1
|
Artsen AM, Liang R, Meyn L, Bradley MS, Moalli PA. Dysregulated wound healing in the pathogenesis of urogynecologic mesh complications. Sci Rep 2023; 13:21437. [PMID: 38052928 PMCID: PMC10698181 DOI: 10.1038/s41598-023-48388-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 11/26/2023] [Indexed: 12/07/2023] Open
Abstract
To test the hypothesis that dysregulated wound healing is associated with Urogynecologic mesh complications, we collected vaginal cell secretions using vaginal swabs after polypropylene mesh implantation in patients with (N = 39) and without (N = 40) complication. A customized multiplex immunoassay measured markers of inflammation (MCP-1, IGFBP-1, IL-2, IL-10, IL-17, PDGF-BB, bFGF, IL-1b, IL-6, IL-12p70, TNF-α), neuroinflammation (IL-1RA, TGF-β, IL-15, IL-18, IL-3, M-CSF), angiogenesis (VEGF), and matrix proteins (fibronectin, tenasin c, thrombospondin-2, lumican) between groups. Patients with complications were younger, heavier, implanted with mesh longer, and more likely to be ever smokers. A 5 kg/m2 BMI increase and ever-smoking were associated with a 2.4-fold and sixfold increased risk of complication, respectively. Patients with the highest tertile of bFGF, fibronectin, thrombospondin-2, TNF-β, or VEGF had an odds ratio (OR) of 11.8 for having a mesh complication while ≥ 3 elevated had an OR of 237 while controlling for age, BMI, and smoking. The highest tertile of bFGF, thrombospondin-2, and fibronectin together perfectly indicated a complication (P < 0.0001). A receiver-operator curve for high bFGF, thrombospondin-2, and fibronectin showed excellent discrimination between complications and controls (AUC 0.87). These data provide evidence of dysregulated wound healing in mesh complications. Modifiable factors provide potential targets for patient counseling and interventions.
Collapse
Affiliation(s)
- Amanda M Artsen
- Department of Obstetrics, Gynecology and Reproductive Sciences at Magee Womens Hospital, Magee-Womens Research Institute, University of Pittsburgh, 204 Craft Avenue 312A, Lab A320, Pittsburgh, PA, 15213, USA.
| | - Rui Liang
- Department of Obstetrics, Gynecology and Reproductive Sciences at Magee Womens Hospital, Magee-Womens Research Institute, University of Pittsburgh, 204 Craft Avenue 312A, Lab A320, Pittsburgh, PA, 15213, USA
| | - Leslie Meyn
- Department of Obstetrics, Gynecology and Reproductive Sciences at Magee Womens Hospital, Magee-Womens Research Institute, University of Pittsburgh, 204 Craft Avenue 312A, Lab A320, Pittsburgh, PA, 15213, USA
| | - Megan S Bradley
- Department of Obstetrics, Gynecology and Reproductive Sciences at Magee Womens Hospital, Magee-Womens Research Institute, University of Pittsburgh, 204 Craft Avenue 312A, Lab A320, Pittsburgh, PA, 15213, USA
| | - Pamela A Moalli
- Department of Obstetrics, Gynecology and Reproductive Sciences at Magee Womens Hospital, Magee-Womens Research Institute, University of Pittsburgh, 204 Craft Avenue 312A, Lab A320, Pittsburgh, PA, 15213, USA
| |
Collapse
|
2
|
Gudde AN, van Velthoven MJJ, Kouwer PHJ, Roovers JPWR, Guler Z. Injectable polyisocyanide hydrogel as healing supplement for connective tissue regeneration in an abdominal wound model. Biomaterials 2023; 302:122337. [PMID: 37793268 DOI: 10.1016/j.biomaterials.2023.122337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/07/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023]
Abstract
In pelvic organ prolapse (POP) patients, the uterus, bladder and/or rectum descends into vagina due to weakened support tissues. High recurrence rates after POP surgery suggest an urgent need for improved surgical outcomes. Our aim is to promote connective tissue healing that results in stimulated tissue support functions by surgically applying a hydrogel functionalized with biological cues. We used known vaginal wound healing promoting factors (basic fibroblast growth factor, β-estradiol, adipose-derived stem cells) in the biomimetic and injectable polyisocyanide (PIC) hydrogel, which in itself induces regenerative vaginal fibroblast behavior. The regenerative capacity of injected PIC hydrogel, and the additional pro-regenerative effects of these bioactive factors was evaluated in abdominal wounds in rabbits. Assessment of connective tissue healing (tensile testing, histology, immunohistochemistry) revealed that injection with all PIC formulations resulted in a statistically significant stiffness and collagen increase over time, in contrast to sham. Histological evaluation indicated new tissue growth with moderate to mild immune activity at the hydrogel - tissue interface. The results suggest that PIC injection in an abdominal wound improves healing towards regaining load-bearing capacity, which encourages us to investigate application of the hydrogel in a more translational vaginal model for POP surgery in sheep.
