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Alonso A, de la Gala F, Vara E, Hortal J, Piñeiro P, Reyes A, Simón C, Garutti I. Lung and blood perioperative metalloproteinases in patients undergoing oncologic lung surgery: Prognostic implications. Thorac Cancer 2024; 15:307-315. [PMID: 38155459 PMCID: PMC10834222 DOI: 10.1111/1759-7714.15190] [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: 10/22/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND Metalloproteinases (MMPs) have been reported to be related to oncologic outcomes. The main goal of the study was to study the relationship between these proteins and the long-term prognosis of patients undergoing oncologic lung resection surgery. METHODS This was a substudy of the phase IV randomized control trial (NCT02168751). We analyzed MMP-2, -3, -7, and -9 in blood samples and bronchoalveolar lavage (LBA) and the relationship between MMPs and long postoperative outcomes (survival and disease-free time of oncologic recurrence). RESULTS Survival was longer in patients who had lower MMP-2 levels than those with higher MMP-2 in blood samples taken 6 h after surgery (6.8 vs. 5.22 years; p = 0.012) and MMP-3 (6.82 vs. 5.35 years; p = 0.03). In contrast, survival was longer when MMP-3 levels were higher in LBA from oncologic lung patients than those with lower MMP-3 (7.96 vs. 6.02 years; p = 0.005). Recurrence-free time was longer in patients who had lower MMP-3 levels in blood samples versus higher (5.97 vs. 4.23 years; p = 0.034) as well as lower MMP-7 (5.96 vs. 4.5 years; p = 0.041) or lower MMP-9 in LBA samples (6.21 vs. 4.18 years; p = 0.012). CONCLUSION MMPs were monitored during the perioperative period of oncologic lung resection surgery. These biomarkers were associated with mortality and recurrence-free time. The role of the different MMPs analyzed during the study do not have the same prognostic implications after this kind of surgery.
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Affiliation(s)
- Angel Alonso
- Department of Anesthesiology, Gregorio Marañon University General Hospital, Madrid, Spain
| | - Francisco de la Gala
- Department of Anesthesiology, Gregorio Marañon University General Hospital, Madrid, Spain
| | - Elena Vara
- Department of Biochemistry and Molecular Biology III, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Javier Hortal
- Department of Anesthesiology, Gregorio Marañon University General Hospital, Madrid, Spain
- Department of Pharmacology, Faculty of Medicine complutense University of Madrid, Madrid, Spain
| | - Patricia Piñeiro
- Department of Anesthesiology, Gregorio Marañon University General Hospital, Madrid, Spain
| | - Almudena Reyes
- Department of Anesthesiology, Gregorio Marañon University General Hospital, Madrid, Spain
| | - Carlos Simón
- Department of Thoracic Surgery, Gregorio Marañon University General Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Ignacio Garutti
- Department of Anesthesiology, Gregorio Marañon University General Hospital, Madrid, Spain
- Department of Pharmacology, Faculty of Medicine complutense University of Madrid, Madrid, Spain
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Jørgensen AB, Jonsson I, Friis-Hansen L, Brandstrup B. Collagenase-producing bacteria are common in anastomotic leakage after colorectal surgery: a systematic review. Int J Colorectal Dis 2023; 38:275. [PMID: 38038731 PMCID: PMC10692267 DOI: 10.1007/s00384-023-04562-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
PURPOSE Some gut bacteria can produce enzymes (collagenases) that can break down collagen in the intestinal wall. This could be a part of the pathophysiology of anastomotic leakage (AL). This systematic review aimed to investigate if such bacteria were present more frequently in AL patients versus non-AL patients following colorectal surgery. METHODS This systematic review was reported according to the PRISMA and AMSTAR guidelines. Before the literature search, a study protocol was registered at PROSPERO (CRD42022363454). We searched PubMed, EMBASE, Google Scholar, and Cochrane CENTRAL on April 9th, 2023, for randomized and observational human studies of AL following colorectal surgery with information on gastrointestinal bacteria. The primary outcome was bacteria with the potential to produce collagenase. The risk of bias was assessed with the Newcastle-Ottawa Scale, as all studies were observational. RESULTS We included 15 studies, with a total of 52,945 patients, of which 1,747 had AL, and bacteriological information from feces, mucosa, the resected specimen, or drain fluid was presented. In 10 of the 15 studies, one or more collagenase-producing bacteria were identified in the patients with AL. Neither the bacteria nor the collagenase production were quantified in any of the studies. The studies varied greatly in terms of sample material, analytical method, and time of collection. Studies using DNA sequencing methods did not report findings of collagenase-producing bacteria. CONCLUSION Collagenase-producing bacteria are more common in patients with AL following colorectal surgery than in patients without AL, but the significance is unclear. From the current studies, it is not possible to determine the pathogenicity of the individual gut bacteria.
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Affiliation(s)
- Anders Bech Jørgensen
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Region Zealand, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Isabella Jonsson
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Region Zealand, Denmark
| | - Lennart Friis-Hansen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Bispebjerg and Frederiksberg University Hospital, Capital Region, Frederiksberg, Denmark
- Department of Microbiology, Rigshospitalet, Capital Region, Denmark
| | - Birgitte Brandstrup
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Region Zealand, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Caulk AW, Chatterjee M, Barr SJ, Contini EM. Mechanobiological considerations in colorectal stapling: Implications for technology development. Surg Open Sci 2023; 13:54-65. [PMID: 37159635 PMCID: PMC10163679 DOI: 10.1016/j.sopen.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/07/2023] [Accepted: 04/08/2023] [Indexed: 05/11/2023] Open
Abstract
Technological advancements in minimally invasive surgery have led to significant improvements in patient outcomes. One such technology is surgical stapling, which has evolved into a key component of many operating rooms by facilitating ease and efficacy in resection and repair of diseased or otherwise compromised tissue. Despite such advancements, adverse post-operative outcomes such as anastomotic leak remain a persistent problem in surgical stapling and its correlates (i.e., hand-sewing), most notably in low colorectal or coloanal procedures. Many factors may drive anastomotic leaks, including tissue perfusion, microbiome composition, and patient factors such as pre-existing disease. Surgical intervention induces complex acute and chronic changes to the mechanical environment of the tissue; however, roles of mechanical forces in post-operative healing remain poorly characterized. It is well known that cells sense and respond to their local mechanical environment and that dysfunction of this "mechanosensing" phenomenon contributes to a myriad of diseases. Mechanosensing has been investigated in wound healing contexts such as dermal incisional and excisional wounds and development of pressure ulcers; however, reports investigating roles of mechanical forces in adverse post-operative gastrointestinal wound healing are lacking. To understand this relationship well, it is critical to understand: 1) the intraoperative material responses of tissue to surgical intervention, and 2) the post-operative mechanobiological response of the tissue to surgically imposed forces. In this review, we summarize the state of the field in each of these contexts while highlighting areas of opportunity for discovery and innovation which can positively impact patient outcomes in minimally invasive surgery.
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Affiliation(s)
- Alexander W. Caulk
- Corresponding author at: 60 Middletown Ave., North Haven, CT 06473, USA.
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Liu Y, Li B, Wei Y. New understanding of gut microbiota and colorectal anastomosis leak: A collaborative review of the current concepts. Front Cell Infect Microbiol 2022; 12:1022603. [PMID: 36389160 PMCID: PMC9663802 DOI: 10.3389/fcimb.2022.1022603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/06/2022] [Indexed: 01/24/2023] Open
Abstract
Anastomotic leak (AL) is a life-threatening postoperative complication following colorectal surgery, which has not decreased over time. Until now, no specific risk factors or surgical technique could be targeted to improve anastomotic healing. In the past decade, gut microbiota dysbiosis has been recognized to contribute to AL, but the exact effects are still vague. In this context, interpretation of the mechanisms underlying how the gut microbiota contributes to AL is significant for improving patients' outcomes. This review concentrates on novel findings to explain how the gut microbiota of patients with AL are altered, how the AL-specific pathogen colonizes and is enriched on the anastomosis site, and how these pathogens conduct their tissue breakdown effects. We build up a framework between the gut microbiota and AL on three levels. Firstly, factors that shape the gut microbiota profiles in patients who developed AL after colorectal surgery include preoperative intervention and surgical factors. Secondly, AL-specific pathogenic or collagenase bacteria adhere to the intestinal mucosa and defend against host clearance, including the interaction between bacterial adhesion and host extracellular matrix (ECM), the biofilm formation, and the weakened host commercial bacterial resistance. Thirdly, we interpret the potential mechanisms of pathogen-induced poor anastomotic healing.
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Affiliation(s)
- Yang Liu
- Pancreatic and Gastrointestinal Surgery Division, HwaMei Hospital, University of Chinese Academy of Science, Ningbo, China,Ningbo Clinical Research Center for Digestive System Tumors, Ningbo, China
| | - Bowen Li
- Pancreatic and Gastrointestinal Surgery Division, HwaMei Hospital, University of Chinese Academy of Science, Ningbo, China,Department of Oncology and Laparoscopy Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yunwei Wei
- Pancreatic and Gastrointestinal Surgery Division, HwaMei Hospital, University of Chinese Academy of Science, Ningbo, China,Ningbo Clinical Research Center for Digestive System Tumors, Ningbo, China,*Correspondence: Yunwei Wei,
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The Microbiota and the Relationship with Colorectal Cancer: Surgical Complications—A Review. GASTROINTESTINAL DISORDERS 2022. [DOI: 10.3390/gidisord4020008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Colorectal cancer (CRC) is one of the most common cancers and represents a major global health burden. While genetics are implicated in a portion of CRC patients, most cases are sporadic. A new possibility of tumor initiation and promotion might be microbiome composition. It was recently shown that bacteria from the gut microbiome might be used as biomarkers for CRC detection, especially Fusobacterium nucleatum, Peptostreoptococcus stomatis, Parvimonas mica, Solobacterium moorei, and Peptostreptococcus anaerobius. Conversely, the healthy gut microbiome is mostly colonized by Bacterioides (Bacterioides fragilis, vulgatus, uniformis), Firmicutes (Clostridium spp., Ruminococcus faecis, Enterococcus faecium), and Actinobacteria (Bifidobacterium bifidum). Some strains of gut bacteria favor tumor promotion through DNA and RNA damage (directly or through interaction with other known food carcinogens) and through local immune inhibition. It is possible that bacteria (e.g., Bacillus polyfermenticus, Alistipes shahii, Lactobacillus casei) exist with protective functions against tumor promotion. Despite current advances in colorectal cancer treatment, especially in the medical oncology and radiotherapy domains, surgery remains the mainstay of curative treatment for colorectal cancer patients, even in the oligometastatic setting. Surgical complications like anastomotic leakage, excessive blood loss, abscess, and abdominal sepsis can reduce 1-year and 5-year overall survival and increase the recurrence rates for these patients; therefore, we reviewed currently published data focusing on the relationship between gut microbiota and postoperative complications for colorectal cancer patients.
