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Baidoo N, Sanger GJ. The human colon: Evidence for degenerative changes during aging and the physiological consequences. Neurogastroenterol Motil 2024:e14848. [PMID: 38887160 DOI: 10.1111/nmo.14848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/16/2024] [Accepted: 06/05/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The incidence of constipation increases among the elderly (>65 years), while abdominal pain decreases. Causes include changes in lifestyle (e.g., diet and reduced exercise), disease and medications affecting gastrointestinal functions. Degenerative changes may also occur within the colo-rectum. However, most evidence is from rodents, animals with relatively high rates of metabolism and accelerated aging, with considerable variation in time course. In humans, cellular and non-cellular changes in the aging intestine are poorly investigated. PURPOSE To examine all available studies which reported the effects of aging on cellular and tissue functions of human isolated colon, noting the region studied, sex and age of tissue donors and study size. The focus on human colon reflects the ability to access full-thickness tissue over a wide age range, compared with other gastrointestinal regions. Details are important because of natural human variability. We found age-related changes within the muscle, in the enteric and nociceptor innervation, and in the submucosa. Some involve all regions of colon, but the ascending colon appears more vulnerable. Changes can be cell- and sublayer-dependent. Mechanisms are unclear but may include development of "senescent-like" and associated inflammaging, perhaps associated with increased mucosal permeability to harmful luminal contents. In summary, reduced nociceptor innervation can explain diminished abdominal pain among the elderly. Degenerative changes within the colon wall may have little impact on symptoms and colonic functions, because of high "functional reserve," but are likely to facilitate the development of constipation during age-related challenges (e.g., lifestyle, disease, and medications), now operating against a reduced functional reserve.
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Affiliation(s)
- Nicholas Baidoo
- School of Life Sciences, University of Westminster, London, UK
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gareth J Sanger
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Humphrey HN, Sibley P, Walker ET, Keller DS, Pata F, Vimalachandran D, Daniels IR, McDermott FD. Genetic, epigenetic and environmental factors in diverticular disease: systematic review. BJS Open 2024; 8:zrae032. [PMID: 38831715 PMCID: PMC11148476 DOI: 10.1093/bjsopen/zrae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 02/07/2024] [Accepted: 03/03/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Diverticulosis is a normal anatomical variant of the colon present in more than 70% of the westernized population over the age of 80. Approximately 3% will develop diverticulitis in their lifetime. Many patients present emergently, suffer high morbidity rates and require substantial healthcare resources. Diverticulosis is the most common finding at colonoscopy and has the potential for causing a significant morbidity rate and burden on healthcare. There is a need to better understand the aetiology and pathogenesis of diverticular disease. Research suggests a genetic susceptibility of 40-50% in the formation of diverticular disease. The aim of this review is to present the hypothesized functional effects of the identified gene loci and environmental factors. METHODS A systematic literature review was performed using PubMed, MEDLINE and Embase. Medical subject headings terms used were: 'diverticular disease, diverticulosis, diverticulitis, genomics, genetics and epigenetics'. A review of grey literature identified environmental factors. RESULTS Of 995 articles identified, 59 articles met the inclusion criteria. Age, obesity and smoking are strongly associated environmental risk factors. Intrinsic factors of the colonic wall are associated with the presence of diverticula. Genetic pathways of interest and environmental risk factors were identified. The COLQ, FAM155A, PHGR1, ARHGAP15, S100A10, and TNFSF15 genes are the strongest candidates for further research. CONCLUSION There is increasing evidence to support the role of genomics in the spectrum of diverticular disease. Genomic, epigenetic and omic research with demographic context will help improve the understanding and management of this complex disease.
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Affiliation(s)
- Hannah N Humphrey
- Department of Colorectal Surgery, Royal Devon University Healthcare Foundation Trust, Exeter, UK
| | - Pauline Sibley
- Department of Colorectal Surgery, Royal Devon University Healthcare Foundation Trust, Exeter, UK
| | - Eleanor T Walker
- Department of Colorectal Surgery, Royal Devon University Healthcare Foundation Trust, Exeter, UK
| | - Deborah S Keller
- Department of Surgery, Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Francesco Pata
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Dale Vimalachandran
- Department of Molecular & Cancer Medicine, Institute of Cancer Medicine, University of Liverpool, Liverpool, UK
- Department of Colorectal Surgery, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Ian R Daniels
- Department of Colorectal Surgery, Royal Devon University Healthcare Foundation Trust, Exeter, UK
| | - Frank D McDermott
- Department of Colorectal Surgery, Royal Devon University Healthcare Foundation Trust, Exeter, UK
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Ariam E, Richter V, Bermont A, Sandler Y, Cohen DL, Shirin H. Prior abdominal surgery as a potential risk factor for colonic diverticulosis or diverticulitis. World J Clin Cases 2023; 11:8320-8329. [PMID: 38130607 PMCID: PMC10731208 DOI: 10.12998/wjcc.v11.i35.8320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/15/2023] [Accepted: 12/04/2023] [Indexed: 12/14/2023] Open
Abstract
BACKGROUND Abnormal colonic pressure profiles have been associated with an increased risk of colonic diverticulosis. A surgical history is a known risk factor for abdominal adhesions and these may lead to increased intraluminal colonic pressure. AIM To assess whether previous abdominal surgery is associated with colonic diverticulosis or diverticulitis. METHODS We analyzed data from a study of patients undergoing colonoscopy for different indications from 2020 through 2021. Patients completed a structured questionnaire concerning previous abdominal surgeries, dietary and lifestyle exposures including smoking, alcohol use and co-morbidities. RESULTS Three hundred and fifty-nine patients were included in the study. The mean age was 67.6 and 46% were females. Diabetes mellitus, hypertension, ischemic heart disease, chronic obstructive pulmonary disease, chronic renal failure, and body mass index were similar in the diverticulosis and control groups. The overall prevalence of colonic diverticulosis was 25% (91/359) and 48% of the patients had previous abdominal surgery. As expected, the prevalence of diverticulosis increased with age. There was no difference in the rate of previous abdominal surgery between patients with or without diverticulosis (49% vs 47%, P = 0.78). In regards to specific surgeries, inguinal hernia repair was significantly associated with diverticulosis (52% vs 20%, P = 0.001), but not diverticulitis. In contrast, appendectomy was not associated with diverticulosis (6% vs 14%, P = 0.048). CONCLUSION These findings suggest that post-operative abdominal adhesions inducing high colonic intraluminal pressures do not appear to be the mechanism for diverticula formation. Rather, inguinal hernia and diverticulosis may share similar connective tissue pathologies with no causative relationship between them.
