoses in septic rats

BACKGROUND

Anastomotic dehiscence is the most severe complication of colorectal surgery and its incidence increases in the presence of infection. It has been reported that immune factors or the activity of matrix metalloproteinases (MMP) may mediate the loss of anastomotic strength in the first postoperative days. In this study, we investigated the effects of abdominal sepsis on the MMP and interleukin (IL) gene expression in left colonic anastomoses in rats.

MATERIALS AND METHODS

Forty rats were divided into two groups of 20 animals according to the presence (group S) or absence (group N) of sepsis induction by cecal ligation and perforation during left colonic anastomosis. Each group was divided into subgroups for euthanasia on the third (N3 and S3) or seventh (N7 and S7) postoperative day (POD). A colonic segment containing anastomosis was removed for analysis of the expression of MMP1a, MMP8, MMP13, IL1β, IL6, IL10, TNFα, and IFNγ genes.

RESULTS

The anastomoses with abdominal sepsis showed increased MMP1a gene expression and decreased MMP8 gene expression both on the third and seventh POD. There was no change in the expression of MMP13. There was an increase in the expression of IL10 only on the third POD and a negative modulation of IL1β, IFNγ, and IL6 genes on both periods. The TNFα gene expression was negatively modulated on the third POD and became not modulated on the seventh POD.

CONCLUSION

Abdominal sepsis induced a specific inflammatory pattern with increased MMP1a and IL10 gene expression and negative modulation of MMP8, IL1β, IFNγ, and TNFα gene expression in left colonic anastomoses in rats.

Rectal cap polyposis masquerading as ulcerative colitis with pseudopolyposis and presenting as chronic anemia: a case study with review of literature

Cap polyposis (CP) is an under recognized form of non-neoplastic colonic polyps, characterised by the presence of inflammatory polyps with a distinct "cap" of granulation tissue. CP is often seen masquerading as chronic inflammatory bowel disease. The most common symptoms are mucoid diarrhoea, bloody stools, abdominal pain, and tenesmus. In this case report, we present a patient who was diagnosed with CP during the investigation of unexplained chronic long standing anemia secondary to intermittent rectal bleeding. CP, although rare, should be considered in the differential diagnosis of patients presenting with intermittent rectal bleeding and mucoid diarrhoea.

Alcohol acute intoxication before sepsis impairs the wound healing of intestinal anastomosis: rat model of the abdominal trauma patient

Introduction

Most trauma patients are drunk at the time of injury. Up to 2% of traumatized patients develop sepsis, which considerably increases their mortality. Inadequate wound healing of the colonic repair can lead to postoperative complications such as leakage and sepsis.

Objective

To assess the effects of acute alcohol intoxication on colonic anastomosis wound healing in septic rats.

Methods

Thirty six Wistar rats were allocated into two groups: S (induction of sepsis) and AS (alcohol intake before sepsis induction). A colonic anastomosis was performed in all groups. After 1, 3 or 7 days the animals were killed. Weight variations, mortality rate, histopathology and tensile breaking strength of the colonic anastomosis were evaluated.

Results

There was an overall mortality of 4 animals (11.1%), three in the group AS (16.6%) and one in the S group (5.5%). Weight loss occurred in all groups. The colon anastomosis of the AS group didn’t gain strength from the first to the seventh postoperative day. On the histopathological analysis there were no differences in the deposition of collagen or fibroblasts between the groups AS and S.

Conclusion

Alcohol intake increased the mortality rate three times in septic animals. Acute alcohol intoxication delays the acquisition of tensile strength of colonic anastomosis in septic rats. Therefore, acute alcohol intoxication before sepsis leads to worse prognosis in animal models of the abdominal trauma patients.