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Saleh SMM, Elghareeb TA, Atia MM, Ahmed MAI. Impact of Glyphosate-Roundup® in the Ileal Structure of Male and Female Rats: A Morphological and Immunohistochemical Study. MICROSCOPY AND MICROANALYSIS : THE OFFICIAL JOURNAL OF MICROSCOPY SOCIETY OF AMERICA, MICROBEAM ANALYSIS SOCIETY, MICROSCOPICAL SOCIETY OF CANADA 2021; 27:1-17. [PMID: 34550058 DOI: 10.1017/s1431927621012782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The current study was aimed to evaluate the effects of variable doses of the weedicide glyphosate on the ileal (the final section of the small intestine) structure of rats of both sexes, using histological, histochemical, and ultrastructural methods. Forty animals were classified into four groups of 10 animals per group (five males and five females). The first group acted as a control, and the remaining groups were treated with glyphosate-Roundup® 25, 50, and 100 mg/kg body weight daily for 15 days. The results indicated extinct histopathological changes manifested in the deformation of villi, foci of leukocytic infiltration in the core of villi, and hyperplasia of goblet cells. Histochemical examination (Alcian blue and Periodic acid-Schiff stain) revealed a strong positive reaction of goblet cells and an increase in their number in all treated groups. In addition, the immunohistochemical investigation revealed the immunoreactivity of matrix metalloproteinase-9 expression. Furthermore, electron microscopic alternations were represented by the deformation of nuclei, destruction of microvilli, and deposition of lipid droplets. Collectively, the present findings indicate that treatment with glyphosate results in extensive morphological alternations to the ileal structure of rats of both sexes and that female rats are more affected than male rats are.
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Affiliation(s)
- Shaimaa M M Saleh
- Department of Zoology and Entomology, Faculty of Science, Assiut University, Assiut71516, Egypt
| | - Tasneem A Elghareeb
- Plant Protection Department, Faculty of Agriculture, Assiut University, Assiut71526, Egypt
| | - Mona M Atia
- Department of Zoology and Entomology, Faculty of Science, Assiut University, Assiut71516, Egypt
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Jiang W, Feng M, Zheng J, Wang G, Xu S, Zhou L, Zhuo S, Yan J. Association of the collagen score with anastomotic leakage in rectal cancer patients after neoadjuvant chemoradiotherapy. Surgery 2021; 170:1331-1341. [PMID: 34116856 DOI: 10.1016/j.surg.2021.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/25/2021] [Accepted: 05/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Collagen changes in the extracellular matrix caused by neoadjuvant chemoradiotherapy are a potential mechanism of anastomotic leakage. We aimed to construct a fully quantitative collagen score to describe collagen structure changes in the extracellular matrix and then develop and validate a prediction model to identify patients who are at a high risk of postoperative anastomotic leakage. METHODS This is a retrospective study in which 372 patients were enrolled, and their baseline clinicopathological characteristics were collected. Anastomotic distal and proximal "doughnut" specimens underwent second harmonic generation imaging, and collagen features were extracted. A LASSO regression was used to select significant predictors, and the collagen score was constructed. A prediction model based on collagen score was developed and internally and externally validated. RESULTS The primary cohort included 214 consecutive patients, and the anastomotic leakage rate was 8.9%. The validation cohort comprised 158 consecutive patients, and the anastomotic leakage rate was 10.1%. The collagen score was significantly related to anastomotic leakage in both cohorts (P < .001). Multivariate analysis revealed that tumor location, preoperative albumin, and collagen score were independent predictors of anastomotic leakage. These 3 predictors were incorporated into the prediction model, and a nomogram was established. The model showed good discrimination in the primary (area under the curve: 0.954) and validation (area under the curve: 0.928) cohorts. Decision curve analysis demonstrated that the nomogram was clinically useful. CONCLUSION The collagen score is associated with anastomotic leakage, and the collagen nomogram based on the collagen score is useful for individualized prediction of anastomotic leakage in rectal cancer patients with neoadjuvant chemoradiotherapy after surgery.
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Affiliation(s)
- Wei Jiang
- Department of General Surgery, Nanfang Hospital, Southern Medical University & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Guangzhou, China; School of Science, Jimei University, Xiamen, Fujian, China. https://twitter.com/DocJiangwei
| | - Mingyuan Feng
- Department of General Surgery, Nanfang Hospital, Southern Medical University & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Guangzhou, China. https://twitter.com/FengmingyuanN
| | - Jixiang Zheng
- Department of General Surgery, Nanfang Hospital, Southern Medical University & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Guangzhou, China. https://twitter.com/ZhengjixiangN
| | - Guangxing Wang
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Normal University, Fuzhou, China. https://twitter.com/PGuangxingwang
| | - Shuoyu Xu
- Department of General Surgery, Nanfang Hospital, Southern Medical University & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Guangzhou, China; Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong China. https://twitter.com/shevashuoyu
| | - Linghong Zhou
- Department of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, China. https://twitter.com/LinghongZhou
| | - Shuangmu Zhuo
- School of Science, Jimei University, Xiamen, Fujian, China.
| | - Jun Yan
- Department of General Surgery, Nanfang Hospital, Southern Medical University & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Guangzhou, China.
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Gray M, Marland JRK, Murray AF, Argyle DJ, Potter MA. Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients. J Pers Med 2021; 11:471. [PMID: 34070593 PMCID: PMC8229046 DOI: 10.3390/jpm11060471] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.
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Affiliation(s)
- Mark Gray
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian, Edinburgh EH25 9RG, UK;
| | - Jamie R. K. Marland
- School of Engineering, Institute for Integrated Micro and Nano Systems, University of Edinburgh, Scottish Microelectronics Centre, King’s Buildings, Edinburgh EH9 3FF, UK;
| | - Alan F. Murray
- School of Engineering, Institute for Bioengineering, University of Edinburgh, Faraday Building, The King’s Buildings, Edinburgh EH9 3DW, UK;
| | - David J. Argyle
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian, Edinburgh EH25 9RG, UK;
| | - Mark A. Potter
- Department of Surgery, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK;
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Silva FS, Canêdo VSR, Abreu BJ, Oliveira MF. Responses of matrix metalloproteinases to hyperbaric oxygen treatment: changing for good or ill? Connect Tissue Res 2021; 62:249-262. [PMID: 32900238 DOI: 10.1080/03008207.2020.1821675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: Hyperbaric oxygen (HBO2) is currently emerging as a promising therapeutic option for diseases involving impaired tissue repair and remodeling. In this regard, HBO2 has been shown to modulate signaling pathways responsible for matrix metalloproteinases (MMPs) regulation, which makes the MMPs interesting targets for investigation. However, the understanding regarding how HBO2 treatment affects the expression and activity of the MMP family members in different tissues and diseases needs to be clarified. The precise roles of MMPs in the physiopathology of various tissue repair disorders also remain unclear. Because of potential off-target systemic effects of the HBO2 on MMPs, researchers and physicians should carefully consider whether their patients could be affected adversely by HBO2 exposure. Aims: This narrative review provides an overview of MMP biology (structure, function, and regulation) and summarizes available data showing how MMPs respond to HBO2 in different tissues and pathologies, also highlighting possible mechanisms.
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Affiliation(s)
- Flávio S Silva
- Department of Health Sciences, Federal Rural University of the Semi-Arid (UFERSA), Mossoró, Brazil
| | - Vítor S R Canêdo
- Department of Health Sciences, Federal Rural University of the Semi-Arid (UFERSA), Mossoró, Brazil
| | - Bento J Abreu
- Department of Morphology, Federal University of Rio Grande Do Norte (UFRN), Natal, Brazil
| | - Moacir F Oliveira
- Department of Animal Sciences, Federal Rural University of the Semi-Arid (UFERSA), Mossoró, Brazil
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Effects of Aloe Vera on healing of colonic anastomoses: experimental rat study. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2018.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Background Although herbal medicinal products are being used widely throughout the World, beneficial and harmful effects have not been well documented. Our aim was to evaluate the effects of Aloe Vera (AV) on colonic anastomosis healing.
Material and methods 112 albino Wistar rats were randomly assigned into five main groups: preoperative Aloe Vera Group (P), pre- and postoperative Aloe Vera Group (PP), Control Group (C), sham Aloe Vera Group (SA) and Sham Control Group (SC). Groups P, PP, and SA received 1.6 mL/kg per day Aloe Vera by orogastric feeding catheter for 1 month prior to the experiment. Groups P, PP, and C underwent anastomosis of the distal colon, and subgroups (n = 4) of each were sacrificed on postoperative day 3, 7, 14 and 21. Anastomotic bursting pressure, perianastomotic collagen content and histopathological changes were studied.
Results The SC Group had significantly higher ABP when compared with the SA Group (p = 0.0002), although hydroxyproline content showed no difference. When ABP was compared between anastomosis groups, it was found significantly lower in Aloe Vera groups on Day 3 (P3 vs. C3, p = 0.003 and PP3 vs. C3, p = 0.007). Hydroxyproline content was significantly lower in Group PP than Group C, also on Day 3 (p = 0.05). Significant difference was not detected after Day 3 in any of the study parameters.
Conclusion
Aloe Vera decreased tissue collagen content in the early postoperative period. It is advisable to call into question the concomitant usage of conventional medicine and the herbal supplements for the surgeons in their clinical practice.
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Heuer A, Stiel C, Elrod J, Königs I, Vincent D, Schlegel P, Trochimiuk M, Appl B, Reinshagen K, Raluy LP, Boettcher M. Therapeutic Targeting of Neutrophil Extracellular Traps Improves Primary and Secondary Intention Wound Healing in Mice. Front Immunol 2021; 12:614347. [PMID: 33717100 PMCID: PMC7947714 DOI: 10.3389/fimmu.2021.614347] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background Neutrophils are the first responders in wound healing after injury that mediate pro- and anti-inflammatory activities i.a. through the formation of extracellular traps (NETs). However, excessive NETs presence in wound tissue can cause local hyperinflammation and -coagulation resulting in delayed wound healing. To improve wound healing, we aimed to examine the role of NETs and DNase1 on primary and secondary wound healing. Methods The study included 93 C57BL/6 mice, with 3 different genotypes: wildtype, Pad4-, and DNase1-Knockout (KO). Pad4-KO mice show limited NETs formation, while DNase1-KO mice cannot disintegrate them. All 3 genotypes were included in (1) a laparotomy group and (2) a thermal injury group. Animals in both groups either received DNase1 or a vehicle i.p. post wound induction and wound assessment and euthanasia were conducted. Laparotomy and burn scars were assessed using the stony brook scar evaluation scale and modified Yeong scale respectively. Tissue was analyzed histologically using H&E staining. Ly6g, Collagen I and III, SMA, and Fibrinogen were visualized and neutrophils activation (NE, MPO) and NETs (H3cit) formation assessed. Results All animals survived with no complications. DNase1 treatment led to a significantly improved scar appearance in both groups, which was also seen in Pad4-KO mice. In the laparotomy group DNase1 improved collagen deposition and fibrin concentration was significantly reduced by DNase1 treatment. Markers of neutrophil activation were significantly reduced in the treatment and Pad4-KO group. In the thermal injury group wound closure time was significantly reduced after DNase1 treatment and in the Pad4-KO group. Even though inflammation remained high in the thermal injury model over time, neutrophil activation and NETs formation were significantly reduced by DNase1 treatment compared to controls. Discussion Primary and secondary intention wound healing is improved by targeting NETs through DNase1 treatment or genetic KO, as assessed by wound closure time and scar appearances. Additionally, wound stability was not affected by DNASE treatment. The results suggest that overall wound healing is accelerated and DNase1 appears to be a promising option to reduce scar formation; which should be evaluated in humans.
