Effects of pirfenidone and dermoid cyst fluid on adhesion formation

Effect of Pirfenidone on Vascular Proliferation, Inflammation and Fibrosis in an Abdominal Adhesion Rat Model

AIM

To study the efficacy of pirfenidone for prevention of postoperative adhesion formation in an adhesion rat model.

MATERIALS AND METHODS

Eighteen female Wistar rats were subjected to right-sided parietal peritoneum and right uterine horn adhesion model. Rats were randomized into three groups: group 1 (control) (closure of midline abdominal incision without any agent administration), group 2 (closure of incision after intraperitoneal administration of pirfenidone), and group 3 (closure of incision and only oral administration of pirfenidone for 14 days). Relaparotomy was performed 14 days after the first surgery. Effect of pirfenidone on adhesion formation was assessed on light microscopy by scoring vascular proliferation, inflammation, fibrosis, and collagen formation in the scarred tissue. Effect of pirfenidone on inflammation was assessed by measurement of transforming growth factor-β and interleukin-17 levels in scarred tissue.

RESULTS

The degree of vascular proliferation (1.32 ± 0.39 versus 2.34 ± 0.46, p < 0.001), inflammation (1.60 ± 0.70 versus 2.60 ± 0.52, p < 0.01), and fibrosis (1.50 ± 0.53 versus 2.40 ± 0.52, p < 0.01) were less prominent in group 2 compared to group 1, respectively. Only vascular proliferation was found to be less prominent in group 3 compared to group 1 (1.60 ± 0.42 versus 2.34 ± 0.46, p < 0.01). Intraperitoneal and oral administration of pirfenidone reduced tissue levels of inflammatory markers (TGF-β and IL-17) in parietal and visceral peritoneum compared to control group. Intraperitoneal administration of pirfenidone compared to oral administration was more effective in reducing tissue levels of inflammatory markers.

CONCLUSION

Pirfenidone is an effective agent on the prevention of postoperative vascular proliferation, inflammation and fibrosis in scarred tissue particularly with intraperitoneal administration.

Pirfenidone prevents capsular contracture after mammary implantation

BACKGROUND

Pirfenidone (PFD), a new antifibrotic and antiinflammatory agent, prevents and resolves fibrous tissue. This study evaluated the effect of PFD on adverse events in mammary implants using an animal model. Mammary implantation, the most frequent aesthetic surgery, may present several complications after surgery such as swelling, capsule contracture, hardness, and pain.

METHODS

Wistar rats underwent submammary implantation with either smooth or textured silicone gel implants and were administrated 200 mg/kg of PFD daily. The control group received saline. The animals were killed at 8 weeks. The capsular tissue of both implants was removed for histologic and molecular analyses.

RESULTS

Typical postaugmentation periimplant capsules with opacity on adjacent tissues developed 8 weeks after silicone implantation. No significant differences were observed between the textured and smooth implants in any analyzed parameter. Clearly, PFD reduced capsule thickness around submmamary tissue, fibroblast-like cell proliferation, and recruitment of inflammatory cells. The total cell numbers per field were reduced as well. In contrast, the control group presented abundant mononuclear cell infiltration and fibroblast-like cell proliferation. The total content of collagen in the PFD group was 50% less than in the control group. Fibroblast cells displayed 45% less activated phenotype in the PFD group than in the control group, as determined by immunohistochemistry techniques. In the PFD animals, transforming growth factor-beta (TGF-beta) decreased 85% and collagen 1 gene expression 60%, compared with the control group.

CONCLUSION

The findings show a positive effect of PFD on mammary contracture in 10 rats. Despite the small number of animals, the differences found in 10 control rats encourage the authors to propose a larger study later and to suggest PFD as a potential preventive strategy in human mammary implantation surgery.

Effect of endometrioma cyst fluid exposure on peritoneal adhesion formation in a rabbit model

OBJECTIVE

To determine whether copious lavage and suction of human endometrioma fluid placed in the peritoneal cavity of rabbits reduces adhesion formation compared to no lavage.

DESIGN

Prospective, randomized, blinded study.

SETTING

Academic research environment.

ANIMAL(S)

Twenty-four female New Zealand white rabbits.

INTERVENTION(S)

Rabbits randomized into three groups: [1] laparoscopy with instillation of human endometrioma material, no lavage; [2] laparoscopy with instillation of human endometrioma material, followed by clearance of all visible endometrioma fluid by saline lavage and suction; [3] laparoscopy alone.