Colonic anastomotic healing in the context of altered macrophage function and endotoxemia

PURPOSE

Prevention of perioperative activation of intestinal muscularis macrophages is a promising intervention to avoid post-traumatic gastrointestinal tract dysfunction. However, impaired macrophage function could have deleterious consequences on anastomotic healing, especially in complications aggravating the healing process itself, such as infectious problems either as preexisting local inflammation or infection (e.g., complicated diverticulitis) or endotoxemia due to early postoperative infections (e.g., pneumonia). Aim of this study was to investigate colonic anastomotic healing in macrophage-depleted mice in the presence of endotoxemia.

METHODS

Colonic anastomoses were performed, and mice were randomized into six groups (wild type; wild type with endotoxemia; pharmacological depletion of macrophages; pharmacological depletion with endotoxemia; genetically conditioned within the gut muscularis macrophage-deficient osteopetrotic mice; osteopetrotic mice with endotoxemia). Anastomotic tissues were removed 2, 5, and 10 days after surgery and used for functional, histological, biochemical, and molecular investigations.

RESULTS

After pharmacological pretreatment, an almost complete depletion of macrophages was found in the muscularis up to 24 h postoperatively. Bursting pressure was significantly lower than 10 days after anastomotic procedure in osteopetrotic mice during endotoxemia, in marked contrast to transient pharmacologically macrophage-depleted mice. Pharmacological depletion during endotoxemia did not affect hydroxyproline concentration. Finally, in osteopetrotic mice during endotoxemia, collagen-3 expression was significantly lower compared to controls.

CONCLUSIONS

In our current model, we demonstrate that perioperative pharmacological macrophage depletion and inactivation transiently diminishes muscularis macrophages and does not affect intestinal anastomotic healing in the presence of endotoxemia. However, a long-lasting macrophage absence or dysfunction impairs anastomotic healing and could be a risk factor for postoperative anastomotic leakage.

Enhancement of colonic anastomotic strength in rats by short-chain fatty acids

BACKGROUND

The present study is aiming at elucidating the effect of intraoperative lavage with short-chain fatty acids (SCFAs) on colonic anastomosis in rats.

METHODS

Forty male Wistar rats were randomized into four groups (10 rats each). After resection of a segment of transverse colon, an end-to-end anastomosis was performed. In the 1st group, no intraoperative large bowel lavage was performed; in the 2nd, a lavage with normal saline solution; in the 3rd, the animals received a diet rich in SCFAs pre- and postoperatively, and a lavage with normal saline was performed; and in the 4th group, an intraoperative lavage with SCFAs was carried out. On the 4th postoperative day, the animals were sacrificed. Septic complications, adhesions and anastomoses were graded macroscopically and histologically, and bursting pressure of the anastomoses, CRP, IL-6 and TNF-a was measured.

RESULTS

Fewer septic complications (abscesses and minimal ruptures) and adhesions were observed in the 4th group with the intraoperative lavage with SCFAs. The bursting pressure also, in the same group, was higher (73.3 mmHg), followed by the 1st group (67.1 mmHg).

CONCLUSION

Intraoperative lavage with SCFAs increases the bursting pressure of colonic anastomoses, while lavage with saline solution decreases it, in comparison to the group without lavage.

Nonselective matrix metalloproteinase but not tumor necrosis factor-α inhibition effectively preserves the early critical colon anastomotic integrity

BACKGROUND

Increased matrix metalloproteinase (MMP) activity has been implicated in the pathogenesis of colorectal anastomotic leakage. Tumor necrosis factor-α (TNF-α) induces MMPs and may influence anastomosis repair.

METHODS

We assessed the efficacies of the nonselective hydroxamate MMP inhibitor GM6001, the selective hydroxamate MMP inhibitor AG3340 and a TNF-α antagonist with respect to anastomotic breaking strength of left-sided colon anastomoses in male Sprague-Dawley rats.