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Affiliation(s)
- Annika Heuer
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carolin Stiel
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Elrod
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingo Königs
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Deirdre Vincent
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Schlegel
- Children's Medical Research Institute, Sydney University, Westmead, NSW, Australia
| | - Magdalena Trochimiuk
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Birgit Appl
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laia Pagerols Raluy
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Türlü C, Willumsen N, Marando D, Schjerling P, Biskup E, Hannibal J, Jorgensen LN, Ågren MS. A Human Cellular Model for Colorectal Anastomotic Repair: The Effect of Localization and Transforming Growth Factor-β1 Treatment on Collagen Deposition and Biomarkers. Int J Mol Sci 2021; 22:ijms22041616. [PMID: 33562728 PMCID: PMC7914853 DOI: 10.3390/ijms22041616] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 01/01/2023] Open
Abstract
Anastomotic leakage (AL) is a devastating complication after colorectal surgery, possibly due to the loss of stabilizing collagen fibers in the submucosa. Our aim was to assess the formation of collagen in the colon versus the rectum with or without transforming growth factor (TGF)-β1 exposure in a human cellular model of colorectal repair. Primary fibroblasts were isolated by an explant procedure from clinically resected tissue rings during anastomosis construction in 19 consecutive colorectal patients who underwent laparoscopy. The cells, identified as fibroblasts by morphologic characteristics and flow cytometry analysis (CD90+), were cultured for 8 days and in 12 patients in the presence of 1 ng/mL TGF-β1. Total collagen deposition was measured colorimetrically after Sirius red staining of fixed cell layers, and type I, III, and VI collagen biosynthesis and degradation were specifically determined by the biomarkers PINP, PRO-C3, PRO-C6, and C3M in conditioned media by competitive enzyme-linked immunosorbent assays. Total collagen deposition by fibroblasts from the colon and rectum did not significantly differ. TGF-β1 treatment increased PINP, PRO-C6, and total collagen deposition. Mechanistically, TGF-β1 treatment increased COL1A1 and ACTA2 (encoding α-smooth muscle actin), and decreased COL6A1 and MMP2 mRNA levels in colorectal fibroblasts. In conclusion, we found no effect of anatomic localization on collagen production by fibroblasts derived from the large intestine. TGF-β1 represents a potential therapeutic agent for the prevention of AL by increasing type I collagen synthesis and collagen deposition.
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Affiliation(s)
- Ceylan Türlü
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen, Denmark; (C.T.); (D.M.); (L.N.J.)
| | | | - Debora Marando
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen, Denmark; (C.T.); (D.M.); (L.N.J.)
| | - Peter Schjerling
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, 2400 Copenhagen, Denmark;
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Edyta Biskup
- Department of Dermatology and Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen, Denmark;
| | - Jens Hannibal
- Department of Clinical Biochemistry, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen, Denmark;
| | - Lars N. Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen, Denmark; (C.T.); (D.M.); (L.N.J.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Magnus S. Ågren
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen, Denmark; (C.T.); (D.M.); (L.N.J.)
- Department of Dermatology and Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, 2400 Copenhagen, Denmark;
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Correspondence: ; Tel.: +45-3863-5954
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13
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Edomskis P, Goudberg MR, Sparreboom CL, Menon AG, Wolthuis AM, D’Hoore A, Lange JF. Matrix metalloproteinase-9 in relation to patients with complications after colorectal surgery: a systematic review. Int J Colorectal Dis 2021; 36:1-10. [PMID: 32865714 PMCID: PMC7782374 DOI: 10.1007/s00384-020-03724-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leakage (AL) is the most severe complication following colorectal resection and is associated with increased mortality. The main group of enzymes responsible for collagen and protein degradation in the extracellular matrix is matrix metalloproteinases. The literature is conflicting regarding anastomotic leakage and the degradation of extracellular collagen by matrix metalloproteinase-9 (MMP-9). In this systematic review, the possible correlation between anastomotic leakage after colorectal surgery and MMP-9 activity is investigated. METHODS Embase, MEDLINE, Cochrane, and Web of Science databases were searched up to 3 February 2020. All published articles that reported on the relationship between MMP-9 and anastomotic leakage were selected. Both human and animal studies were found eligible. The correlation between MMP-9 expression and anastomotic leakage after colorectal surgery. RESULTS Seven human studies and five animal studies were included for analysis. The human studies were subdivided into those assessing MMP-9 in peritoneal drain fluid, intestinal biopsies, and blood samples. Five out of seven human studies reported elevated levels of MMP-9 in patients with anastomotic leakage on different postoperative moments. The animal studies demonstrated that MMP-9 activity was highest in the direct vicinity of an anastomosis. Moreover, MMP-9 activity was significantly reduced in areas further proximally and distally from the anastomosis and was nearly or completely absent in uninjured tissue. CONCLUSION Current literature shows some relation between MMP-9 activity and colorectal AL, but the evidence is inconsistent. Innovative techniques should further investigate the value of MMP-9 as a clinical biomarker for early detection, prevention, or treatment of AL.
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Affiliation(s)
- Pim Edomskis
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Max R. Goudberg
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cloë L. Sparreboom
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anand G. Menon
- grid.414559.80000 0004 0501 4532Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
| | - Albert M. Wolthuis
- grid.410569.f0000 0004 0626 3338Departmenf of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Andre D’Hoore
- grid.410569.f0000 0004 0626 3338Departmenf of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Johan F. Lange
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands ,grid.414559.80000 0004 0501 4532Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
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14
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Tu L, Zhou Y, Song C, Li Y, Chen L, Xue Y. Preliminary study of a control algorithm for radio-frequency-induced intestinal tissue fusion. Int J Hyperthermia 2020; 36:1297-1306. [PMID: 31856611 DOI: 10.1080/02656736.2019.1702723] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Purpose: A control algorithm for radio-frequency-induced intestinal tissue fusion was developed to explore the effects of different control parameters on intestinal tissue fusion.Materials and methods: Radio-frequency-induced fusion was performed on ex vivo small intestine tissue. The effect on the fusion was observed by changing the control parameters (power, interval time, and terminal impedance) in the algorithm. The quality of fusion was evaluated using the burst pressure and thermal damage measurement. Histological evaluation was used to assess the fusion quality indirectly.Results: A maximum burst pressure of 8.460 ± 0.2674 KPa was acquired when the power was set to 100 W, the interval time was set to 2000 ms, and the terminal impedance was set to 50 Ω. Moreover, the thermal damage range increased with an increase in power but decreased with an increase in the interval time and terminal impedance. Furthermore, the thermal damage range and temperature were presumably related.Conclusions: For an ex vivo small intestine tissue, the appropriate control parameters could be set when the power was approximately 100 W, the interval time was approximately 2000 ms, and the terminal impedance was approximately 50 Ω. This study could provide a basis for the selection of control parameters for intestinal tissue fusion.
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Affiliation(s)
- Liangyong Tu
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Yu Zhou
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Chengli Song
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Yuan Li
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Lin Chen
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Yinmin Xue
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
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15
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Ghiselli R, Lucarini G, Ortenzi M, Salvolini E, Saccomanno S, Orlando F, Provinciali M, Casciani F, Guerrieri M. Anastomotic healing in a rat model of peritonitis after non-steroidal anti-inflammatory drug administration. Eur J Histochem 2020; 64. [PMID: 31941266 PMCID: PMC6985910 DOI: 10.4081/ejh.2020.3085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 12/27/2019] [Indexed: 01/01/2023] Open
Abstract
The tissue inflammatory response can influence the outcome of anastomotic healing. Anastomotic leakage represents a dreadful complication after gastrointestinal surgery, in particular sepsis and intra-abdominal infections impair the restorative process of colic anastomoses. It has been debated whether the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is a risk factor for dehiscence, since many patients receive NSAIDs in the early postoperative period. Our aim was, for the first time, to analyze the morpho-functional effects of postoperative administration of two commonly used NSAIDs, Diclofenac and Ketorolac, on the healing process of colo-colic anastomoses constructed under condition of fecal peritonitis in a rat model. Sixty adult male rats underwent two surgical procedures: peritonitis induction and colo-colic anastomosis, and were divided into three groups: 20 rats received saline; 20 rats 4 mg/kg Diclofenac and 20 rats 5 mg/kg Ketorolac. We assessed anastomosis strength, morphological features of tissue wound healing, immunohistochemical metalloproteinase 9 (MMP9) expression and collagen deposition and content by Sirius red staining and hydroxyproline level. We found no significant difference in bursting pressure, collagen content and organization and morphological features between the groups, except a significantly reduced presence of inflammatory cells and MMP9 expression in the groups treated with NSAIDs. Our findings showed that Diclofenac and Ketorolac administration did not affect post-surgical healing and did not increase the leakage risk of colo-colic anastomoses during peritonitis.
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16
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Sparreboom CL, Komen N, Rizopoulos D, Verhaar AP, Dik WA, Wu Z, van Westreenen HL, Doornebosch PG, Dekker JWT, Menon AG, Daams F, Lips D, van Grevenstein WMU, Karsten TM, Bayon Y, Peppelenbosch MP, Wolthuis AM, D'Hoore A, Lange JF. A multicentre cohort study of serum and peritoneal biomarkers to predict anastomotic leakage after rectal cancer resection. Colorectal Dis 2020; 22:36-45. [PMID: 31344302 PMCID: PMC6973162 DOI: 10.1111/codi.14789] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
AIM Anastomotic leakage (AL) is one of the most feared complications after rectal resection. This study aimed to assess a combination of biomarkers for early detection of AL after rectal cancer resection. METHOD This study was an international multicentre prospective cohort study. All patients received a pelvic drain after rectal cancer resection. On the first three postoperative days drain fluid was collected daily and C-reactive protein (CRP) was measured. Matrix metalloproteinase-2 (MMP2), MMP9, glucose, lactate, interleukin 1-beta (IL1β), IL6, IL10, tumour necrosis factor alpha (TNFα), Escherichia coli, Enterococcus faecalis, lipopolysaccharide-binding protein and amylase were measured in the drain fluid. Prediction models for AL were built for each postoperative day using multivariate penalized logistic regression. Model performance was estimated by the c-index for discrimination. The model with the best performance was visualized with a nomogram and calibration was plotted. RESULTS A total of 292 patients were analysed; 38 (13.0%) patients suffered from AL, with a median interval to diagnosis of 6.0 (interquartile ratio 4.0-14.8) days. AL occurred less often after partial than after total mesorectal excision (4.9% vs 15.2%, P = 0.035). Of all patients with AL, 26 (68.4%) required reoperation. AL was more often treated by reoperation in patients without a diverting ileostomy (18/20 vs 8/18, P = 0.03). The prediction model for postoperative day 1 included MMP9, TNFα, diverting ileostomy and surgical technique (c-index = 0.71). The prediction model for postoperative day 2 only included CRP (c-index = 0.69). The prediction model for postoperative day 3 included CRP and MMP9 and obtained the best model performance (c-index = 0.78). CONCLUSION The combination of serum CRP and peritoneal MMP9 may be useful for earlier prediction of AL after rectal cancer resection. In clinical practice, this combination of biomarkers should be interpreted in the clinical context as with any other diagnostic tool.