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Affiliation(s)
- Eran Ariam
- Department of Gastroenterology, Kaplan Medical Center, Rehovot 76100, Israel
| | - Vered Richter
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin 70300, Israel and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anton Bermont
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin 70300, Israel and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Sandler
- Department of Surgery Division, Shamir Medical Center, Zerifin 70300, Israel
| | - Daniel L Cohen
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin 70300, Israel and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Shirin
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin 70300, Israel and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Baidoo N, Sanger GJ, Belai A. Histochemical and biochemical analysis of collagen content in formalin-fixed, paraffin embedded colonic samples. MethodsX 2023; 11:102416. [PMID: 37876831 PMCID: PMC10590991 DOI: 10.1016/j.mex.2023.102416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 10/04/2023] [Indexed: 10/26/2023] Open
Abstract
Collagen is the most abundant structural protein and extracellular matrix component in mammals. In the colon, collagen fibres reside in all the major sublayers; namely, the mucosa, submucosa, muscularis externa and the serosa. Methods to quantify collagen content in formalin-fixed, paraffin-embedded (FFPE) stained sections are required and image analysis offers a technique by which the spatial distribution and localisation of collagen fibres can be easily measured. This laboratory protocol was developed from established techniques using FFPE colon. Human colonic samples embedded transversally in paraffin wax were serially sectioned and stained with either Masson's trichrome (MT) or Picrosirius red (PSR). Quantitation estimation of collagen content in each sublayer was performed via ImageJ processing. Hydroxyproline content was quantified using a rapid and sensitive assay in sectioned tissue. Either MT or PSR staining followed by morphometric image analysis via ImageJ provided equally appreciable quantitative results. Moreso, analysis of hydroxyproline content in our samples indicate that this protocol could be useful in retrospective studies for FFPE samples. This laboratory protocol provides a systematic and reproducible method that can be utilized to accurately assess collagen content in individual sublayers of the colonic wall as well as detection of overall hydroxyproline content in FFPE specimens.
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Affiliation(s)
- Nicholas Baidoo
- University of Roehampton, School of Life Sciences. Holybourne Ave, London. SW15 4JD, UK
| | - Gareth J. Sanger
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Abi Belai
- University of Roehampton, School of Life Sciences. Holybourne Ave, London. SW15 4JD, UK
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Jk L, B R, B O, K S. Lack of autoantibodies against collagen and related proteins in collagenous colitis. BMC Immunol 2022; 23:29. [PMID: 35668375 PMCID: PMC9171945 DOI: 10.1186/s12865-022-00504-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 06/01/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Collagenous colitis (CC) is a common cause of chronic diarrhea and is characterized by a subepithelial thickened collagen layer in the colonic mucosa. It shares many of the characteristics found in autoimmune diseases, but no autoantibodies have been identified. In CC, an imbalance in collagen turnover is evident. The purpose of the present study was to investigate whether any collagen-associated autoantibodies or other antibodies such as TPO and ASCA were present, and if levels of total IgE were increased. Methods Sera from women with active CC were analysed with ELISA for detection of autoantibodies against collagen type III and IV (Col III and IV), matrix metalloproteinase-9 (MMP-9), tissue inhibitors of metalloproteinase-1 (TIMP-1) and tenascin-C (TNC). Sera were also analysed for TPO, ASCA and total IgE. Healthy female blood donors served as controls. The cut-off value in the control group was defined as relative units > 97.5th percentile. Results Sixty-six women were included (mean age 60 years; range 31–74, mean disease duration 6 years; range 1–22). No autoantibody was significantly overexpressed in the CC population compared to controls. The mean disease duration was lower (p = 0.03) in the subjects who expressed collagen-associated autoantibodies (3.7 years; range 1–14), compared to those who did not (6.4 years; range 1–22). Treatment with budesonide was not associated with any of these autoantibodies. Conclusion No increased presence of the investigated antibodies could be found in the present study of CC. Neither could antibodies against ASCA or TPO, or elevated levels of IgE, be found. Consequently, no association was found between CC and these proteins, even though this may not be generalizable to other compounds in the collagen layer.
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Affiliation(s)
- Larsson Jk
- Department of Clinical Sciences, Department of Gastroenterology and Nutrition, Lund University, Skåne University Hospital, Malmö, Sweden.