RESULTS

Systemic GM6001 treatment effectively blocked MMP activity and maintained the initial breaking strength day 0 of the anastomoses when administered subcutaneously as daily depositions (100 mg/kg) or continuously (10 mg/kg/day). In contrast, the anastomotic biomechanic strength was lowered by 55% (p < 0.001) in vehicle-treated rats on postoperative day 3. GM6001 treatment increased breaking strength by 88% (p < 0.0005) compared with vehicle-treated rats day 3 and reduced (p = 0.003) the occurrence of spontaneous anastomotic dehiscence. Histologically, the anastomotic wound was narrower (p < 0.05) in the longitudinal direction in GM6001-treated animals whereas GM6001 had no significant effect on inflammatory cell infiltration or epithelialization. AG3340 (10 mg/kg) increased (p < 0.012) breaking strength by 47% compared with vehicle on day 3 but did not significantly prevent the reduction of the initial breaking strength on day 0. Although the increased TNF-α levels in the wound were attenuated, the anastomotic breaking strength was not improved (p = 0.62) by the TNF-α (10 mg/kg) inhibitor given systemically.

CONCLUSIONS

Pharmacological nonselective MMP inhibition ought to be explored as a prophylactic regimen to reduce anastomotic complications following colorectal resection. The involvement of TNF-α was insignificant in anastomotic wound healing in an experimental model.

Temporal expression of cytokines in rat cutaneous, fascial, and intestinal wounds: a comparative study

BACKGROUND

Previous studies have shown that healing in intestinal wounds is proportionally faster than skin. Cytokines and growth factors play a major role in these coordinated wound-healing events. We hypothesized that this more rapid intestinal healing is due to an early upregulation of proinflammatory cytokines (IL-1beta, TNF-alpha, and IFN-gamma), followed by increases in the expression of the anti-inflammatory cytokine IL-10 and growth factor TGF-beta.

METHODS

Four wounds (skin, fascia, small intestinal, and colonic anastomosis) were created in each of 48 juvenile male Sprague Dawley rats; tissue samples of each site were harvested at 0, 1, 3, 5, 7, and 14 days postoperatively (n = 8/group) and levels of IL-1beta, IFN-gamma, TNF-alpha, IL-10 and TGF-beta expression from each site were measured using ELISA kits.

RESULTS

IL-1beta expression peaked earlier in small-intestinal and colonic wounds when compared to skin or fascia (e.g., small intestine: day 3 and colon day 5, P < 0.05 by ANOVA). Post-wounding levels of TNF-alpha were elevated in fascial wounds, but decreased in small-intestinal and colonic wounds. IFN-gamma levels were not significantly altered in any wounds. IL-10 showed a similar downregulation pattern in all wounds, while TGF-B levels were decreased in colonic and fascial wounds, but relatively unchanged in SI and skin.

CONCLUSIONS

An earlier peak in IL-1beta levels and a consistent decrease in TNF-alpha were seen in healing intestinal tissues; but no clear pattern of increased anti-inflammatory or regulatory cytokines was seen, which might explain the earlier healing of intestinal tissues. Additional studies are required to determine the role of individual cytokines, or the intrinsic reactivity of the tissues may explain the site specific differences of healing rates in different tissues.

Nontraditional Risk Factors in Carotid Artery Disease

Carotid atherosclerosis (AS) is one of the main risk factors for ischemic stroke. Our aim is to evaluate the nontraditional biochemical markers in asymptomatic and symptomatic patients with carotid artery plaque. This study was conducted on 55 patients: 43 with symptomatic and 12 with asymptomatic carotid artery disease. Lipoprotein (a) (Lp(a)), homocysteine, adiponectin, nitric oxide (NO), and tumor necrosis factor α (TNF-α) levels were measured in the plasma. The mean of total cholesterol, triglyceride, and homocysteine levels was significantly elevated in the symptomatic group as compared with the asymptomatic group (P = .03). In the asymptomatic group, adiponectin and NO levels showed elevations as compared with the symptomatic group but this increase was not significant (P > .05). Lipoprotein (a) and TNF-α levels acted inversely with adiponectin and NO. There was an insignificant decline in Lp(a) and TNF-α levels in the asymptomatic group as compared with the symptomatic group (P > .05).