Collapse
Affiliation(s)
- Aksel N Gudde
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center-location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam University Medical Center-location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Melissa J J van Velthoven
- Department of Urology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, the Netherlands; Institute for Molecules and Materials, Radboud University, Heyendaalseweg 135, 6525 AJ, Nijmegen, the Netherlands
| | - Paul H J Kouwer
- Institute for Molecules and Materials, Radboud University, Heyendaalseweg 135, 6525 AJ, Nijmegen, the Netherlands
| | - Jan-Paul W R Roovers
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center-location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam University Medical Center-location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Zeliha Guler
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center-location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam University Medical Center-location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| |
Collapse
|
3
|
Chen J, Tang X, Wang Z, Perez A, Yao B, Huang K, Zhang Y, King MW. Techniques for navigating postsurgical adhesions: Insights into mechanisms and future directions. Bioeng Transl Med 2023; 8:e10565. [PMID: 38023705 PMCID: PMC10658569 DOI: 10.1002/btm2.10565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 12/01/2023] Open
Abstract
Postsurgical adhesions are a common complication of surgical procedures that can lead to postoperative pain, bowel obstruction, infertility, as well as complications with future procedures. Several agents have been developed to prevent adhesion formation, such as barriers, anti-inflammatory and fibrinolytic agents. The Food and Drug Administration (FDA) has approved the use of physical barrier agents, but they have been associated with conflicting clinical studies and controversy in the clinical utilization of anti-adhesion barriers. In this review, we summarize the human anatomy of the peritoneum, the pathophysiology of adhesion formation, the current prevention agents, as well as the current research progress on adhesion prevention. The early cellular events starting with injured mesothelial cells and incorporating macrophage response have recently been found to be associated with adhesion formation. This may provide the key component for developing future adhesion prevention methods. The current use of physical barriers to separate tissues, such as Seprafilm®, composed of hyaluronic acid and carboxymethylcellulose, can only reduce the risk of adhesion formation at the end stage. Other anti-inflammatory or fibrinolytic agents for preventing adhesions have only been studied within the context of current research models, which is limited by the lack of in-vitro model systems as well as in-depth study of in-vivo models to evaluate the efficiency of anti-adhesion agents. In addition, we explore emerging therapies, such as gene therapy and stem cell-based approaches, that may offer new strategies for preventing adhesion formation. In conclusion, anti-adhesion agents represent a promising approach for reducing the burden of adhesion-related complications in surgical patients. Further research is needed to optimize their use and develop new therapies for this challenging clinical problem.