| | - Roth B
- Department of Clinical Sciences, Department of Gastroenterology and Nutrition, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Ohlsson B
- Department of Clinical Sciences, Department of Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Sjöberg K
- Department of Clinical Sciences, Department of Gastroenterology and Nutrition, Lund University, Skåne University Hospital, Malmö, Sweden
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Broad JB, Wu Z, Clark TG, Musson D, Jaung R, Arroll B, Bissett IP, Connolly MJ. Diverticulosis and nine connective tissue disorders: epidemiological support for an association. Connect Tissue Res 2019; 60:389-398. [PMID: 30719942 DOI: 10.1080/03008207.2019.1570169] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Purpose: An underlying connective tissue disorder (CTD) may predispose to formation of intestinal diverticula. We assess the association of diverticulosis with nine selected CTDs, to inform the pathophysiology of diverticula. Methods: A population-based period-prevalence study. Individuals (3.5 million New Zealand residents born 1901-1986) with a health system record 1999-2016 were grouped into those with a hospital diagnosis of diverticulosis or diverticulitis (ICD-10-AM K57), and those without. Also recorded were any hospital diagnoses of nine selected CTDs. The association of exposure to diverticulosis and each CTD was assessed using logistic regressions adjusted for age, gender, ethnicity and region. Results: In all, 85,958 (2.4%) people had a hospital diagnosis of diverticulosis. Hospitalisation with diverticulosis was highly significantly associated with rectal prolapse (adjusted odds ratio [OR] = 3.9), polycystic kidney disease (OR = 3.8), heritable syndromes (Marfan or Ehlers-Danlos) (OR = 2.4), female genital prolapse (OR = 2.3), non-aortic aneurysm (OR = 2.3), aortic aneurysm (OR = 2.2), inguinal hernia (OR = 1.9) and dislocations of shoulder and other joints (OR = 1.7), but not subarachnoid haemorrhage (OR = 1.0). Conclusion: People with diverticulosis are more likely to have colonic extracellular matrix (ECM)/connective tissue alterations in anatomical areas other than the bowel, suggesting linked ECM/connective tissue pathology. Although biases may exist, the results indicate large-scale integrated studies are needed to investigate underlying genetic pathophysiology of colonic diverticula, together with fundamental biological studies to investigate cellular phenotypes and ECM changes.
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Affiliation(s)
- Joanna B Broad
- a Freemasons' Department of Geriatric Medicine , University of Auckland , Auckland , New Zealand
| | - Zhenqiang Wu
- a Freemasons' Department of Geriatric Medicine , University of Auckland , Auckland , New Zealand
| | - Taane G Clark
- b Faculty of Epidemiology and Population Health & Faculty of Infectious and Tropical Diseases , London School of Hygiene and Tropical Medicine , London , UK
| | - David Musson
- c Department of Medicine , University of Auckland , Auckland , New Zealand
| | - Rebekah Jaung
- d Department of Surgery , University of Auckland , Auckland , New Zealand
| | - Bruce Arroll
- e Primary Care, Department of General Practice and Primary Healthcare , University of Auckland , Auckland , New Zealand
| | - Ian P Bissett
- d Department of Surgery , University of Auckland , Auckland , New Zealand
| | - Martin J Connolly
- f Waitemata District Health Board , University of Auckland, and Geriatrician , Auckland , New Zealand
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Guo X, Patel B, Han L, Al-Dulaimi H, Van Alstine WG, Noblet JN, Chambers S, Kassab GS. Novel swine model of colonic diverticulosis. Am J Physiol Gastrointest Liver Physiol 2019; 317:G51-G56. [PMID: 31091148 DOI: 10.1152/ajpgi.00408.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The pathophysiology of colonic diverticulosis has not been completely understood. The development of appropriate animal models is essential to study diverticular disease. To date, no large animal models are available for this disease condition. The objective of this study was to develop a swine model by damaging the colon wall, combined with or without a low-fiber diet to mimic the pathogenesis of diverticulosis. To create a weakness on the colon wall, collagenase was applied in vivo to degrade the collagen in the colon wall. Three groups of Yucatan minipigs were included. Group 1 (n = 12) underwent collagenase injection (CI) with a low-fiber diet for 6 mo, group 2 (n = 8) underwent CI alone with a standard swine diet for 6 mo, and group 3 (n = 12) received a low-fiber diet alone for 6 mo. We found that diverticulosis occurred in 91.7% (11 of 12) of pigs in the CI + diet group and 100% (8 of 8) in CI-alone group. Moreover, around 30-75% of colon CI spots for each pig developed diverticular lesions. Diet alone for 6 mo did not induce diverticulosis. The endoscopic and histological examinations revealed the formation of multiple wide-mouthed diverticular lesions along the descending colon. Our results provide convincing evidence of the high efficacy of the reduced colon wall strength caused by CI in the development of a swine model of diverticulosis. Low-fiber diet consumption for 6 mo had no influence on the generation time or incidence rate of diverticulosis. In this model, digestion of the collagen in the colonic wall is sufficient to cause diverticulosis. NEW & NOTEWORTHY Effective large animal models of diverticulosis are currently lacking for the study of diverticular disease. This study marks the first time that a swine model of diverticulosis was developed by damaging colon wall structure, combined with or without a low-fiber diet. We found that a defect of colon wall could result in colon diverticular lesions within 6 mo in swine. This animal model mimicking the pathological process of diverticulosis is of great clinical value.
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Affiliation(s)
- Xiaomei Guo
- California Medical Innovations Institute , San Diego, California
| | - Bhavesh Patel
- California Medical Innovations Institute , San Diego, California
| | - Ling Han
- California Medical Innovations Institute , San Diego, California
| | - Hiba Al-Dulaimi
- California Medical Innovations Institute , San Diego, California
| | | | | | | | - Ghassan S Kassab
- California Medical Innovations Institute , San Diego, California
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Kulacoglu H, Köckerling F. Hernia and Cancer: The Points Where the Roads Intersect. Front Surg 2019; 6:19. [PMID: 31024927 PMCID: PMC6460227 DOI: 10.3389/fsurg.2019.00019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/18/2019] [Indexed: 12/24/2022] Open
Abstract
Introduction: This review aimed to present common points, intersections, and potential interactions or mutual effects for hernia and cancer. Besides direct relationships, indirect connections, and possible involvements were searched. Materials and Methods: A literature search of PubMed database was performed in July 2018 as well as a search of relevant journals and reference lists. The total number of screened articles was 1,422. Some articles were found in multiple different searches. A last PubMed search was performed during manuscript writing in December 2018 to update the knowledge. Eventually 427 articles with full text were evaluated, and 264 included, in this review. Results: There is no real evidence for a possible common etiology for abdominal wall hernias and any cancer type. The two different diseases had been found to have some common points in the studies on genes, integrins, and biomarkers, however, to date no meaningful relationship has been identified between these points. There is also some, albeit rather conflicting, evidence for inguinal hernia being a possible risk factor for testicular cancer. Neoadjuvant or adjuvant therapeutic modalities like chemotherapy and radiotherapy may cause postoperative herniation with their adverse effects on tissue repair. Certain specific substances like bevacizumab may cause more serious complications and interfere with hernia repair. There are only two articles in PubMed directly related to the topic of "hernia and cancer." In one of these the authors claimed that there was no association between cancer development and hernia repair with mesh. The other article reported two cases of squamous-cell carcinoma developed secondary to longstanding mesh infections. Conclusion: As expected, the relationship between abdominal wall hernias and cancer is weak. Hernia repair with mesh does not cause cancer, there is only one case report on cancer development following a longstanding prosthetic material infections. However, there are some intersection points between these two disease groups which are worthy of research in the future.