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Affiliation(s)
- C. L. Sparreboom
- Department of SurgeryErasmus MC – University Medical CentreRotterdamThe Netherlands
| | - N. Komen
- Department of Abdominal SurgeryUniversity Hospital AntwerpUniversity of AntwerpEdegemBelgium
| | - D. Rizopoulos
- Department of BiostatisticsErasmus MC – University Medical CenterRotterdamThe Netherlands
| | - A. P. Verhaar
- Department of Gastroenterology and HepatologyErasmus MC – University Medical CenterRotterdamThe Netherlands
| | - W. A. Dik
- Department of ImmunologyLaboratory Medical ImmunologyErasmus MC – University Medical CenterRotterdamThe Netherlands
| | - Z. Wu
- Department of SurgeryErasmus MC – University Medical CentreRotterdamThe Netherlands
| | | | - P. G. Doornebosch
- Department of SurgeryIJsselland ZiekenhuisCapelle aan den IjsselThe Netherlands
| | - J. W. T. Dekker
- Department of SurgeryReinier de Graaf GasthuisDelftThe Netherlands
| | - A. G. Menon
- Department of SurgeryIJsselland ZiekenhuisCapelle aan den IjsselThe Netherlands,Department of SurgeryHavenziekenhuisRotterdamThe Netherlands
| | - F. Daams
- Department of SurgeryVU University Medical CenterAmsterdamThe Netherlands
| | - D. Lips
- Department of SurgeryJeroen Bosch ZiekenhuisHertogenboschThe Netherlands
| | | | - T. M. Karsten
- Department of SurgeryOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands
| | - Y. Bayon
- Sofradim Production, A Medtronic CompanyTrévouxFrance
| | - M. P. Peppelenbosch
- Department of Gastroenterology and HepatologyErasmus MC – University Medical CenterRotterdamThe Netherlands
| | - A. M. Wolthuis
- Department of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
| | - A. D'Hoore
- Department of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
| | - J. F. Lange
- Department of SurgeryErasmus MC – University Medical CentreRotterdamThe Netherlands
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17
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Meyer J, Naiken S, Christou N, Liot E, Toso C, Buchs NC, Ris F. Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges. World J Gastroenterol 2019; 25:5017-5025. [PMID: 31558854 PMCID: PMC6747296 DOI: 10.3748/wjg.v25.i34.5017] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leak (AL) constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The use of intra-abdominal drain or the use of mechanical bowel preparation alone have been proven to be useless in preventing AL and should be abandoned. The role or oral antibiotics preparation regimens should be clarified and compared to other routes of administration, such as the intravenous route or enema. In parallel, preoperative antibiotherapy should aim at targeting collagenase-inducing pathogens, as identified by the microbiome analysis. AL can be further reduced by fluorescence angiography, which leads to significant intraoperative changes in surgical strategies. Implementation of fluorescence angiography should be encouraged. Progress made in AL comprehension and prevention might probably allow reducing the rate of diverting stoma and conduct to a revision of its indications.
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Affiliation(s)
- Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Surennaidoo Naiken
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Niki Christou
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Emilie Liot
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | | | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
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Abstract
OBJECTIVE The aim of this study was to investigate the clinical effects of prostaglandin E1 (PGE1) in patients who underwent surgery for gastrointestinal (GI) trauma, perforation, or obstruction. BACKGROUND PGE1 is thought to enhance intestinal blood supply and reduce GI complications during the postoperative period. METHODS The medical records of 889 patients undergoing major GI surgery were reviewed retrospectively. Propensity score matching was performed to adjust for any baseline differences. Clinical outcomes, including early GI function recovery, postoperative complications, and length of hospital stay, were evaluated in all patients. In 278 paired patients, selected nutritional, immunologic, and inflammatory variables were compared based on PGE1 administration. RESULTS After propensity score 1:1 matching, the baseline characteristics were similar for both groups. PGE1 was associated with prompt postoperative GI function recovery, including first bowel movement [2.6 ± 0.9 vs 3.1 ± 1.0 days after surgery in patients with and without PGE1 treatment, risk ratio 0.51, 95% confidence interval (CI) 0.41-0.65, P < 0.001] and first feeding within postoperative day 3 [179 (64.39%) vs 152 (54.68%); risk ratio 0.61, 95% CI 0.42-0.90, P = 0.012]. A lower overall postoperative complication rate, including infectious complications [45 (16.2%) vs 68 (24.5%); odds ratio 0.60, 95% CI 0.39-0.91, P = 0.010] and major complications [23 (8.3%) vs 48 (17.3%); odds ratio 0.43, 95% CI 0.26-0.73, P = 0.001], was noted in patients with PGE1 treatment than in patients without PGE1 treatment. Furthermore, the immunologic and inflammatory variable C-reactive protein on postoperative day 3 was reduced by PGE1 treatment (52.5 ± 36.4 vs 89.6 ± 42.4 mg/L; P = 0.037, t test). CONCLUSIONS PGE1 is associated with beneficial clinical effects, such as prompt postoperative GI function recovery and reduced overall postoperative complications after emergency GI surgery, which may be attributed to a reduced inflammatory response.
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19
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Chikhladze S, Kupreishvili S, Korsake K, Sick O, Fink J, Seifert G, Läßle C, Nenova G, Höppner J, Glatz T, Fichtner-Feigl S, Marjanovic G. Recurring Anastomotic Leak-A Prospective Clinicopathological Investigation of a Distinct Disease Pattern. J Surg Res 2019; 239:201-207. [PMID: 30851519 DOI: 10.1016/j.jss.2019.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/14/2019] [Accepted: 02/06/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intestinal anastomotic insufficiency (AI) is a common problem in visceral surgery associated with overexpression of matrix metalloproteinases (MMPs). In some patients it occurs more than once. The etiology of recurring anastomotic insufficiency (RAI) is not understood yet and should be addressed as an independent disease entity. MATERIALS AND METHODS Thirty nine consecutive patients with AI were treated at our university center and were included in this prospective study. Clinical data were evaluated by correlative statistical analysis to identify independent risk factors for RAI. Patients were divided in two groups: 18 patients had a single operative revision until restoration (group SAI), and 21 patients had two or more revisions (group RAI). Anastomotic tissue samples as well as untouched bowel wall were collected during reoperations for analysis of MMPs and tissue inhibitor of metalloproteinases (TIMP2). Clinical data were correlated with pathological observations. RESULTS Significant differences of clinical and molecular pathological data were found between the two groups. Transfusion of red blood cells until the first reoperation and alcohol abuse led to RAI and were the only independent risk factors for RAI in multivariate analysis. Overexpression of MMP-8, -9, and -13 in anastomotic tissue correlated with the administration of red blood cells during initial operation. Reduced expression of TIMP2 was frequent in nearly all patients without differences throughout the subgroups. CONCLUSIONS RAI seems to have an independent disease pattern. Transfusion of blood products is not only a known risk factor for AI but seems to significantly disturb the anastomotic healing process leading to RAI.
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Affiliation(s)
- Sophia Chikhladze
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany.
| | - Shota Kupreishvili
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Kristina Korsake
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Olivia Sick
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Jodok Fink
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Gabriel Seifert
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Claudia Läßle
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Gergana Nenova
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Jens Höppner
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Torben Glatz
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Goran Marjanovic
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
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20
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Lee JC, Chen CH, Chen TC, Yeh CN, Yeh TS. Preoperative tyrosine kinase inhibitors risks bowel anastomotic healing in patients with advanced primary and recurrent/metastatic gastrointestinal stromal tumors--- A rose has its thorns. Eur J Surg Oncol 2018; 45:153-159. [PMID: 30712551 DOI: 10.1016/j.ejso.2018.09.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 08/31/2018] [Accepted: 09/05/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The combination of tyrosine kinase inhibitors (TKIs) and surgery has created a paradigm shift for advanced primary and metastatic gastrointestinal stromal tumors (GISTs). However, the associated surgical morbidity rate is reportedly high, which we hypothesized is attributable to the adverse effects of the previous use of TKIs on bowel anastomosis healing. METHODS A total of 613 GIST patients with (n = 108) and without (n = 505) preoperative TKI treatment were enrolled. Propensity score matching compared the surgical morbidities and mortalities between the two cohorts. An animal model was used to elucidate the relevant mechanism. RESULTS After propensity score matching, the incidence and severity of surgical complications were higher in patients with preoperative TKIs than in those without (34% vs 10%, p < 0.0001; grades 3-5, 16% vs 2%, p < 0.0001). Specifically, the incidence of bowel anastomosis leakage was increased in those with versus those without preoperative TKI (18% vs 6%, p = 0.032). A constellation of mucosal shedding, shortening of villus height and crypt depth, and disarrayed epithelial lining of the bowel was observed with preoperative TKI treatment. The animal model showed that bowel anastomosis healing was weakened by imatinib through the downregulation of Col1A1, Col3A1, and MMPs. CONCLUSIONS Impaired bowel anastomosis healing was responsible for the extraordinarily high surgical morbidity rate of patients with GIST after TKI treatment. The mechanism involved altered tissue microarchitecture and dysregulated Col1A1, Col3A1, and MMP expressions.
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Affiliation(s)
- Jin-Chiao Lee
- Department of Surgery, Chang Gung Memorial Hospital at LinKou, Chang Gung University Medical College, Taoyuan, Taiwan
| | - Chun-Han Chen
- Department of Surgery, Chang Gung Memorial Hospital at Chia-Yi, Taoyuan, Taiwan
| | - Tse-Ching Chen
- Department Pathology, Chang Gung Memorial Hospital at LinKou, Chang Gung University Medical College, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- Department of Surgery, Chang Gung Memorial Hospital at LinKou, Chang Gung University Medical College, Taoyuan, Taiwan
| | - Ta-Sen Yeh
- Department of Surgery, Chang Gung Memorial Hospital at LinKou, Chang Gung University Medical College, Taoyuan, Taiwan.
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21
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Kjaer M, Kristjánsdóttir H, Andersen L, Heegaard AM, Ågren MS, Jorgensen LN. The effect of gender on early colonic anastomotic wound healing. Int J Colorectal Dis 2018; 33:1269-1276. [PMID: 29850942 DOI: 10.1007/s00384-018-3089-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Clinically, male patients subjected to colorectal surgery are more prone to develop anastomotic leakage than female patients by unknown mechanisms. Our aim was to investigate the impact of gender on anastomotic wound healing using an experimental model. METHODS One-layer colonic anastomosis was constructed in 8-week-old 28 male and 32 female Sprague-Dawley rats. Animals of one group (n = 30) were sacrificed immediately after surgery day 0 and the other group (n = 30) on postoperative day 3. Anastomotic breaking strength, total collagen (hydroxyproline), soluble collagen (Sircol), matrix metalloproteinase (MMP)-9, and transforming growth factor (TGF)-β1 were measured. RESULTS The anastomotic breaking strength decreased from day 0 to day 3 with no significant gender differences either in the extent of decline (P = 0.122) or absolute day 3 strengths (P = 0.425). Analogously, total collagen concentration in the anastomotic wounds decreased postoperatively and were lower (P = 0.043) in the male compared with the female rats on day 3. MMP-9 levels increased in the anastomoses postoperatively, but they did not differ (P = 0.391) between male and female animals. Soluble collagen levels were lower in the day-3 anastomoses of male versus female rats (P = 0.015) and correlated positively with total TGF-β1 levels (rS = 0.540, P = 0.006). Although TGF-β1 tended to be lower in male compared with the female rats, the differences did not reach statistical significance. CONCLUSION Our findings point towards a less favorable collagen metabolism in colonic anastomoses of male compared with female rats during early wound healing.
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Affiliation(s)
- Marie Kjaer
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Hrefna Kristjánsdóttir
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Line Andersen
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Marie Heegaard
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Magnus S Ågren
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lars N Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Landes LC, Drescher D, Tagkalos E, Grimminger PP, Thieme R, Jansen-Winkeln B, Lang H, Gockel I. Upregulation of VEGFR1 in a rat model of esophagogastric anastomotic healing. Acta Chir Belg 2018; 118:161-166. [PMID: 29065778 DOI: 10.1080/00015458.2017.1394673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Anastomotic leakage after gastrointestinal surgery is a significant cause of morbidity and mortality. Esophagogastric and colorectal anastomoses are vulnerable to leakage. Extended knowledge of growth factors and their receptors is needed to understand anatomic healing. METHODS The expression pattern of vascular growth factor receptor (VEGFR1-3), epidermal growth factor receptor (EGFR), platelet-derived growth factor receptor (PDGFRα/β) and keratinocyte growth factor receptor (KGFR) were analyzed by semiquantitative-PCR in the rat intestinal tract and in esophagogastric anastomosis 5d after surgery. RESULTS VEGFR1, VEGFR2, EGFR, KGFR and PDGFRα expression was observed throughout the intestinal tract including esophagus, stomach, small bowl and colon. VEGFR3 was not found in gastric samples and PDGFRβ expression was not detected in the small bowl. Semiquantitative analyses of the VEGFR1, PDGFRα and EGFR expression in esophagogastric anastomotic tissues revealed a 2-fold upregulation of the VEGFR1 in gastric samples, while no change was observed in the esophageal anastomotic side. CONCLUSION Our results revealed a distinct expression pattern of the investigated growth factor receptors in rat intestinal tract. Showing higher expression levels of growth factor receptors at the gastric anastomotic tissue at the fifth postoperative day suggests a different contribution of the gastric and the esophageal side to the anastomotic healing.