Inhibition of p38 mitogen-activated protein kinase pathway as prophylaxis of postoperative ileus in mice

BACKGROUND & AIMS

Postoperative ileus, an iatrogenic complication of abdominal surgery, is mediated by severe inflammation of the tunica muscularis. Macrophages that reside in the muscularis have important roles in initiating the inflammation. We investigated whether activation of the p38 mitogen-activated protein kinase (MAPK) and stress-activated protein kinase is involved in the genesis of postoperative ileus, and whether p38-MAPK inhibition by the macrophage-specific inhibitor semapimod prevents intestinal dysmotility.

METHODS

Postoperative ileus was induced by intestinal manipulation of the small bowel in mice. Protein kinase phosphorylation was assessed by immunoblotting of muscularis externa preparations. Proinflammatory gene expression was quantified by real-time polymerase chain reaction. Myeloperoxidase histochemistry for neutrophils was performed in jejunal segments. Nitric oxide production was measured by Griess reaction in smooth-muscle organ culture supernatants. Jejunal contractility was assessed within an organ bath setup. Intestinal motility was analyzed by gastrointestinal and colonic transit measurements.

RESULTS

High levels of p38-MAPK and stress-activated protein kinase phosphorylation were observed immediately after intestinal manipulation. Semapimod treatment led to a significant decrease of p38-MAPK phosphorylation in macrophages; proinflammatory gene expression of macrophage inflammatory protein-1alpha, interleukin-6, monocyte chemoattractant protein-1, and intercellular adhesion molecule-1; and neutrophil infiltration. Furthermore, semapimod completely abrogated nitric oxide production within the tunica muscularis. Subsequently, semapimod prevented the suppression of smooth muscle contractility and small intestinal and colonic motility after intestinal manipulation.

CONCLUSION

A single preoperative semapimod administration prevents intestinal macrophage activation and subsequent gastrointestinal dysmotility induced by abdominal surgery. Semapimod inhibits p38-MAPK and nitric oxide production in macrophages, making it a promising strategy for prophylaxis of postoperative ileus.

Effect of melatonin on healing of colonic anastomosis in a rat model of peritonitis

BACKGROUND

The aim of this study is to determine the effect of melatonin on intestinal anastomosis in the presence of peritonitis.

MATERIAL AND METHODS

32 Wistar albino rats were randomized into four groups (n = 8): A (sham), B (control), C (melatonin 5 mg/kg), and D (melatonin 10 mg/kg). In group A, only cecal dissection was carried out. In the other groups, cecal ligation and puncture (CLP) followed cecal dissection in order to induce bacterial peritonitis. 24 h after the previous operation, cecal resection and ileocolic anastomosis were performed in the rats of all groups. In group C (5 mg/kg) and group D (10 mg/kg), melatonin was injected for 5 consecutive days starting after CLP. At the 48th hour of the CLP procedure, blood was drawn via the tail vein for tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) analysis, and on the 4th day of the experiment relaparotomy was carried out for bursting pressure (BP) measurements. The intestinal tissue containing the anastomotic line was then snap-frozen in liquid nitrogen and stored at -80 degrees C for determination of tissue levels of malondialdehyde (MDA) and glutathione (GSH).

RESULTS

The tissue MDA level, blood TNF-alpha and IL-6 levels of group B were significantly higher than in the other groups, whereas the BP results and GSH levels of group B were found to be significantly lower than in the other groups. The results of groups C and D are statistically different from those of group B. When we compared the results of groups C and D, we found significantly higher results in terms of BP and GSH levels in group D and also significantly lower results in terms of MDA, blood TNF-alpha and IL-6 levels in group D.

CONCLUSION

The findings of this experiment suggest that melatonin has a dose-independent positive effect on wound healing of colonic anastomosis.

TNF-α is required for late ischemic preconditioning but not for remote preconditioning of trauma

BACKGROUND

Ischemic preconditioning (IPC) and remote IPC are cardioprotective phenomena in which ischemia of the myocardium or of a remote tissue, respectively, induces cardioprotection. Despite clinical evidence that surgical trauma can remotely affect myocardial infarction, to date there are no basic science studies addressing the effect of nonischemic trauma at distant sites upon cardiac ischemia/reperfusion (I/R) injury. The objectives of this study were to determine the effects of nonischemic remote surgical trauma upon infarct size after myocardial I/R and to determine the effects of TNF-alpha ablation upon cardioprotective phenomena.