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Affiliation(s)
| | - Ferdinand Köckerling
- Department of Surgery, Centre for Minimally Invasive Surgery, Vivantes Klinikum, Berlin, Germany
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Colonic diverticulosis is associated with abdominal wall hernia. Hernia 2017; 21:525-529. [DOI: 10.1007/s10029-017-1598-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/22/2017] [Indexed: 11/26/2022]
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Küper MA, Trütschel S, Weinreich J, Königsrainer A, Beckert S. Growth hormone abolishes the negative effects of everolimus on intestinal wound healing. World J Gastroenterol 2016; 22:4321-4329. [PMID: 27158200 PMCID: PMC4853689 DOI: 10.3748/wjg.v22.i17.4321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 02/10/2016] [Accepted: 03/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether the simultaneous treatment with human growth hormone (hGH) abolishes the negative effects of everolimus on anastomotic healing.
METHODS: Forty-eight male Sprague-Dawley-rats were randomized to three groups of 16 animals each (I: vehicle; II: everolimus 3 mg/kg po; III: everolimus 3 mg/kg po + hGH 2.5 mg/kg sc). Animals were pre-treated with hGH and/or everolimus daily for seven days. Then a standard anastomosis was created in the descending colon and treatment was continued for another seven days. The anastomosis was resected in toto and the bursting pressure was assessed as a mechanical parameter of intestinal healing. Moreover, biochemical (Hydroxyproline, PCNA, MPO, MMP-2 and MMP-9) and histological (cell density, angiogenesis, amount of granulation tissue) parameters of intestinal healing were assessed.
RESULTS: Anastomotic bursting pressure was significantly reduced by everolimus and a simultaneous treatment with hGH resulted in considerably higher values (I: 134 ± 19 mmHg, II: 85 ± 25 mmHg, III: 114 ± 25 mmHg; P < 0.05, I vs II; P = 0.09, I vs III and II vs III) Hydroxyproline concentration was significantly increased by hGH compared to everolimus alone (I: 14.9 ± 2.5 μg/mg, II: 8.9 ± 3.6 μg/mg, III: 11.9 ± 2.8 μg/mg; P < 0.05, I vs II/III and II vs III). The number of MPO-positive cells was reduced significantly by hGH compared to everolimus alone (I: 10 ± 1 n/mm², II: 15 ± 3 n/mm², III: 9 ± 2 n/mm²; P < 0.05, I vs II and II vs III), while the number of PCNA-positive cells were increased by hGH (I: 28 ± 3 /mm², II: 12 ± 3 /mm², III: 26 ± 12 /mm²; P < 0.05, I vs II and II vs III). Corresponding to these biochemical findings, HE-histology revealed significantly increased amount of granulation tissue in hGH-treated animals.
CONCLUSION: Inhibition of intestinal wound healing by everolimus is partially neutralized by simultaeous treatment with hGH. Both inflammation as well as collagen deposition is influenced by hGH.
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Pantaroto M, Lopes Filho GDJ, Pinto CAL, Antico Filho A. Comparative study of collagen deposition in the colon wall of patients operated for sigmoid diverticular disease. Acta Cir Bras 2015; 30:715-9. [DOI: 10.1590/s0102-865020150100000010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/15/2015] [Indexed: 01/19/2023] Open
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Connelly TM, Berg AS, Harris LR, Tappouni R, Brinton D, Deiling S, Koltun WA. Surgical diverticulitis is not associated with defects in the expression of wound healing genes. Int J Colorectal Dis 2015; 30:1247-54. [PMID: 26003116 DOI: 10.1007/s00384-015-2263-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The development of diverticuli may represent defects in collagen vascular tissue integrity possibly from a genetic predisposition. We evaluated the tissue expression of wound healing genes in sigmoid tissue from youthful patients undergoing surgery for diverticulitis and thus would more likely suffer from a genetic predisposition (SD mean age 39 ± 0.9) versus controls in the form of patients over the age of 50 (mean age 52.9 ± 10.5 years) without evidence of diverticular disease. METHODS The mRNA expression of 84 genes associated with the extracellular matrix, cellular adhesion, growth factors, inflammatory cytokines, and signal transduction was evaluated in 16 SD and 15 control tissues using a Qiagen Wound Healing Array. Vitronectin, the gene protein with the highest potential significance on raw analysis, was further investigated using a Taqman assay with an additional 11 SD (total n = 27) and four control (total n = 19) samples. Statistics were by Student's t and Mann-Whitney tests with Bonferroni correction. RESULTS No significant differences in mRNA expression between the SD and control tissue in the 84 measured genes were demonstrated after correction. Vitronectin mRNA expression was downregulated 2.7-fold in SD tissue vs. tissue from non-neoplastic control patients (p = 0.001 raw/0.08 corrected). However, on vitronectin TaqMan analysis, no difference in expression was seen in SD vs. all controls or in all subset comparisons. CONCLUSIONS The lack of significant alteration in mRNA expression of traditionally associated wound healing genes/proteins in young SD patients suggests that such genes play a minor role in the genetic predisposition to youthful diverticulitis.