MAIN OUTCOME MEASURE(S)

Six weeks after laparoscopy, adhesions scored by laparotomy using standard visual assessment scoring system and histologic microscopic evaluation. Data evaluated using Kruskal-Wallis and median nonparametric tests.

RESULT(S)

For groups 1, 2, and 3, respectively, mean total clinical adhesion scores were 0.67 (95% confidence interval [CI] -0.87, 2.2), 3.67 (95% CI 1.27, 6.07), and 0 (95% CI 0, 0). Group 2 had statistically significantly higher mean adhesion scores compared to group 1. Histologic adhesion scores followed the trend of clinical adhesion scores.

CONCLUSION(S)

In this rabbit model, human endometrioma fluid exposure in the peritoneal cavity is not associated with adhesion formation. Instillation of endometrioma fluid followed by copious saline lavage is strongly associated with adhesion formation.

Laparoscopic Treatment of Ovarian Dermoid Cysts: Eleven Years' Experience

STUDY OBJECTIVE

To compare laparoscopic and open approaches in the management of benign ovarian teratomas (dermoid cysts) with regard to operative outcome, complications, and postoperative follow-up. Factors that predispose to rupture of dermoid cysts during laparoscopic removal and rates of adhesion formation in women with and without cyst rupture during laparoscopic surgery also were considered.

DESIGN

Review of cases of women with dermoid cysts who underwent cystectomy either by laparoscopy or laparotomy in our department from 1992 through 2002 (Canadian Task Force classification III).

SETTING

The Infertility and Operative Laparoscopy units of the First Department of Obstetrics and Gynecology of the University of Athens, Alexandra Maternity Hospital, Athens, Greece.

PATIENTS

Two hundred twenty-two women with an ovarian mass requiring surgical management. Of these, 187 women with benign cystic teratomas underwent laparoscopic cystectomy, and 35 underwent cystectomy by laparotomy.

INTERVENTIONS

Cystectomy either by laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Potential benefits of operative laparoscopy include reduced blood loss, less postoperative pain, shorter hospital stay, fast recovery, and an excellent cosmetic result.

CONCLUSION

Laparoscopy should be considered the method of choice for the removal of benign ovarian cystic teratomas as it offers the advantages of fewer postoperative adhesions, reduced pain, shorter hospital stay, and better cosmetic result. It should be performed by surgeons with considerable experience in advanced laparoscopic surgery.

Pirfenidone: A novel anti-fibrotic agent and progressive chronic allograft rejection

In our established model of heterotopic tracheal transplantation, at day 28 following transplantation, obliteration of the lumen is observed, which is histologically similar to that seen in Obliterative Bronchiolitis (OB). Pirfenidone (Pir) is a novel anti-fibrotic agent that causes no immunosuppression, but does downregulate the production of TGF-beta and collagen in vitro. We hypothesized that when used in this in vivo model, that Pir may alter the observed luminal fibrosis and obliteration.

METHODS

The treatment groups were: CSA, Pir and CSA, Pir only (n=6 each). Luminal supernatants and tissue were obtained from these groups at day 28. H&E staining was completed, as well as MTS proliferation assays, and TGF-beta ELISA on the fluids.

RESULTS

The CSA-Pir combined treatment group was the least fibrogenic in vitro (p<0.001). The TGF-beta levels were elevated in all groups (range 203-372 pg/ml). The H&E staining revealed that the luminal obliteration was less organized in the combined CSA-Pir group.

CONCLUSIONS

Our study shows that the combination of CSA-Pir results in a less fibrogenic luminal fluid and a less dense fibrous luminal plug. Pir should be further studied in obliterative airways disease (OAD).

Pirfenidone effectively reverses experimental liver fibrosis

BACKGROUND/AIMS

Our group has been involved in searching for different strategies to ameliorate hepatic cirrhosis. The aim of this study was to evaluate the effect of Pirfenidone in the reversion or prevention of cirrhosis experimentally induced in rats by chronic administration of CCl(4) and bile-duct ligation (BDL).

METHODS

Male cirrhotic Wistar rats (8 weeks of intoxication and then hepatotoxin was discontinued) received either oral saline or Pirfenidone at 500 mg/kg per day.