Collapse
Affiliation(s)
- Jiahui Chen
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Xiaoqi Tang
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Ziyu Wang
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Arielle Perez
- UNC School of Medicine Department of SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Benjamin Yao
- Montefiore Medical Center Department of Obstetrics & Gynecology & Women's Health ServicesMontefiore Medical CenterBronxNew YorkUSA
| | - Ke Huang
- Joint Department of Biomedical EngineeringNorth Carolina State University & University of North Carolina at Chapel HillRaleighNorth CarolinaUSA
- Department of Molecular Biomedical SciencesNorth Carolina State UniversityRaleighNorth CarolinaUnited States
| | - Yang Zhang
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Martin W. King
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
- College of Textiles, Donghua UniversityShanghaiSongjiangChina
| |
Collapse
|
4
|
Knight KM. Biomaterials Interventions for Pelvic Organ Prolapse. JPHYS MATERIALS 2023; 6:19-21. [PMID: 36883191 PMCID: PMC9986830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Katrina M Knight
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
5
|
Knight KM, King GE, Palcsey SL, Suda A, Liang R, Moalli PA. Mesh Deformation: a mechanism underlying polypropylene prolapse mesh complications in vivo. Acta Biomater 2022; 148:323-335. [PMID: 35671876 DOI: 10.1016/j.actbio.2022.05.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 05/12/2022] [Accepted: 05/31/2022] [Indexed: 12/12/2022]
Abstract
Polypropylene meshes used in pelvic organ prolapse (POP) repair are hampered by complications. Most POP meshes are highly unstable after tensioning ex vivo, as evidenced by marked deformations (pore collapse and wrinkling) that result in altered structural properties and material burden. By intentionally introducing collapsed pores and wrinkles into a mesh that normally has open pores and remains relatively flat after implantation, we reproduce mesh complications in vivo. To do this, meshes were implanted onto the vagina of rhesus macaques in nondeformed (flat) vs deformed (pore collapse +/- wrinkles) configurations and placed on tension. Twelve weeks later, animals with deformed meshes had two complications, 1) mesh exposure through the vaginal epithelium, and 2) myofibroblast proliferation with fibrosis - a mechanism of pain. The overarching response to deformed mesh was vaginal thinning associated with accelerated apoptosis, reduced collagen content, increased proteolysis, deterioration of mechanical integrity, and loss of contractile function consistent with stress shielding - a precursor to mesh exposure. Regional differences were observed, however, with some areas demonstrating myofibroblast proliferation and matrix deposition. Variable mechanical cues imposed by deformed meshes likely induce these two disparate responses. Utilizing meshes associated with uniform stresses on the vagina by remaining flat with open pores after tensioning is critical to improving outcomes. STATEMENT OF SIGNIFICANCE: Pain and exposure are the two most reported complications associated with the use of polypropylene mesh in urogynecologic procedures. Most meshes have unstable geometries as evidenced by pore collapse and wrinkling after tensioning ex vivo, recapitulating what is observed in meshes excised from women with complications in vivo. We demonstrate that collapsed pores and wrinkling results in two distinct responses 1) mesh exposure associated with tissue degradation and atrophy and 2) myofibroblast proliferation and matrix deposition consistent with fibrosis, a tissue response associated with pain. In conclusion, mesh deformation leads to areas of tissue degradation and myofibroblast proliferation, the likely mechanisms of mesh exposure and pain, respectively. These data corroborate that mesh implantation in a flat configuration with open pores is a critical factor for reducing complications in mesh-augmented surgeries.
Collapse
Affiliation(s)
- Katrina M Knight
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Magee-Womens Research Institute, Pittsburgh, PA.
| | | | | | - Amanda Suda
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rui Liang
- Magee-Womens Research Institute, Pittsburgh, PA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Pamela A Moalli
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA; Division of Urogynecology and Reconstructive Pelvic Surgery, Magee-Womens Hospital of the University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
6
|
Kyriakides TR, Kim HJ, Zheng C, Harkins L, Tao W, Deschenes E. Foreign body response to synthetic polymer biomaterials and the role of adaptive immunity. Biomed Mater 2022; 17:10.1088/1748-605X/ac5574. [PMID: 35168213 PMCID: PMC9159526 DOI: 10.1088/1748-605x/ac5574] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 02/15/2022] [Indexed: 02/06/2023]
Abstract
Implanted biomaterials elicit a series of distinct immune and repair-like responses that are collectively known as the foreign body reaction (FBR). These include processes involving innate immune inflammatory cells and wound repair cells that contribute to the encapsulation of biomaterials with a dense collagenous and largely avascular capsule. Numerous studies have shown that the early phase is dominated by macrophages that fuse to form foreign body giant cells that are considered a hallmark of the FBR. With the advent of more precise cell characterization techniques, specific macrophage subsets have been identified and linked to more or less favorable outcomes. Moreover, studies comparing synthetic- and natural-based polymer biomaterials have allowed the identification of macrophage subtypes that distinguish between fibrotic and regenerative responses. More recently, cells associated with adaptive immunity have been shown to participate in the FBR to synthetic polymers. This suggests the existence of cross-talk between innate and adaptive immune cells that depends on the nature of the implants. However, the exact participation of adaptive immune cells, such as T and B cells, remains unclear. In fact, contradictory studies suggest either the independence or dependence of the FBR on these cells. Here, we review the evidence for the involvement of adaptive immunity in the FBR to synthetic polymers with a focus on cellular and molecular components. In addition, we examine the possibility that such biomaterials induce specific antibody responses resulting in the engagement of adaptive immune cells.