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Affiliation(s)
- Laura Christina Landes
- Department of General, Visceral and Transplantation Surgery, University Medical Center of Mainz, Mainz, Germany
| | - Daniel Drescher
- Department of General, Visceral and Transplantation Surgery, University Medical Center of Mainz, Mainz, Germany
- Department of General and Visceral Surgery, St. Juliusspital, Würzburg, Germany
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplantation Surgery, University Medical Center of Mainz, Mainz, Germany
| | - Peter P. Grimminger
- Department of General, Visceral and Transplantation Surgery, University Medical Center of Mainz, Mainz, Germany
| | - René Thieme
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Medical Center of Leipzig, Leipzig, Germany
| | - Boris Jansen-Winkeln
- Department of General, Visceral and Transplantation Surgery, University Medical Center of Mainz, Mainz, Germany
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Medical Center of Leipzig, Leipzig, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Center of Mainz, Mainz, Germany
| | - Ines Gockel
- Department of General, Visceral and Transplantation Surgery, University Medical Center of Mainz, Mainz, Germany
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Medical Center of Leipzig, Leipzig, Germany
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23
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The extracellular matrix of the gastrointestinal tract: a regenerative medicine platform. Nat Rev Gastroenterol Hepatol 2017; 14:540-552. [PMID: 28698662 DOI: 10.1038/nrgastro.2017.76] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The synthesis and secretion of components that constitute the extracellular matrix (ECM) by resident cell types occur at the earliest stages of embryonic development, and continue throughout life in both healthy and diseased physiological states. The ECM consists of a complex mixture of insoluble and soluble functional components that are arranged in a tissue-specific 3D ultrastructure, and it regulates numerous biological processes, including angiogenesis, innervation and stem cell differentiation. Owing to its composition and influence on embryonic development, as well as cellular and organ homeostasis, the ECM is an ideal therapeutic substrate for the repair of damaged or diseased tissues. Biologic scaffold materials that are composed of ECM have been used in various surgical and tissue-engineering applications. The gastrointestinal (GI) tract presents distinct challenges, such as diverse pH conditions and the requirement for motility and nutrient absorption. Despite these challenges, the use of homologous and heterologous ECM bioscaffolds for the focal or segmental reconstruction and regeneration of GI tissue has shown promise in early preclinical and clinical studies. This Review discusses the importance of tissue-specific ECM bioscaffolds and highlights the major advances that have been made in regenerative medicine strategies for the reconstruction of functional GI tissues.
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Costa BP, Gonçalves AC, Abrantes AM, Matafome P, Seiça R, Sarmento-Ribeiro AB, Botelho MF, Castro-Sousa F. Teduglutide effects on gene regulation of fibrogenesis on an animal model of intestinal anastomosis. J Surg Res 2017; 216:87-98. [DOI: 10.1016/j.jss.2017.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 04/14/2017] [Accepted: 04/26/2017] [Indexed: 02/07/2023]
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Buch AS, Schjerling P, Kjaer M, Jorgensen LN, Krarup PM, Ågren MS. Impaired collagen synthesis in the rectum may be a molecular target in anastomotic leakage prophylaxis. Wound Repair Regen 2017; 25:532-535. [PMID: 28371122 DOI: 10.1111/wrr.12535] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/07/2017] [Accepted: 02/21/2017] [Indexed: 02/06/2023]
Abstract
The underlying molecular mechanisms for anastomotic leakage (AL) after colorectal surgery are unknown and there are no therapeutics for AL prevention. Our aim was to correlate endogenous matrix metalloproteinase (MMP) activity, collagen concentration, and collagen/MMP/cytokine mRNA levels with anatomic location in human colorectal tissue. We enrolled 22 patients in this prospective study: 7 underwent elective laparoscopic sigmoid resection and 15 underwent low anterior resection for colorectal cancer. Full-thickness intestinal tissue rings from anastomoses constructed with a circular stapler were used for the determination of the MMP activity, tissue collagen concentration and mRNA levels. COL1A1 (p = 0.017) and COL3A1 (p = 0.0013) mRNA levels were lower in rectal tissue than in colonic samples. Neither MMP activities nor collagen concentrations differed significantly between the two anatomic locations. By elucidating the factors responsible for the decreased collagen production we may identify specific molecular targets in AL prophylaxis.
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Affiliation(s)
- Anastasia S Buch
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Schjerling
- Department of Orthopedic Surgery M, Faculty of Health and Medical Sciences, Institute of Sports Medicine, Bispebjerg Hospital and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Marie Kjaer
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Peter-Martin Krarup
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Magnus S Ågren
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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26
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Vallance A, Wexner S, Berho M, Cahill R, Coleman M, Haboubi N, Heald RJ, Kennedy RH, Moran B, Mortensen N, Motson RW, Novell R, O'Connell PR, Ris F, Rockall T, Senapati A, Windsor A, Jayne DG. A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Colorectal Dis 2017; 19:O1-O12. [PMID: 27671222 DOI: 10.1111/codi.13534] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.
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Affiliation(s)
- A Vallance
- Royal College of Surgeons of England, London, UK
| | - S Wexner
- Cleveland Clinic Florida, Weston, Florida, USA
| | - M Berho
- Cleveland Clinic Florida, Weston, Florida, USA
| | - R Cahill
- University College Dublin, Dublin, Ireland
| | | | - N Haboubi
- University Hospital of South Manchester, Manchester, UK
| | - R J Heald
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - B Moran
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - R W Motson
- The ICENI Centre, Colchester University Hospital, Colchester, UK
| | - R Novell
- The Royal Free Hospital, London, UK
| | | | - F Ris
- Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - T Rockall
- Royal Surrey County Hospital, Guildford, UK
| | | | - A Windsor
- University College Hospital, London, UK
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de Bont MP, Malbon AJ, Blundell R, Archer DC. Idiopathic eosinophilic colitis lesions of the equine small (descending) colon. EQUINE VET EDUC 2016. [DOI: 10.1111/eve.12700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - A. J. Malbon
- Institute of Veterinary Pathology; Vetsuisse Faculty; University of Zurich; Switzerland
| | - R. Blundell
- Department of Pathology; University of Liverpool; Neston UK
| | - D. C. Archer
- The Philip Leverhulme Equine Hospital; University of Liverpool; Neston UK
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Tognoli E, Luigi Giuseppe Leoni M, Morelli D, Sottotetti E, Martinetti A, Signoroni S, Galeone C, Gallino G. Serum soluble urokinase-type plasminogen activator receptor as a serum marker of inflammatory response that leads to tissue damage and surgical complication. Wound Repair Regen 2016; 24:1036-1040. [PMID: 27759946 DOI: 10.1111/wrr.12493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 10/02/2016] [Accepted: 10/11/2016] [Indexed: 11/29/2022]
Abstract
Unrestrained activation of the proteolytic systems in anastomotic tissue during repair has been implicated in the pathogenesis of anastomotic leakage. We hypothesized that this mechanism may promote an up-regulation of the urokinase-type plasminogen activator system and a spillover of soluble urokinase-type plasminogen activator receptor (suPAR) into blood. In this retrospective analysis patients with anastomotic leakage were compared with a group of matched uncomplicated patients. Anastomotic leakage complicated patients had significantly higher suPAR (p = 0.04) levels until day 3 after surgery. The area under the receiver-operating characteristic (ROC) for suPAR was higher than that CRP (0.874 vs. 0.836). Their analysis suggests the possible use of suPAR as serum marker to characterize the persistent inflammatory response that lead to tissue damage and surgical complication.
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Affiliation(s)
- Emiliano Tognoli
- Department of Anesthesia, Intensive Care and Palliative Care, Istituto Nazionale Tumori, IRCCS Foundation
| | - Matteo Luigi Giuseppe Leoni
- Department of Anesthesia, Intensive Care and Palliative Care, Istituto Nazionale Tumori, IRCCS Foundation.,Department of Pathophysiology and Transplantation, University of Milan
| | - Daniele Morelli
- Department of Pathology and Laboratory Medicine, Istituto Nazionale Tumori, IRCCS Foundation
| | - Elisa Sottotetti
- Medical Oncology Department, Istituto Nazionale Tumori, IRCCS Foundation
| | - Antonia Martinetti
- Medical Oncology Department, Istituto Nazionale Tumori, IRCCS Foundation
| | - Stefano Signoroni
- Department of Preventive and Predictive Medicine, Unit of Hereditary Digestive Tract Tumors, Istituto Nazionale Tumori, IRCCS Foundation
| | - Carlotta Galeone
- Department of Clinical Sciences and Community Health, University of Milan, and
| | - Gianfranco Gallino
- Department of Surgery, Istituto Nazionale Tumori, IRCCS Foundation, Milan, Italy
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Abstract
The aim of this article is to present strategies for preventing and managing the failure of the surgical restoration of intestinal continuity. Despite improvements in surgical technique and perioperative care, anastomotic leaks still occur, and with them occur increased morbidity, mortality, length of stay, and costs. Due to the devastating consequences for patients with failed anastomoses, there have been a myriad of materials and techniques used by surgeons to create better intestinal anastomoses. We will also discuss the management strategies for anastomotic leak when they do inevitably occur.
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Affiliation(s)
- Michael S Thomas
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, University of Queensland Ochsner Clinical School, New Orleans, Louisiana
| | - David A Margolin
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, University of Queensland Ochsner Clinical School, New Orleans, Louisiana
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30
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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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31
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Shogan BD, Belogortseva N, Luong PM, Zaborin A, Lax S, Bethel C, Ward M, Muldoon JP, Singer M, An G, Umanskiy K, Konda V, Shakhsheer B, Luo J, Klabbers R, Hancock LE, Gilbert J, Zaborina O, Alverdy JC. Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal anastomotic leak. Sci Transl Med 2016; 7:286ra68. [PMID: 25947163 DOI: 10.1126/scitranslmed.3010658] [Citation(s) in RCA: 253] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Even under the most expert care, a properly constructed intestinal anastomosis can fail to heal, resulting in leakage of its contents, peritonitis, and sepsis. The cause of anastomotic leak remains unknown, and its incidence has not changed in decades. We demonstrate that the commensal bacterium Enterococcus faecalis contributes to the pathogenesis of anastomotic leak through its capacity to degrade collagen and to activate tissue matrix metalloproteinase 9 (MMP9) in host intestinal tissues. We demonstrate in rats that leaking anastomotic tissues were colonized by E. faecalis strains that showed an increased collagen-degrading activity and also an increased ability to activate host MMP9, both of which contributed to anastomotic leakage. We demonstrate that the E. faecalis genes gelE and sprE were required for E. faecalis-mediated MMP9 activation. Either elimination of E. faecalis strains through direct topical antibiotics applied to rat intestinal tissues or pharmacological suppression of intestinal MMP9 activation prevented anastomotic leak in rats. In contrast, the standard recommended intravenous antibiotics used in patients undergoing colorectal surgery did not eliminate E. faecalis at anastomotic tissues nor did they prevent leak in our rat model. Finally, we show in humans undergoing colon surgery and treated with the standard recommended intravenous antibiotics that their anastomotic tissues still contained E. faecalis and other bacterial strains with collagen-degrading/MMP9-activating activity. We suggest that intestinal microbes with the capacity to produce collagenases and to activate host metalloproteinase MMP9 may break down collagen in the intestinal tissue contributing to anastomotic leak.