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Affiliation(s)
- Tara M Connelly
- Department of Surgery, Division of Colon and Rectal Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, 17033-0850, USA
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Connelly TM, Tappouni R, Mathew P, Salgado J, Messaris E. Risk Factors for the Development of an Incisional Hernia after Sigmoid Resection for Diverticulitis: An Analysis of 33 Patient, Operative and Disease-associated Factors. Am Surg 2015. [DOI: 10.1177/000313481508100531] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Incisional hernia (IH) is a relatively common sequelae of sigmoidectomy for diverticulitis. The aim of this study was to investigate factors that may predict IH in diverticulitis patients. Two hundred and one diverticulitis patients undergoing sigmoidectomy between January 2002 and December 2012 were identified (mean follow-up 5.15 ± 2.33 years). Patients with wound infections were excluded. Thirteen patient-associated, three diverticular disease-related, and 17 operative variables were evaluated in patients with and without IH. Volumetric fat was measured on pre-operative CTs. Fischer's exact, χ2, and Mann–Whitney tests and multivariate regression analysis were used for statistics. Thirty-four (17%) patients had an IH. On multivariate analysis, wound packing (OR 3.4, P = 0.017), postoperative nonwound infection (OR 7.4, P = 0.014), and previous hernia (OR 3.6, P = 0.005) were as independent predictors of IH. Fifteen of 34 (44%) patients who developed a hernia had a history of prior hernia. Of 33 potential risk factors analyzed, including smoking, chronic obstructive pulmonary disease, and obesity, the only patient factor present preoperatively associated with increased risk of a postsigmoidectomy hernia after multivariate analysis was a history of a previous hernia. Preoperative identification of patients with a history of hernia offers the opportunity to employ measures to decrease the likelihood of IH.
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Affiliation(s)
- Tara M. Connelly
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, Pennsylvania and
| | - Rafel Tappouni
- Department of Radiology, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, Pennsylvania
| | - Paul Mathew
- Department of Radiology, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, Pennsylvania
| | - Javier Salgado
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, Pennsylvania and
| | - Evangelos Messaris
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, Pennsylvania and
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Simić A, Skrobić O, Djurić-Stefanović A, Stojakov D, Peško P. From Ockham’s razor to Hickam’s dictum and back—Saint’s theory and the insights in herniosis. Eur Surg 2015. [DOI: 10.1007/s10353-014-0292-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lundy JB. A primer on wound healing in colorectal surgery in the age of bioprosthetic materials. Clin Colon Rectal Surg 2014; 27:125-33. [PMID: 25435821 DOI: 10.1055/s-0034-1394086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Wound healing is a complex, dynamic process that is vital for closure of cutaneous injuries, restoration of abdominal wall integrity after laparotomy closure, and to prevent anastomotic dehiscence after bowel surgery. Derangements in healing have been described in multiple processes including diabetes mellitus, corticosteroid use, irradiation for malignancy, and inflammatory bowel disease. A thorough understanding of the process of healing is necessary for clinical decision making and knowledge of the current state of the science may lead future researchers in developing methods to enable our ability to modulate healing, ultimately improving outcomes. An exciting example of this ability is the use of bioprosthetic materials used for abdominal wall surgery (hernia repair/reconstruction). These bioprosthetic meshes are able to regenerate and remodel from an allograft or xenograft collagen matrix into site-specific tissue; ultimately being degraded and minimizing the risk of long-term complications seen with synthetic materials. The purpose of this article is to review healing as it relates to cutaneous and intestinal trauma and surgery, factors that impact wound healing, and wound healing as it pertains to bioprosthetic materials.
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Affiliation(s)
- Jonathan B Lundy
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
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de ARAÚJO LMG, SERIGIOLLE LC, GOMES HMP, RODRIGUES DAB, LOPES CM, LEME PLS. Volume calculation of rats' organs and its application in the validation of the volume relation between the abdominal cavity and the hernial sac in incisional hernias with "loss of abdominal domain". ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2014; 27:177-81. [PMID: 25184766 PMCID: PMC4676367 DOI: 10.1590/s0102-67202014000300004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/20/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND The calculation of the volume ratio between the hernia sac and the abdominal cavity of incisional hernias is based on tomographic sections as well as the mathematical formula of the volume of the ellipsoid, which allows determining whether this is a giant hernia or there is a "loss of domain". As the images used are not exact geometric figures, the study of the volume of two solid organs of Wistar rats was performed to validate these calculations. AIM To correlate two methods for determining the volume of the kidney and spleen of rats, comparing a direct method of observation of the volume with the mathematical calculation of this value. METHODS The volume of left kidney, geometrically more regular, and spleen, with its peculiar shape, of ten animals was established in cubic centimeters after complete immersion in water with the aid of a beaker graduated in millimeters. These values were compared with those obtained by calculating the same volume with a specific mathematical formula: V = 4/3 × π × (r1 x r2 x r3). Data were compared and statistically analyzed by Student's t test. RESULTS Although the average volume obtained was higher through the direct method (1.13 cm3 for the left kidney and 0.71 cm3 for the spleen) than the values calculated with the mathematical formula (0.81 cm3 and 0.54 cm3), there were no statistically significant differences between the values found for the two organs (p>0.05). CONCLUSION There was adequate correlation between the direct calculation of the volume of the kidney and spleen with the result of mathematical calculation of these values in the animals' studies.