Collapse
Affiliation(s)
- Themis R. Kyriakides
- Department of Biomedical Engineering, Yale University. New Haven CT 06405,Department of Pathology, Yale University. New Haven CT 06405,Vascular Biology and Therapeutics Program. Yale University. New Haven CT 06405
| | - Hyun-Je Kim
- Department of Biomedical Engineering, Yale University. New Haven CT 06405
| | - Christy Zheng
- Department of Biomedical Engineering, Yale University. New Haven CT 06405
| | - Lauren Harkins
- Department of Biomedical Engineering, Yale University. New Haven CT 06405
| | - Wanyun Tao
- Department of Biomedical Engineering, Yale University. New Haven CT 06405
| | - Emily Deschenes
- Department of Biomedical Engineering, Yale University. New Haven CT 06405
| |
Collapse
|
7
|
Farr NTH, Roman S, Schäfer J, Quade A, Lester D, Hearnden V, MacNeil S, Rodenburg C. A novel characterisation approach to reveal the mechano-chemical effects of oxidation and dynamic distension on polypropylene surgical mesh. RSC Adv 2021; 11:34710-34723. [PMID: 35494782 PMCID: PMC9042683 DOI: 10.1039/d1ra05944k] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/17/2021] [Indexed: 11/21/2022] Open
Abstract
Polypropylene (PP) surgical mesh, used successfully for the surgical repair of abdominal hernias, is associated with serious clinical complications when used in the pelvic floor for repair of stress urinary incontinence or support of pelvic organ prolapse. While manufacturers claim that the material is inert and non-degradable, there is a growing body of evidence that asserts PP fibres are subject to oxidative damage and indeed explanted material from patients suffering with clinical complications has shown some evidence of fibre cracking and oxidation. It has been proposed that a pathological cellular response to the surgical mesh contributes to the medical complications; however, the mechanisms that trigger the specific host response against the material are not well understood. Specifically, this study was constructed to investigate the mechano-chemical effects of oxidation and dynamic distension on polypropylene surgical mesh. To do this we used a novel advanced spectroscopical characterisation technique, secondary electron hyperspectral imaging (SEHI), which is based on the collection of secondary electron emission spectra in a scanning electron microscope (SEM) to reveal mechanical-chemical reactions within PP meshes.
Collapse
Affiliation(s)
- Nicholas T H Farr
- Department of Materials Science and Engineering, University of Sheffield Sir Robert Hadfield Building, Mappin Street UK
- Insigneo Institute for in silico Medicine The Pam Liversidge Building, Sir Robert Hadfield Building, Mappin Street Sheffield UK
| | - Sabiniano Roman
- Department of Materials Science and Engineering, University of Sheffield Sir Robert Hadfield Building, Mappin Street UK
| | - Jan Schäfer
- Leibniz Institute for Plasma Science and Technology (INP e.V.) Felix-Hausdorff-Str. 2 17489 Greifswald Germany
| | - Antje Quade
- Leibniz Institute for Plasma Science and Technology (INP e.V.) Felix-Hausdorff-Str. 2 17489 Greifswald Germany
| | - Daniel Lester
- Polymer Characterisation Research Technology Platform, University of Warwick Library Road CV4 7AL Coventry UK
| | - Vanessa Hearnden
- Department of Materials Science and Engineering, University of Sheffield Sir Robert Hadfield Building, Mappin Street UK
| | - Sheila MacNeil
- Department of Materials Science and Engineering, University of Sheffield Sir Robert Hadfield Building, Mappin Street UK
| | - Cornelia Rodenburg
- Department of Materials Science and Engineering, University of Sheffield Sir Robert Hadfield Building, Mappin Street UK
| |
Collapse
|