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Affiliation(s)
- Benjamin D Shogan
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | | | - Preston M Luong
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Alexander Zaborin
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Simon Lax
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Cindy Bethel
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Marc Ward
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | | | - Mark Singer
- NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Gary An
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | | | - Vani Konda
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Baddr Shakhsheer
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - James Luo
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Robin Klabbers
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA. Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | - Jack Gilbert
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA. Argonne National Laboratory, Argonne, IL 60439, USA
| | - Olga Zaborina
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - John C Alverdy
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
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Bosmans JWAM, Jongen ACHM, Bouvy ND, Derikx JPM. Colorectal anastomotic healing: why the biological processes that lead to anastomotic leakage should be revealed prior to conducting intervention studies. BMC Gastroenterol 2015; 15:180. [PMID: 26691961 PMCID: PMC4687306 DOI: 10.1186/s12876-015-0410-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/10/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) remains the most dreaded complication after colorectal surgery and causes high morbidity and mortality. The pathophysiology of AL remains unclear, despite numerous studies that have been conducted on animals and humans, probably due to the undetermined healing process of colorectal anastomoses. Increasing basic knowledge on this healing process may shed more light on causal factors of AL, and additionally reduce the quantity and accelerate the quality of experimental studies. In this debate article, our aim was to provide different perspectives on what is known about the colorectal healing process in relation to wound healing and AL. DISCUSSION Since knowledge on anastomotic healing is lacking, it remains difficult to conclude which factors are essential in preventing AL. This is essential information in the framework of humane animal research, where the focus should lie on Replacement, Reduction and Refinement (3Rs). While many researchers compare anastomotic healing with wound healing in the skin, there are substantial recognized differences, e.g. other collagen subtypes and different components involved. Based on our findings in literature as well as discussions with experts, we advocate stop considering anastomotic healing in the gastrointestinal tract and cutaneous healing as a similar process. Furthermore, intervention studies should at least address the anastomotic healing process in terms of histology and certain surrogate markers. Finally, the anastomotic healing process ought to be further elucidated - with modern techniques to achieve 3Rs in animal research--to provide starting points for potential interventions that can prevent AL.
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Affiliation(s)
- Joanna W A M Bosmans
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands. .,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands.
| | - Audrey C H M Jongen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands. .,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands.
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands. .,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands.
| | - Joep P M Derikx
- NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands. .,Pediatric Surgical Center Amsterdam, Emma Children's Hospital AMC/VUMC, P.O.Box 22660, 1100 DD, Amsterdam, The Netherlands.
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Influence of gentamicin-coded PVDF suture material on the healing of intestinal anastomosis in a rat model. Int J Colorectal Dis 2015; 30:1571-80. [PMID: 26260480 DOI: 10.1007/s00384-015-2345-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Intestinal anastomosis is a fundamental procedure in general surgery and required to restore intestinal continuity following resection. The aim of this study was to evaluate whether a gentamicin-coated polyvinylidene fluoride (PVDF) suture material has beneficial effect on anastomotic healing. METHODS Ninety Sprague-Dawley rats were divided into three groups: a PVDF-suture group, a gentamicin-coated PVDF (GPVDF)-suture group and a control group using Maxon® (polyglycolid-co-trimethylene carbonate). For each animal, a colonic anastomosis was performed. Ten animals from each group were sacrificed on postoperative days 3, 5, and 14. Measurements of anastomotic bursting pressure were performed on days 3 and 5. At each time, collagen type I/III ratio, MMP 2 and MMP-9 expression and the proliferation index (Ki67) were analyzed. RESULTS In total, 90 animals underwent surgery without postoperative complications. Bursting strength in the GPVDF group was significantly elevated on day 5. Immunohistochemistry showed significant increase of the collagen type I/III ratio for PVDF and GPVDF on days 3 and 5. MMP2 was significantly increased for PVDF on days 3 and 5 and for GPVDF on day 5. The analysis of MMP9 revealed significant increase compared to control on day 3 and 5 (GPVDF) as well as on day 5 (PVDF). Staining for Ki67 revealed a significant elevation on postoperative day 3 for the PVDF and the GPVDF group. CONCLUSIONS The present data shows the feasibility of PVDF as suture material for colonic anastomosis and confirms the ability of gentamicin to increase the stability of colonic anastomosis when used as coating material.
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Rehn M, Krarup PM, Christensen LH, Seidelin JB, Ågren MS, Syk I. GM6001 Increases Anastomotic Leakage following Colonic Obstruction Possibly by Impeding Epithelialization. Surg Infect (Larchmt) 2015; 16:702-8. [PMID: 26171681 DOI: 10.1089/sur.2014.248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Emergency operations performed on an obstructed colon are accompanied by an increased risk of anastomotic insufficiency. Tissue-destructive matrix metalloproteinase (MMP) activity is elevated in the obstructed colon and contributes to a loss of suture-holding submucosal collagen, which may be mediated by tumor necrosis factor (TNF)-α. Our aim was to study the effect of the non-selective MMP and TNF-α converting enzyme (TACE) inhibitor GM6001 (30 mg/kg) on anastomosis repair in obstructed left colon. GM6001 has been proved to be highly efficacious in elective anastomosis rodent models. METHODS A partial obstruction of the distal colon was induced in male Sprague-Dawley rats. After 4 d the obstructed colonic segment was resected, and an end-to-end anastomosis was constructed. Seven days later, the anastomoses were evaluated for clinical leakage. Histopathological and immunohistochemical assessments were also performed. Finally, the direct effect of GM6001 on epithelialization was studied in cultured colonic epithelial cells. RESULTS Unlike the robust beneficial effect on anastomosis under uncomplicated conditions, here GM6001 had a negative impact on anastomotic wound healing following colonic obstruction and substantially (p=0.004) more rats in the GM6001 group (75%) than in the control group (11%) had developed anastomotic leakage. In the anastomotic wounds, the myofibroblast abundance and cell proliferation were similar in the two groups. Histologically, GM6001 treatment resulted in wider and minimally epithelialized wounds that were commonly necrotic on the luminal side and infiltrated with numerous granulocytes. In vitro, GM6001 also delayed (p=0.026) epithelialization of denuded intestinal epithelium grown on type I collagen. CONCLUSIONS Non-selective MMP/TACE inhibition with GM6001 increased the anastomotic complications following colon obstruction. Inhibition of epithelialization is one possible mechanism responsible for the increased leakage following GM6001 treatment.
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Affiliation(s)
- Martin Rehn
- 1 Department of Surgery, Skåne University Hospital , Malmö, Sweden
| | - Peter-Martin Krarup
- 2 Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen , Copenhagen, Denmark
| | - Lise H Christensen
- 3 Department of Pathology, Bispebjerg Hospital, University of Copenhagen , Copenhagen, Denmark
| | - Jakob B Seidelin
- 2 Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen , Copenhagen, Denmark
| | - Magnus S Ågren
- 2 Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen , Copenhagen, Denmark .,4 Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen , Copenhagen, Denmark .,5 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | - Ingvar Syk
- 1 Department of Surgery, Skåne University Hospital , Malmö, Sweden
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LINDHOLM EE, AUNE E, SELJEFLOT I, OTTERSTAD JE, KIRKEBØEN KA. Biomarkers of inflammation in major vascular surgery: a prospective randomised trial. Acta Anaesthesiol Scand 2015; 59:773-87. [PMID: 25626738 DOI: 10.1111/aas.12466] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/10/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgery induces inflammation and pro-inflammatory cytokines are associated with post-operative complications. In cardiac surgery, it has been shown that volatile anaesthetics have cardioprotective properties. We explored whether sevoflurane affects the pro-inflammatory response favourably compared with total intravenous anaesthesia (TIVA) after surgery. METHODS We measured monocyte chemotactic protein 1 (MCP-1), matrix metalloproteinase 9 (MMP-9), C-reactive protein (CRP), vascular cell adhesion molecule 1 (VCAM-1), interleukin (IL)-6 and IL-8 perioperatively and evaluated if the anaesthetic regimen affected these mediators. Our hypothesis was that sevoflurane-based anaesthesia is associated with a reduced release of biomarkers of inflammation compared with TIVA with propofol/remifentanil. RESULTS In the total population, MCP-1, MMP-9, IL-6 and IL-8 increased 30 min after arrival intensive care unit, compared with before surgery (P < 0.001), whereas CRP and VCAM-1 transiently declined (P < 0.001). From 30 min after arrival intensive care unit to 1st post-operative day, MCP-1 and IL-6 levels declined (P < 0.001), CRP and VCAM-1 increased (P < 0.001), whereas MMP-9 and IL-8 were not significantly altered. Pre-operatively there were no significant differences in any variables between the two anaesthetic groups. Lower levels of MCP-1 and IL-8 (P < 0.001) and higher levels of IL-6 and MMP-9 (P = 0.003) were found in the sevoflurane group, compared with the TIVA group 30 min post-operatively. CRP and VCAM-1 levels did not differ. There were no significant differences between the two anaesthetic groups before surgery or at 1st post-operative day. CONCLUSION We found an inflammatory response during the observation period, which was modified by the anaesthetic regimen in the early phase. This short-lasting difference is probably too short to support a cardioprotective effect of sevoflurane compared with TIVA in open abdominal aortic surgery.
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Affiliation(s)
- E. E. LINDHOLM
- Department of Anaesthesiology; Vestfold Hospital Trust; Tønsberg Norway
| | - E. AUNE
- Department of Cardiology; Vestfold Hospital Trust; Tønsberg Norway
| | - I. SELJEFLOT
- Center for Clinical Heart Research; Department of Cardiology; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; University of Oslo; Oslo Norway
| | - J. E. OTTERSTAD
- Department of Cardiology; Vestfold Hospital Trust; Tønsberg Norway
| | - K. A. KIRKEBØEN
- Department of Anaesthesiology; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; University of Oslo; Oslo Norway
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Vascular anatomy of the small intestine-a comparative anatomic study on humans and pigs. Int J Colorectal Dis 2015; 30:683-90. [PMID: 25694139 DOI: 10.1007/s00384-015-2163-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Porcine models are well established for studying intestinal anastomotic healing. In this study, we aimed to clarify the anatomic differences between human and porcine small intestines. Additionally, we investigated the influences of longitudinal and circular sutures on human small intestine perfusion. METHODS Intestines were obtained from human cadavers (n = 8; small intestine, n = 51) and from pigs (n = 10; small intestine, n = 60). Vascularization was visualized with mennige gelatin perfusion and high-resolution mammography. Endothelial cell density was analyzed with immunohistochemistry and factor VIII antibodies. We also investigated the influence of suture techniques (circular anastomoses, n = 19; longitudinal sutures, n = 15) on vascular perfusion. RESULTS Only human samples showed branching of mesenteric vessels. Compared to the pig, human vessels showed closer connections at the entrance to the bowel wall (p = 0.045) and higher numbers of intramural anastomoses (p < 0.001). Porcine main vessels formed in multifilament-like vessel bundles and displayed few intramural vessel anastomoses. Circular anastomoses induced a circular perfusion defect at the bowel wall; longitudinal anastomoses induced significantly smaller perfusion defects (p < 0.001). Both species showed higher vascular density in the jejunum than in the ileum (p < 0.001). Human samples showed similar vascular density within the jejunum (p = 0.583) and higher density in the ileum (p < 0.001) compared to pig samples. CONCLUSION The results showed significant differences between human and porcine intestines. The porcine model remains the standard for studies on anastomotic healing because it is currently the only viable model for studying anastomosis and wound healing. Nevertheless, scientific interpretations must consider the anatomic differences between humans and porcine intestines.