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The TNFSF15 gene single nucleotide polymorphism rs7848647 is associated with surgical diverticulitis. Ann Surg 2014; 259:1132-7. [PMID: 24814505 DOI: 10.1097/sla.0000000000000232] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine if single nuclear polymorphisms (SNPs) in the TFNSF15 gene play a role in patients requiring surgery for diverticulitis. BACKGROUND A role for a genetic predisposition in diverticulitis is suggested by its association with hereditary connective tissue disorders, youthful onset in some patients, and the observation of families with multiple affected individuals. The TNFSF15 gene has been associated with other inflammatory diseases affecting the colon such as medically refractory ulcerative colitis (UC), aggressive Crohn's disease (CD), and pouchitis after restorative proctocolectomy. METHODS In the discovery phase of this study, 21 sporadic surgical diverticulitis (SD) patients (9 female, mean age = 52 ± 5) and 5 individuals from a single family with surgically managed diverticulitis [familial diverticulitis (FD), 4 female, mean age = 51.1 ± 7] were studied. SD patients were age and sex matched with 3 separate groups of healthy, CD and UC control patients. All patients were genotyped for 5 known TNFSF15-associated SNPs. The SNP discovered to be associated with diverticulitis (rs7848647) was then confirmed in a separate test group composed of 34 additional patients (20 female, mean age 57.7 ± 2) who also underwent surgical treatment for diverticulitis. These patients were age matched to a new control cohort of patients having no history of diverticulitis (26 female). Patients were genotyped using a TaqMan assay. In the discovery phase, logistical regression on matched subjects was performed to determine an association of TNFSF SNP with diverticulitis versus the control groups. In the test phase, significance for the rs7848647 SNP was assessed by the Fischer's exact test. RESULTS In the discovery phase, the TNFSF15 SNP rs7848647 was significantly associated with SD (p = 0.0003) versus all control groups studied. The risk allele for this SNP (G substituted for A) was found in all SD patients. The homozygous GG allele was found in 62% (13/21) of SD patients versus only 5% (1/21) of healthy controls (p = 0.001) and 24% (10/42) of all UC + CD controls (p = 0.002). All 5 members of the FD cohort were homozygous for the at-risk "G" allele. In the test group, the homozygous GG genotype was found in 56% of SD patients compared with 17% of healthy controls (p = 0.006). Risk of SD seemed to increase with number of the G alleles with 8% of SD patients having AA homozygosity, 35% of SD patients having AG heterozygosity, and 56% of SD patients having GG homozygosity. CONCLUSIONS The SNP rs7848647 associated with the TNFSF15 gene is associated with surgical diverticulitis. This finding suggests a fundamental role for TNFSF15, a T-cell receptor gene involved in T-cell maturation, in the pathophysiology of diverticulitis requiring surgery. This SNP may be a marker of diverticular disease severity that might assist in surgical decision making.
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Gladkova N, Kiseleva E, Robakidze N, Balalaeva I, Karabut M, Gubarkova E, Feldchtein F. Evaluation of oral mucosa collagen condition with cross-polarization optical coherence tomography. JOURNAL OF BIOPHOTONICS 2013; 6:321-9. [PMID: 22764058 DOI: 10.1002/jbio.201200059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 05/30/2012] [Accepted: 06/08/2012] [Indexed: 05/15/2023]
Abstract
The goal of the research was analysis of the effect of collagen condition in formation of cross-polarized CP OCT images. We used of the CP OCT technique for studying collagen condition on an example of oral mucosa. Special histologic picrosirius red (PSR) staining of cheek mucosa specimens was used with subsequent assessing of the result of collagen staining in polarized light. High correlation (r = 0.692, p = 0.0001) between OCT signal standard deviation (SD) in cross-polarized images and brightness of PSR stained collagen fibers in cheek mucosa specimens was demonstrated in patients with inflammatory intestine and oral mucosa diseases. We have found that the OCT signal SD in cross-polarized images reflects two boundary conditions of collagen disorganization, namely, loss of fiber properties at active inflammation which attenuates the signal and fibrosis that occurs due to synthesis of a new remodeled collagen which amplifies the OCT signal.
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Read RC. Systemic hernial disease protects against cancer: an hypothesis. Hernia 2009; 14:119-21. [DOI: 10.1007/s10029-009-0583-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Accepted: 10/16/2009] [Indexed: 12/31/2022]
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Abstract
INTRODUCTION Despite herniorrhaphy being performed frequently, most surgeons consider it to be a minor procedure. However, a few surgeons' views differed. THE PAST The Master was Bassini (1884), who introduced a radical cure for inguinal hernia. Incising his triple layer, internal oblique, transversus, and transversalis, he entered the preperitoneal space, allowing high ligation of the sac and mass suturing to the inguinal ligament. A 2.7% recurrence rate evoked worldwide emulation. Corruption ensued. The cremaster remained and few unincised layers were stitched, without imbrications, along with reinforcement using the cremaster or rectus muscles, fascial flaps, relaxing incisions, and silver coils. Little improvement cast doubt on Bassini's work. Russell's (Lancet 2:1197-1203, 1906) ligation of the hernial sac was adopted until 1953, when the Shouldice clinic revived Bassini's tenets, becoming the gold standard for decades. Cheatle (Br Med J 2:68-69, 1920) introduced posterior pre-peritoneal repair. Acquaviva and Bourret (Presse Med 73:892, 1948) designed the first plastic prosthesis (nylon), replaced by polypropylene. Usher (Surg Gynecol Obstet 117:239-240, 1963) parietalized the cord. These contributions paved the way for the Rives, Stoppa, Wantz, and Gilbert repairs, Ger's laparoscopic approach, and less common herniorrhaphies. THE PRESENT Chevrel (1979) formed the GREPA, which evolved into the European Hernia Society (EHS), joining with the American Hernia Society (AHS) to form the journal 'Hernia.' Nilsson (1993) instituted national hernia registries, enabling less recurrences and better prospective research. THE FUTURE In the 21st century, the Lichtenstein procedure has dominated inguinal herniorrhaphy. Herniologists accepted systemic connective tissue disorder as the etiology of abdominal hernia and pelvic prolapses. This malady explains why prostheses slow but do not eliminate recurrence. Antidotes need to be developed and employed. CONCLUSION This malady explains why prostheses slow but do not eliminate recurrence. Antidotes need to be developed and employed.
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Affiliation(s)
- R C Read
- University of Arkansas for Medical Sciences, Rockville, MD 20850, USA.