RESULTS

High levels of alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase decreased significantly (P<0.001) in animals treated with Pirfenidone (n=11) with regard to saline-administrated animals (n=9). Prothrombin activity and bilirubins were also reduced. Computerized fibrosis index demonstrated a 70% decrease (P<0.001) along with less hydroxyproline content, reduction in activated HSC and higher active cell regeneration. A rearrangement of the parenchyma was also noted and gene expression of collagens I, III and IV, transforming growth factor beta-1, Smad-7, TIMP-1 and PAI-1 decreased considerably in treated animals. Cirrhotic rats in which CCl(4) was not discontinued displayed 40% liver fibrosis reduction. In a different cirrhosis model, 4-week BDL rats treated with the drug showed a significant 50% reduction in hepatic fibrosis (P<0.01).

CONCLUSIONS

This new drug might be useful in healing human disease.

Effects of leuprolide acetate on adhesion formation and wound healing in the rat model

STUDY OBJECTIVE

To assess the effects of a hypoestrogenic state on adhesion formation and reformation and on wound healing in the rat model.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SUBJECTS

Forty-eight female Sprague-Dawley rats.

INTERVENTIONS

Rats were injected with gonadotropin-hormone releasing hormone (GnRH) agonist and control rats with normal saline. Two weeks later (day zero) laparotomy was performed to create adhesions and a full-thickness wound on the flank. On day 14 the adhesions were scored and liberated. The rats were sacrificed on day 28 and adhesion reformation was evaluated. The wound surface area was measured serially until complete closure.

MEASUREMENTS AND MAIN RESULTS

Mean adhesion scores on day 14 after adhesion formation were not significantly different between GnRH agonist and control groups. Preadhesiolysis and postadhesiolysis scores were not significantly different. There was no significant difference in size of wounds between groups on days zero, 7, or 14.

CONCLUSION

Administration of a GnRH agonist does not seem to influence postoperative adhesion formation or wound healing in the rat model. (J Am Assoc Gynecol Laparosc 8(1):124-128, 2001)

Managing mature cystic teratomas of the ovary

Mature cystic teratomas (MCT), commonly called dermoid cysts, are the most common benign germ cell tumors of the ovary in women of reproductive age. Future fertility is of major concern among these women; therefore, the surgical management must focus on preserving ovarian tissue and minimizing adhesion formation. Patients requiring surgery should be appropriately counseled about the risks and benefits of laparoscopy and laparotomy, the risks of intraoperative MCT spillage and adhesion formation. In addition, the risks of recurrence and malignant transformation should be discussed. The parents of children with MCTs have the same concerns as older women and a similar discussion should take place. The goal of this article is to review these issues and provide the physician with the information to counsel their patients preoperatively.

New directions in the prevention of adhesion in laparoscopic surgery

The aim of this review is to appraise critically the literature over the past year with respect to new developments in adhesion prevention strategies. The majority of the work continues to be focused on animal models, and interest continues into the usage of heterologous barriers, which are increasingly derived from or related to hyaluronic acid. The recent trend has been to develop barriers that are not only effective but also technically easy to use for the laparoscopic surgeon--hence the development of barrier gels. It is only through the development of these user-friendly barriers that many laparoscopic surgeons will be willing to incorporate these important preventative measures into their busy daily practice. Routine usage of adhesion prevention measures will ultimately reduce patient morbidity and mortality and relieve the burden on health service provision.

Incidental liver abnormalities at laparoscopy for benign gynecologic conditions

STUDY OBJECTIVE

To evaluate liver abnormalities among women undergoing laparoscopy for benign gynecologic conditions.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Tertiary care academic centers.

PATIENTS

Women undergoing laparoscopy for benign gynecologic indications.

INTERVENTION

The upper abdomen was examined by directing the laparoscope cranially.

MEASUREMENTS AND MAIN RESULTS

Incidental liver abnormalities were found in 4.7% of 823 patients. The most common was perihepatic adhesions (Fitz-Hugh-Curtis syndrome), located mainly on the right lobe (66.7%) or on both lobes. Pelvic inflammatory disease was present in one-half of women with perihepatic adhesions. Other abnormalities were consistent with hepatic cirrhosis, adenoma, and hemangioma.

CONCLUSION

Our results suggest the importance of exploring the upper abdomen during laparoscopic surgery.