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Cakir T, Ozer I, Bostanci EB, Keklik TT, Ercin U, Bilgihan A, Akoglu M. Increased collagen maturity with sildenafil citrate: experimental high risk colonic anastomosis model. Int J Surg 2014; 13:152-156. [PMID: 25498489 DOI: 10.1016/j.ijsu.2014.11.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 11/20/2014] [Accepted: 11/27/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Inadequate healing and high anastomosis leak rates at rectal anastomosis may be due to lack of supportive serosal layer and technical difficulty of low anterior resections. Positive effects of sildenafil on wound healing were observed. The aim of this study was to simulate rectal anastomosis as a technical insufficient anastomosis and investigate the effects of sildenafil on anastomosis healing. METHODS Colonic anastomoses were carried out in 64 rats and randomized into four groups, CA-S, complete anastomoses without sildenafil (10 mg/kg for 5 days); CA+S, complete anastomoses with sildenafil; IA-S, incomplete anastomoses without sildenafil; IA+S, incomplete anastomoses with sildenafil. Half of the rats in every group were sacrificed on post-operative day (POD) 3, half of them sacrificed on POD 7. Tissues from the anastomoses were used for functional, histochemical, biochemical investigations. RESULTS Sildenafil treatment resulted in increased bursting pressures in IA+S on POD 7 (p=0.010). Collagen maturity was higher in IA+S on POD 3 and POD 7, CA+S on POD 7 (p=0.010; p=0.010; p<0.007). Collagen content was higher in IA+S on POD 7 (p<0.001). Glutathione, hydroxyproline levels were similar. Malondialdehyde levels were lower in IA+S on POD 3 (p<0.001). Epithelization score was higher in IA+S on POD 7 (p=0.007). Inflammation score was higher in CA-S group on POD 3 and POD 7 (p<0.001; p<0.001). Neutrophil score was lower in CA+S on POD 3 (p=0.005). CONCLUSION An increase in collagen content, maturity, and epithelization, a decrease in neutrophil infiltration, oxidative stress and better mechanical strength were observed with the administration of sildenafil.
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Affiliation(s)
- Tebessum Cakir
- Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Hacettepe Mah, 06230 Ankara, Turkey.
| | - Ilter Ozer
- Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Hacettepe Mah, 06230 Ankara, Turkey
| | - Erdal Birol Bostanci
- Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Hacettepe Mah, 06230 Ankara, Turkey
| | - Tulay Timucin Keklik
- Department of Pathology, Turkiye Yuksek Ihtisas Training and Research Hospital, Hacettepe Mah, 06230 Ankara, Turkey
| | - Ugur Ercin
- Department of Biochemistry, Bilecik Public Hospital, Ertuğrulgazi Mah, 11040 Bilecik, Turkey
| | - Ayse Bilgihan
- Department of Biochemistry, Gazi University School of Medicine, Emniyet Mah, 06560 Ankara, Turkey
| | - Musa Akoglu
- Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Hacettepe Mah, 06230 Ankara, Turkey
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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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Nordentoft T, Pommergaard HC, Rosenberg J, Achiam MP. Fibrin glue does not improve healing of gastrointestinal anastomoses: a systematic review. Eur Surg Res 2014; 54:1-13. [PMID: 25247310 DOI: 10.1159/000366418] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/04/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM Anastomotic leakage remains a frequent and serious complication in gastrointestinal surgery. In order to reduce its incidence, several clinical and experimental studies on anastomotic sealing have been performed. In a number of these studies, the sealing material has been fibrin glue (FG), and the results in individual studies have been varying. The positive effect of anastomotic sealing with FG might be due to the mechanical/physical properties, the increased healing of the anastomoses or both. The aim of this systematic review was to evaluate the existing evidence on the healing effects of FG on gastrointestinal anastomoses. METHODS PubMed, EMBASE and the Cochrane databases were searched for studies evaluating the healing process of gastrointestinal anastomoses after any kind of FG application. The search period was from 1953 to December 2013. RESULTS Twenty-eight studies were included in the qualitative synthesis. These studies were all experimental studies, since no human studies used histological or biochemical evaluation of healing. In 7 of the 28 studies, a positive effect of FG on healing was found, while 8 studies reported a negative effect and 11 studies found no effect. Furthermore, 2 studies reported unclear results. The difference in the study outcome was independent of the study design and the type of FG used. CONCLUSION In the available studies, FG did not consistently have a positive influence on the healing of gastrointestinal anastomoses. It is consequently plausible that the positive effect of FG sealing of gastrointestinal anastomoses, if there is any, may be due to a mechanical sealing effect rather than due to improved healing per se.
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Affiliation(s)
- Tyge Nordentoft
- Department of Gastrointestinal Surgery 360, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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Papaconstantinou I, Zeglinas C, Gazouli M, Nastos K, Yiallourou A, Lykoudis P, Evangelou K, Papalois A, Papaioannou M, Vlachogiannakos J, Tzathas C. Effect of infliximab on the healing of intestinal anastomosis. An experimental study in rats. Int J Surg 2014; 12:969-75. [PMID: 25091401 DOI: 10.1016/j.ijsu.2014.07.271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/14/2014] [Accepted: 07/28/2014] [Indexed: 12/14/2022]
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Silva SM, Jerônimo MS, Silva-Pereira I, Bocca AL, Sousa JB. Effects of bromopride on expression of metalloproteinases and interleukins in left colonic anastomoses: an experimental study. Braz J Med Biol Res 2014; 47:911-6. [PMID: 25140813 PMCID: PMC4181227 DOI: 10.1590/1414-431x20143431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 06/02/2014] [Indexed: 11/22/2022] Open
Abstract
Anastomotic dehiscence is the most severe complication of colorectal surgery.
Metalloproteinases (MMPs) and interleukins (ILs) can be used to analyze the healing
process of anastomosis. To evaluate the effects of bromopride on MMP and cytokine
gene expression in left colonic anastomoses in rats with or without induced abdominal
sepsis, 80 rats were divided into two groups for euthanasia on the third or seventh
postoperative day (POD). They were then divided into subgroups of 20 rats for sepsis
induction or not, and then into subgroups of 10 rats for administration of bromopride
or saline. Left colonic anastomosis was performed and abdominal sepsis was induced by
cecal ligation and puncture. A colonic segment containing the anastomosis was removed
for analysis of gene expression of MMP-1α, MMP-8, MMP-13, IL-β, IL-6, IL-10, tumor
necrosis factor-α (TNF-α), and interferon-γ (IFN-γ). On the third POD, bromopride was
associated with increased MMP-1α, MMP-13, IL-6, IFN-γ, and IL-10 gene expression. On
the seventh POD, all MMP transcripts became negatively modulated and all IL
transcripts became positively modulated. In the presence of sepsis, bromopride
administration increased MMP-8 and IFN-γ gene expression and decreased MMP-1, TNF-α,
IL-6, and IL-10 gene expression on the third POD. On the seventh POD, we observed
increased expression of MMP-13 and all cytokines, except for TNF-α. In conclusion,
bromopride interferes with MMP and IL gene expression during anastomotic healing.
Further studies are needed to correlate these changes with the healing process.
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Affiliation(s)
- S M Silva
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF, Brasil
| | - M S Jerônimo
- Programa de Pós-Graduação em Patologia Molecular, Faculdade de Medicina, Universidade de Brasília, Brasília, DF, Brasil
| | - I Silva-Pereira
- Departamento de Biologia Celular, Instituto de Biologia, Universidade de Brasília, Brasília, DF, Brasil
| | - A L Bocca
- Departamento de Biologia Celular, Instituto de Biologia, Universidade de Brasília, Brasília, DF, Brasil
| | - J B Sousa
- Departamento de Clínica Cirúrgica, Faculdade de Medicina, Universidade de Brasília, Brasília, DF, Brasil
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Seifert GJ, Seifert M, Kulemann B, Holzner PA, Glatz T, Timme S, Sick O, Höppner J, Hopt UT, Marjanovic G. Searching for the Molecular Benchmark of Physiological Intestinal Anastomotic Healing in Rats: An Experimental Study. Eur Surg Res 2014; 53:73-85. [DOI: 10.1159/000365751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 07/02/2014] [Indexed: 11/19/2022]
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Influence of CD68+ macrophages and neutrophils on anastomotic healing following laparoscopic sigmoid resection due to diverticulitis. Int J Colorectal Dis 2014; 29:681-8. [PMID: 24728515 DOI: 10.1007/s00384-014-1855-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this prospective study was to evaluate the predictive value of a potential preexisting low-grade inflammation regarding the incidence of anastomotic leakage in elective laparoscopic sigmoid resection due to diverticulitis. METHODS Patients with either chronically recurrent diverticulitis or sigmoid stenosis caused by chronic diverticulitis were included in this study. All patients with acute local or systemic inflammation were excluded. Detailed patient information (e.g. American Society of Anesthesiologists (ASA) grade, comorbidities, duration of hospital stay, and anastomotic leakage) was prospectively recorded. CD68(+) macrophages, neutrophils, CD3(+) T-lymphocytes, CD11c(+) dendritic cells, MHCII, TNFR1, and NF-κB were evaluated by immunohistochemistry within the acquired sample of colonic bowel wall tissue. Clinical and immunohistochemical data was compared between groups (leakage vs. no leakage). Additionally, a matched-pair analysis was performed due to the widely heterogeneous groups concerning the number of patients and to minimize the effect of extraneous variables. RESULTS A total of 83 patients were included in the study, of which 7 patients suffered an anastomotic leakage. Neither the clinical nor the immunohistochemical parameters were significantly different between the groups. The matched-pair analysis revealed a nonsignificant increase in mean duration of hospital stay for the group with anastomotic leakage and a significantly higher percentage of CD68(+) macrophages and neutrophils in the colonic wall obtained at the index operation in both the mucosal and submucosal layers for the leakage group. CONCLUSIONS A preexisting low-grade inflammation represented by infiltrates of macrophages and neutrophils is a predictor for increased risk of developing colon anastomotic leakage.
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Wang Y, Cai X, Mei J, Liu K, Cai X. Colonic anastomosis with a doxycycline-coated stent: an experimental study in a porcine model. Dig Surg 2014; 31:87-94. [PMID: 24776716 DOI: 10.1159/000358811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 01/15/2014] [Indexed: 01/30/2023]
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) are supposed to be potential drug targets to prevent leakage after colonic anastomosis. A method of colonic anastomosis by using a stent coated with doxycycline, a MMP inhibitor, was developed and its safety and feasibility, as well as the effect of locally regulating MMPs, were evaluated by comparing with the conventional method or the method with a doxycycline-free stent. METHODS 48 pigs were assigned randomly to doxycycline-coated stent anastomosis group (DSA), doxycycline-free stent anastomosis group (SA), or conventional anastomosis group (CA). In each group, pigs were subdivided into four subgroups according to postoperative observation time (3, 7, 14, and 30 days). Healing of anastomosis and expressions of MMP-2/9 were evaluated. RESULTS No anastomotic leakage, stricture or necrosis was observed in the DSA group. No significant difference of bursting pressure was found between the DSA group and SA group. Relative expression of MMP-2 in the DSA group was significantly lower than in the SA group on postoperative days 3 and 7. No significant differences of hydroxyproline content, microvessel density and TGF-β1 level were found in these groups. CONCLUSION These results suggested this method was feasible and safe for colonic anastomosis with the advantage of locally inhibiting MMPs.