MATERIALS AND METHODS

A minimally traumatic mouse model was used to ascertain the effect of remote nonischemic surgical trauma upon I/R injury. TNF-alpha knockout mice were employed to determine the effect of TNF-alpha ablation.

RESULTS

Carotid artery vascular surgery remotely exacerbates cardiac I/R injury increasing infarct size by 287% (remote cardiac injury or RCI). Nonischemic, nonvascular trauma (abdominal incision) results in remote preconditioning of trauma (RPCT), decreasing infarct size by 81% (early phase) and 40% (late phase) relative to controls. Finally, TNF-alpha is required for late IPC but is not necessary for RCI or for RPCT.

CONCLUSIONS

We show that late IPC is TNF-alpha-dependent and describe two unique TNF-alpha-independent remote effects of nonischemic trauma upon myocardial infarction. Understanding the mechanism of these remote effects will allow the development of novel therapies for the treatment of ischemic heart disease. RPCT and TNF-alpha ablation have an additive protective effect suggesting that combinations of complementary approaches may be a useful strategy for maximizing the clinical efficacy of cardioprotective therapies.

Inflammatory response after abdominal surgery

Surgical manipulation of the gut elicits an inflammatory cascade within the intestinal muscularis that contributes to postoperative bowel dysmotility. A range of cytokines is sequentially released into the peritoneal fluid following abdominal surgery, their concentrations reflecting the magnitude of surgical trauma. The overproduction of inflammatory mediators might have detrimental effects on organ function and contribute to the enhanced risk of anastomotic leakage in the presence of sepsis. Specific cellular immune functions such as the microbicidal activity of peritoneal phagocytes are depressed after elective surgery, imposing a risk of infectious complications. Laparoscopic surgery decreases the local and systemic production of cytokines and acute-phase reactants, and better preserves peritoneal immunity compared with open surgery. As concluded from animal studies, the gas used for the pneumoperitoneum may possess substantial immunomodulatory activity.

Interleukin-10 Suppresses Proliferation and Remodeling of Extracellular Matrix of Cultured Human Skin Fibroblasts

When we previously examined the participation of local expression of interleukin-10 (IL-10) and tumor necrosis factor-alpha (TNFalpha) in wound healing of an intestinal anastomosis under septic conditions in mice, we found that IL-10 and TNFalpha expressions were markedly enhanced around the anastomosis and that wound healing was impaired in this animal model. The purpose of the present study was to investigate the combined effect of IL-10 on proliferation and remodeling of the extracellular matrix (ECM) of cultured human skin fibroblasts. Human skin fibroblasts were cultured for 48 h with IL-10 and/or TNFalpha at various concentrations, then the proliferation rates were determined using the MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay. The concentration of transforming growth factor-beta1 (TGFbeta1) in cell culture supernatants was measured by enzyme-linked immunosorbent assay, and type I collagen protein and matrix metalloproteinase-I (MMP-I) were detected by indirect immunofluorescence in cultured cells incubated for 48 h with 10 ng/ml of IL-10 and/or 10 ng/ml of TNFalpha. IL-10 itself had no effect on fibroblast proliferation, but reduced TNFalpha-induced fibroblast proliferation. The concentration of TGFbeta1 in cell culture supernatants was significantly lower in the presence of TNFalpha and IL-10 than in the presence of TNFalpha alone. Immunolabeling of fibroblasts for type I collagen protein was decreased in cells incubated with IL-10 and/or TNFalpha compared to controls. MMP-I immunolabeling was increased in cells incubated with IL-10, IL-10 and TNFalpha compared to control and cells incubated with TNFalpha. It is suggested that IL-10 is an inhibitory factor for the remodeling of the ECM during wound healing.