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Abstract
INTRODUCTION Despite herniorrhaphy being performed frequently, most surgeons consider it to be a minor procedure. However, a few surgeons' views differed. THE PAST The Master was Bassini (1884), who introduced a radical cure for inguinal hernia. Incising his triple layer, internal oblique, transversus, and transversalis, he entered the preperitoneal space, allowing high ligation of the sac and mass suturing to the inguinal ligament. A 2.7% recurrence rate evoked worldwide emulation. Corruption ensued. The cremaster remained and few unincised layers were stitched, without imbrications, along with reinforcement using the cremaster or rectus muscles, fascial flaps, relaxing incisions, and silver coils. Little improvement cast doubt on Bassini's work. Russell's (Lancet 2:1197-1203, 1906) ligation of the hernial sac was adopted until 1953, when the Shouldice clinic revived Bassini's tenets, becoming the gold standard for decades. Cheatle (Br Med J 2:68-69, 1920) introduced posterior pre-peritoneal repair. Acquaviva and Bourret (Presse Med 73:892, 1948) designed the first plastic prosthesis (nylon), replaced by polypropylene. Usher (Surg Gynecol Obstet 117:239-240, 1963) parietalized the cord. These contributions paved the way for the Rives, Stoppa, Wantz, and Gilbert repairs, Ger's laparoscopic approach, and less common herniorrhaphies. THE PRESENT Chevrel (1979) formed the GREPA, which evolved into the European Hernia Society (EHS), joining with the American Hernia Society (AHS) to form the journal 'Hernia.' Nilsson (1993) instituted national hernia registries, enabling less recurrences and better prospective research. THE FUTURE In the 21st century, the Lichtenstein procedure has dominated inguinal herniorrhaphy. Herniologists accepted systemic connective tissue disorder as the etiology of abdominal hernia and pelvic prolapses. This malady explains why prostheses slow but do not eliminate recurrence. Antidotes need to be developed and employed. CONCLUSION This malady explains why prostheses slow but do not eliminate recurrence. Antidotes need to be developed and employed.
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Affiliation(s)
- R C Read
- University of Arkansas for Medical Sciences, Rockville, MD 20850, USA.
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Küper MA, Schölzl N, Traub F, Mayer P, Weinreich J, Coerper S, Steurer W, Königsrainer A, Beckert S. Everolimus interferes with the inflammatory phase of healing in experimental colonic anastomoses. J Surg Res 2009; 167:158-65. [PMID: 19922952 DOI: 10.1016/j.jss.2009.07.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 06/03/2009] [Accepted: 07/08/2009] [Indexed: 12/23/2022]
Abstract
BACKGROUND Delayed wound healing is a serious side effect of mTOR inhibitor-based immunosuppression after solid organ transplantation. The aim of this study was to test the hypothesis that the mTOR inhibitor everolimus interferes with the inflammatory phase of healing in experimental colonic anastomoses. MATERIALS AND METHODS Thirty male Sprague-Dawley rats received a colonic anastomosis. Then, animals were randomized to three groups of daily treatment with either vehicle or everolimus in two different dosages (1.0mg/kg or 3.0mg/kg). After 7 d, rats were sacrificed, and mechanical, histologic, and biochemical parameters of intestinal healing were assessed. RESULTS Anastomotic bursting pressure was significantly decreased by everolimus in both dosages, whereas hydroxyproline content was reduced only by the high everolimus dosage. Everolimus diminished cellular proliferation and new vessel growth. Furthermore, both quantity as well as quality of newly synthesized collagen fibers in the anastomotic granulation tissue was reduced. On the other hand, myeloperoxidase-positive (MPO) cells and interleukin-6 (IL-6) concentrations were increased, as was the activity of matrix-metalloproteinases MMP-2 and MMP-9. CONCLUSION Everolimus interferes with the inflammatory phase of healing. However, it remains unclear whether this phenomenon is involved in everolimus impairment of experimental anastomotic repair.
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Affiliation(s)
- Markus A Küper
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Germany
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Araki K, Mikami T, Yoshida T, Kikuchi M, Sato Y, Oh-ishi M, Kodera Y, Maeda T, Okayasu I. High expression of HSP47 in ulcerative colitis-associated carcinomas: proteomic approach. Br J Cancer 2009; 101:492-7. [PMID: 19603022 PMCID: PMC2720226 DOI: 10.1038/sj.bjc.6605163] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Ulcerative colitis (UC) is a chronic relapsing inflammatory bowel disease, known to be associated with a markedly increased risk of colorectal carcinoma development. METHODS Using proteomic analysis with two-dimensional gel electrophoresis and mass spectrometry, differentially expressed proteins were assessed between UC-associated cancer and sporadic colon cancer cell lines. Western blot and immunostaining were performed for confirming the expression. RESULTS Heat-shock protein of 47 kDa (HSP47) was identified as one of the proteins expressed more highly in UC-associated cancer cell lines, and an immunohistochemical examination confirmed significantly higher levels of HSP47 in UC-associated colon cancers than in sporadic counterparts, the expression increasing with a progression of neoplastic lesions. Heat-shock protein of 47 kDa was further found to be coexpressed with type I collagen in the cytoplasm, and both HSP47 and type I collagen were released from cultured cells into the culture medium. CONCLUSION These results suggest that overexpression of HSP47 is a unique characteristic of UC-associated carcinoma related to type I collagen synthesis, with possible clinical applications.
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Affiliation(s)
- K Araki
- Department of Cellular and Histo-pathology, Kitasato University Postgraduate School of Medical Sciences, Sagamihara, Kanagawa, Japan.