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Affiliation(s)
- YiFan Wang
- Department of Surgery, Sir Run Run Shaw Hospital of Zhejiang University, Hangzhou, China
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Hirst NA, Tiernan JP, Millner PA, Jayne DG. Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery. Colorectal Dis 2014; 16:95-109. [PMID: 23992097 DOI: 10.1111/codi.12411] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/01/2013] [Indexed: 12/11/2022]
Abstract
AIM Anastomotic leakage is a serious complication of gastrointestinal surgery resulting in increased morbidity and mortality, poor function and predisposing to cancer recurrence. Earlier diagnosis and intervention can minimize systemic complications but is hindered by current diagnostic methods that are non-specific and often uninformative. The purpose of this paper is to review current developments in the field and to identify strategies for early detection and treatment of anastomotic leakage. METHOD A systematic literature search was performed using the MEDLINE, Embase, PubMed and Cochrane Library databases. Search terms included 'anastomosis' and 'leak' and 'diagnosis' or 'detection' and 'gastrointestinal' or 'colorectal'. Papers concentrating on the diagnosis of gastrointestinal anastomotic leak were identified and further searches were performed by cross-referencing. RESULTS Computerized tomography CT scanning and water-soluble contrast studies are the current preferred techniques for diagnosing anastomotic leakage but suffer from variable sensitivity and specificity, have logistical constraints and may delay timely intervention. Intra-operative endoscopy and imaging may offer certain advantages, but the ability to predict anastomotic leakage is unproven. Newer techniques involve measurement of biomarkers for anastomotic leakage and have the potential advantage of providing cheap real-time monitoring for postoperative complications. CONCLUSION Current diagnostic tests often fail to diagnose anastomotic leak at an early stage that enables timely intervention and minimizes serious morbidity and mortality. Emerging technologies, based on detection of local biomarkers, have achieved proof of concept status but require further evaluation to determine whether they translate into improved patient outcomes. Further research is needed to address this important, yet relatively unrecognized, area of unmet clinical need.
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Affiliation(s)
- N A Hirst
- Section of Translational Anaesthesia and Surgical Sciences, Leeds Institute of Molecular Medicine, St James's University Hospital, Leeds, UK
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Son KH, Jeong HW, Jung WW, Kim HS, Lee SK, Kim KT, Ahn CB, Park KY, Kim BM, Lee SH. The use of collagen content as determined by spectral domain polarization-sensitive optical coherence tomography to assess colon anastomosis healing in a rat model. Eur Surg Res 2014; 52:32-40. [PMID: 24480934 DOI: 10.1159/000358057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 12/17/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Many studies have been undertaken to prevent anastomosis leakage of the colon, and several methods have been used to assess anastomosis healing, such as measurement of bursting pressure or hydroxyproline (a marker of collagen) content at the anastomosis site. However, these methods are inappropriate for comparing anastomosis healing at two time points in the same animals. In the present study, we measured the collagen level by spectral domain polarization-sensitive optical coherence tomography (SD-PS-OCT) to assess anastomosis healing. METHODS Sprague-Dawley rats were divided into groups C (saline-administered controls; study group) and M [a 5-fluorouracil (5-FU)-administered experimental group]. Immediately after end-to-end anastomosis of the colon, SD-PS-OCT images of anastomoses were taken (baseline). Animals were administered saline or 5-FU for 7 days. On the 7th postoperative day, SD-PS-OCT images were acquired, a histopathologic exam was performed, and hydroxyproline levels as well as mRNA expressions of collagen-1 and collagen-3 were measured at the anastomosis site. RESULTS Fibroblast proliferation and inflammatory cell infiltration were greater in group C than in group M. The mRNA expressions of collagen-1 and collagen-3 were substantially higher in group C. Hydroxyproline levels were higher in group M than in group C. Though collagen levels measured by SD-PS-OCT at 7 days were elevated compared with baseline in group C, no such changes were observed for group M. CONCLUSION Collagen levels at the colon anastomosis site, measured with SD-PS-OCT, were not increased at 7 days postoperatively versus baseline when 5-FU was injected, but were increased in saline-treated controls. The measurement of collagen content by SD-PS-OCT was found to provide a good means of assessing anastomosis healing, because it allows in situ assessment of collagen contents at baseline and during the postoperative period.
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Affiliation(s)
- K H Son
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University, Incheon, South Korea
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Trentini A, Bellini T, Manfrinato MC, Dallocchio F, Fainardi E, Alvisi R, Alvisi V, Volta CA. Balanced and unbalanced solutions modulate the release of Matrix Metalloproteinase-9 (MMP-9) from neutrophils in response to inflammatory stimuli: an in vitro study. Inflamm Res 2014; 63:325-8. [PMID: 24458309 PMCID: PMC3983875 DOI: 10.1007/s00011-014-0709-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 01/07/2014] [Accepted: 01/12/2014] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES AND DESIGN We investigated the effect of balanced (BS) and unbalanced (UBS) solutions in the absence or presence of hydroxyethyl starch (HES) on neutrophil functionality, evaluating the release of matrix metalloproteinase (MMP)-9, myeloperoxidase (MPO), and MMP-8. MATERIALS AND METHODS Neutrophils were isolated by gradient centrifugation and dextran sedimentation and incubated in BS or UBS without or with HES, in the absence or presence of Interleukin-8 (IL-8) or Lipopolysaccharide (LPS). MMP-9, MPO, and MMP-8 were assayed by commercially available ELISA kits. RESULTS There was not any influence of volume replacement solutions on the release of the enzymes from resting neutrophils. After IL-8 stimulation, the release of MMP-9 was higher in BS than in UBS or RPMI-1640, whereas HES enhanced its release regardless of the composition. After LPS stimulation, the release of MMP-9 was higher in both UBS and BS than RPMI-1640, but HES brought its release back to physiological conditions. No difference was found in the release of MPO and MMP-8 after stimulation with IL-8 or LPS. CONCLUSION Volume replacement solutions might have an impact on the release of MMP-9 depending on the inflammatory milieu, suggesting that the use of balanced or unbalanced solutions is not a neutral choice.
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Affiliation(s)
- Alessandro Trentini
- Department of Biomedical and Specialty Surgery Sciences, University of Ferrara, Luigi Borsari 46, 44121, Ferrara, Italy
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Denost Q, Adam JP, Rullier E, Bareille R, Montembault A, David L, Bordenave L. Colorectal tissue engineering: prerequisites, current status and perspectives. Expert Rev Med Devices 2014; 10:501-7. [DOI: 10.1586/17434440.2013.811834] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Volta CA, Trentini A, Farabegoli L, Manfrinato MC, Alvisi V, Dallocchio F, Marangoni E, Alvisi R, Bellini T. Effects of two different strategies of fluid administration on inflammatory mediators, plasma electrolytes and acid/base disorders in patients undergoing major abdominal surgery: a randomized double blind study. JOURNAL OF INFLAMMATION-LONDON 2013; 10:29. [PMID: 24059479 PMCID: PMC4015738 DOI: 10.1186/1476-9255-10-29] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 09/20/2013] [Indexed: 10/31/2022]
Abstract
BACKGROUND Administration of normal saline might increase circulating levels of pro-inflammatory cytokines and may cause variation of plasmatic electrolytic and hyperchloremic acidosis, which in turn can impair renal function. Hence the use of balanced solutions could influence the inflammatory cascade triggered by the surgical procedures, the plasmatic electrolyte concentration, the acid-base equilibrium, and the renal function. METHODS This is a double blind randomized trial. Forty patients undergoing major abdominal surgery (bowel cancer) were allocated in two groups, the balanced solution (BS) group in which the fluids administered were balanced solutions (colloids and crystalloids); and the unbalanced solution (UBS) group in which the fluids administered were unbalanced solutions (colloids and crystalloids). Measurements were performed after anaesthesia induction (T0), at the end of surgery (T1), within 2 h after surgery (T2) and 24 h after the beginning of surgery (T3). The following data were collected: 1) active matrix metalloproteinase 9 (MMP-9) and its tissue inhibitor (TIMP-1), IL-6, IL-8, IL-10; 2) blood gases variables; 3) electrolytes, albumin, total serum protein and the strong ion difference; 4) neutrophil gelatinase-associated lipocalin (NGAL) from urinary sample. RESULTS The BS group exhibited higher circulating level of IL-10 and TIMP-1 and lower level of active MMP-9. The UBS group experienced hypercloremia, hypocalcemia, hypomagnesemia, worse acid-base equilibrium and higher level of NGAL. CONCLUSIONS The use of balanced solutions was responsible of less alteration of plasmatic electrolytes, acid-base equilibrium, kidney function and it might be associated with an early anti-inflammatory mechanisms triggering. TRIAL REGISTRATION ClinicalTrials.gov (Ref: NCT01320891).
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Affiliation(s)
- Carlo Alberto Volta
- Department of Surgical, Anaesthesiological and Radiological Science, Section of Anaesthesia and Intensive Care, S, Anna Hospital, University of Ferrara, Via Aldo Moro n, 8-44124 Cona, Ferrara, Italy.
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Krarup PM, Eld M, Heinemeier K, Jorgensen LN, Hansen MB, Ågren MS. Expression and inhibition of matrix metalloproteinase (MMP)-8, MMP-9 and MMP-12 in early colonic anastomotic repair. Int J Colorectal Dis 2013; 28:1151-9. [PMID: 23619615 DOI: 10.1007/s00384-013-1697-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Submucosal collagen is paramount for colonic anastomotic integrity. Matrix metalloproteinases (MMPs) mediate collagen degradation that increases the risk of wound dehiscence. Although broad-spectrum MMP inhibitors are beneficial for anastomotic strength, they can cause adverse reactions. Knowledge of specific MMPs responsible for the weakening of anastomoses can be used to optimise MMP inhibition therapy. We aimed to quantify transcript and protein levels of multiple MMPs in colonic anastomoses and evaluate the effect of inhibiting the MMPs that displayed the highest expression levels on anastomotic repair. METHODS Left-sided colonic anastomoses were made in male Sprague-Dawley rats. After 3 days when biomechanical strength is lowest, MMP mRNA and protein levels were measured by quantitative real-time polymerase chain reaction, enzyme-linked immunosorbent assays and gelatin zymography. The effects of the MMP-8, MMP-9 and MMP-12 synthetic inhibitor AZD3342 was also studied. RESULTS MMP-8, MMP-9 and MMP-12 gene and protein expression increased profoundly (p < 0.01), and MMP-13 mRNA and MMP-2 mRNA and protein modestly (p < 0.001) in the anastomoses. MMP-3 mRNA levels were not up-regulated significantly compared with adjacent uninjured colon. Increased anastomotic MMP-12 levels paralleled macrophage infiltration by immunohistochemical analyses. AZD3342 (50 mg/kg) treatment increased the anastomotic breaking strength by 29% (p = 0.015) day 3 compared with vehicle. Improved anastomotic strength was not accompanied with alterations of type I or type III procollagen mRNA but was possibly due to inhibition of the concerted digestive action on the existent submucosal collagens by the targeted MMPs. CONCLUSION The present findings justify the concept of selective MMP inhibition to enhance anastomotic strength in colon.
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Affiliation(s)
- Peter-Martin Krarup
- Department of Surgery K, Bispebjerg Hospital, Bispebjerg Bakke 23, DK 2400 Copenhagen NV, Denmark.
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