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Is herniosis the single etiology of Saint's triad? Hernia 2008; 13:29-34. [PMID: 18704619 DOI: 10.1007/s10029-008-0421-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Accepted: 07/16/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Sixty years ago, Saint's triad (hiatus hernia, diverticulosis of the colon, and gallbladder disease) was first described in three patients. Since then, the association of these conditions has been questioned. We tested the hypothesis that these conditions are associated, and, based on recent research, propose a common etiology. METHODS Data from the U.S. Veterans Integrated Service Network (VISN) 16 Data Warehouse were analyzed. Chi-square tests and calculated odds ratios (ORs) were utilized to describe the magnitude of association, and multivariable logistic regression models were used to determine the variables associated with Saint's triad. RESULTS Among 637,518 patient records (1996-2005), any hernia was diagnosed among 22,181 (3.5%) patients, hiatus hernia among 1,661 (0.3%), diverticulosis of the colon among 14,375 (2.3%), and gallbladder disease among 5,284 (0.8%). The following associations were observed: diverticulosis, hiatus hernia (OR: 6.9), hiatus hernia, gallbladder disease (OR = 3.8), and gallbladder disease, diverticulosis (OR = 5.9). Patients with both diverticulosis and gallbladder disease were more likely to have hiatus hernia (OR = 3.8; P = 0.0012) or any hernia (OR = 10.7; P < 0.0001). Diseases associated with Saint's triad (incorporating any hernia) included chronic obstructive pulmonary disease (OR = 4.3), hypertension (OR = 3.1), aortic aneurysm (OR = 2.2), and diabetes (OR = 1.8). CONCLUSIONS Herniosis, the systemic connective tissue disease known to cause diverticulosis and herniae, may be responsible for Saint's triad. Diabetes, like aging, enhanced herniosis. Further research on the gallbladder wall pathology in patients with cholelithiasis or cholecystitis is needed.
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Tsereteli Z, Sporn E, Geiger TM, Cleveland D, Frazier S, Rawlings A, Bachman SL, Miedema BW, Thaler K. Placement of a covered polyester stent prevents complications from a colorectal anastomotic leak and supports healing: randomized controlled trial in a large animal model. Surgery 2008; 144:786-92. [PMID: 19081022 DOI: 10.1016/j.surg.2008.05.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Accepted: 05/29/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leaks after colorectal operation continue to be a significant cause of morbidity. A covered endoluminal stent could seal a leak and eliminate the need for diversion. The aim of this study was to test the efficacy of a temporary covered stent to prevent leak related complications. METHODS Sixteen adult pigs (80-120 lbs) underwent open transection of the rectosigmoid followed by anastomosis with a circular stapler. Eight animals (study group) underwent endoscopic placement of a 21-mm covered polyester stent. Eight control group animals were left without stents. In all animals, a 2-cm leak was created along the anterior portion of the anastomosis. The animals were killed after 2 weeks and evaluated for abdominal infection, fistulae, and adhesions. The anastomosis was excised and the following parameters were assessed by a pathologist blinded to treatment: mucosal interruption (mm), inflammatory response, collagen type I and III, granulation, and fibrosis (grade 0-4). RESULTS Stents were spontaneously expelled between postoperative days 6 and 9. At necropsy, none of the animals in the study group had leak related complications, whereas in the control group, 5 (63%) developed intraabdominal infection (4 abscesses, 1 fistula) at the anastomosis (P = .002). Dense adhesions to the anastomosis were found in 7 (88%) control animals. On histology, anastomotic sites in the study group had significantly less mucosal interruption and granulation. Two pigs in the study group died on postoperative day 7, one due to evisceration and one from bladder necrosis. The mortality result is not different from controls (P = .47), both events seem to be unrelated to stent placement. CONCLUSION Temporary placement of a covered polyester stent across a colorectal anastomosis prevents leak-related complications and supports the healing of anastomotic leaks.
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Affiliation(s)
- Zurab Tsereteli
- Department of General Surgery, University of Missouri, Columbia, MO 65212, USA
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August DA, Serrano D, Poplin E. "Spontaneous," delayed colon and rectal anastomotic complications associated with bevacizumab therapy. J Surg Oncol 2008; 97:180-5. [PMID: 18095268 DOI: 10.1002/jso.20938] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Bevacizumab, a humanized monoclonal antibody used to treat recurrent and metastatic colorectal cancer, targets the vascular endothelial growth factor (VEGF) molecule. It is hypothesized that bevacizumab works by both depriving tumors of the neovascularity they require to grow, and by improving local delivery of chemotherapy through alterations of tumor vasculature permeability and Starling forces. Complications of bevacizumab treatment include bowel ischemia and perforation, but to date, these complications have only rarely been described as occurring at the site of presumably healed anastomoses following surgery. We report two cases of delayed, "spontaneous" low anterior colorectal anastomotic dehiscence and one right colon anastomotic colocutaneous fistula associated with bevacizumab therapy. After seeing three patients with complications arising from apparently healed low anterior colorectal or right colon anastomoses following initiation of bevacizumab therapy for treatment of metastatic colorectal cancer, we reviewed the experience of The Cancer Institute of New Jersey (CINJ) with use of bevacizumab in approximately 50 patients between April 2004 and December 2006. The three index cases had been treated surgically at CINJ but received chemotherapy elsewhere. None of the 50 patients receiving bevacizumab at CINJ who had previous colon or rectal anastomoses were identified as having this complication. The medical records of the three index cases were reviewed and analyzed. Additionally, a Medline search was performed to identify other reports documenting similar cases. Two reports of related cases were found in the literature. In two of our index cases who underwent low anterior anastomoses, the patients had received preoperative pelvic irradiation before their initial low anterior resection. In one of the two cases, the initial resection was complicated by an anastomotic leak requiring proximal diversion and then subsequent stoma takedown. In both cases, the dehiscence occurred more than 1 year after anastomosis, and became evident 1-10 months following initiation of bevacizumab treatment. In the third index case, a colocutaneous fistula arising from the anastomotic site presented 5 months following right colon resection and 3 months after starting adjuvant systemic therapy with FOLFOX (5-fluorouracil (5-FU), leucovorin, and oxaliplatin) and bevacizumab. Delayed colorectal anastomotic complications may occur in association with bevacizumab therapy. Contributing factors may include anastomotic leak at the time of the original operation and history of anastomotic irradiation. Clinicians treating patients who receive bevacizumab following colectomy for colorectal cancer should be aware of this possible life-threatening complication. These findings may also be relevant to the design of trials of the use of bevacizumab for the postoperative adjuvant treatment of patients with colorectal cancer.
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Affiliation(s)
- David A August
- Division of Surgical Oncology, Department of Surgery, UMDNJ/Robert Wood Johnson Medical School, The Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA.
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