Prevention of Peritoneal Adhesions by Ferric Ion-Cross-Linked Hydrogels of Hyaluronic Acid Modified with Iminodiacetic Acids

Development of novel iron(III) crosslinked bioinks comprising carboxymethyl cellulose, xanthan gum, and hyaluronic acid for soft tissue engineering applications

The advent of three-dimensional (3D) bioprinting offers a feasible approach to construct complex structures for soft tissue regeneration. Carboxymethyl cellulose (CMC) has been emerging as a very promising biomaterial for 3D bioprinting. However, due to the inability to maintain the post-printed stability, CMC needs to be physically blended and/or chemically crosslinked with other polymers. In this context, this study presents the combination of CMC with xanthan gum (XG) and hyaluronic acid (HA) to formulate a multicomponent bioink, leveraging the printability of CMC and XG, as well as the cellular support properties of HA. The ionic crosslinking of printed constructs with iron(III) via the metal-ion coordination between ferric cations and carboxylate groups of the three polymers was introduced to induce improved mechanical strength and long-term stability. Moreover, immortalized human epidermal keratinocytes (HaCaT) and human foreskin fibroblasts (HFF) encapsulated within iron-crosslinked printed hydrogels exhibited excellent cell viability (more than 95%) and preserved morphology. Overall, the presented study highlights that the combination of these three biopolymers and the ionic crosslinking with ferric ions is a valuable strategy to be considered for the development of new and advanced hydrogel-based bioinks for soft tissue engineering applications.

Injectable, pore-forming, self-healing, and adhesive hyaluronan hydrogels for soft tissue engineering applications

Most existing injectable hydrogels are non-porous, thereby lacking a microporous structure to promote cell ingrowth. Also, most hydrogels do not effectively adhere to the host tissue. The present study describes an injectable double network hydrogel formed by combining two hyaluronic acid (HA) derivatives, namely dopamine grafted HA (DAHA) and methacrylated HA (HAMA). These constituents instantly form a physically crosslinked network through Fe3+-dopamine coordination, and confer fast gelation, pore formation, and self-healing properties to the hydrogel. Photocroslinked upon UV exposure, HAMA forms a chemically crosslinked network, thereby improving mechanical and degradation properties. The adhesive properties of this hydrogel are attributed to the presence of dopamine groups, inspired by mussel creatures. Proper modification of HA chains was confirmed by NMR spectroscopy. The physical, mechanical, rheological, and biological properties of the new hydrogels were quantified in wet laboratory conditions. The results revealed that the DAHA/HAMA hydrogel rapidly forms a self-healing microporous adhesive scaffold with a 26.9 µm pore size, 29.4 kPa compressive modulus, and 12.8 kPa adhesion strength in under 6 s. These findings suggest that the new hydrogel is a promising candidate for in situ repair of soft tissues, particularly mechanically dynamic ones such as the vocal folds, cartilage, and dermis.

The Therapeutic Potential of Targeting Key Signaling Pathways as a Novel Approach to Ameliorating Post-Surgical Adhesions

BACKGROUND

Peritoneal adhesions (PA) are a common complication of abdominal operations. A growing body of evidence shows that inhibition of inflammation and fibrosis at sites of peritoneal damaging could prevent the development of intra-abdominal adhesions.

METHODS

A search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords 'postsurgical adhesion', 'post-operative adhesion', 'peritoneal adhesion', 'surgery-induced adhesion' and 'abdominal adhesion'. Studies detailing the use of pharmacological and non-pharmacological agents for peritoneal adhesion prevention were identified, and their bibliographies were thoroughly reviewed to identify further related articles.

RESULTS

Several signaling pathways, such as tumor necrosis factor-alpha, tissue plasminogen activator, and type 1 plasminogen activator inhibitor, macrophages, fibroblasts, and mesothelial cells play a key part in the development of plasminogen activator. Several therapeutic approaches based on anti-PA drug barriers and traditional herbal medicines have been developed to prevent and treat adhesion formation. In recent years, the most promising method to prevent PA is treatment using biomaterial-based barriers.

CONCLUSION

In this review, we provide an overview of the pathophysiology of adhesion formation and various agents targeting different pathways, including chemical agents, herbal agents, physical barriers, and clinical trials concerning this matter.

Physically Cross-Linked Hyaluronan-Based Ultrasoft Cryogel Prepared by Freeze-Thaw Technique as a Barrier for Prevention of Postoperative Adhesions

Postsurgical peritoneal adhesions are a common and serious postoperative complication after various peritoneal surgeries, such as pelvic and abdominal surgery. Various studies have shown that peritoneal adhesions can be minimized or prevented by physical anti-adhesion barriers, including membranes, knits, and hydrogels. Hydrogels have attracted great attention in preventing peritoneal adhesions because the dimensional architecture of hydrogels is similar to that of the native extracellular matrix. However, chemical cross-linkers had to be used in the preparation of chemical hydrogels, which may have problems in cytotoxicity or unwanted side effects. This fact prompts us to create alternative cross-linking methods for the development of biocompatible hydrogels as physical barriers. Herein, we report a physically cross-linked flexible hyaluronan (HA) cryogel prepared via a freeze-thaw technique as a novel anti-adhesion biomaterial for completely preventing postsurgical peritoneal adhesions. In vitro studies demonstrated that this physically cross-linked HA cryogel exhibited excellent biocompatibility, the inherently desirable biocompatibility and functionality of HA being integrally retained as much as possible. Intriguingly, the rheological properties and appropriate biodegradability of the cryogels were readily tailored and tunable by way of the gelation process. In vivo assessments suggested that the cryogel, as a physical barrier, satisfactorily prevented fibroblast penetration and attachment between the injured tissues and nearby normal organs. Furthermore, the molecular mechanism studies revealed that the HA cryogel could prevent peritoneal adhesion by inhibiting inflammatory response and modulation of the fibrinolytic system. Our results show that HA ultrasoft cryogel is a promising clinical candidate for prolonged adhesion prevention.

Tunable Crosslinking, Reversible Phase Transition, and 3D Printing of Hyaluronic Acid Hydrogels via Dynamic Coordination of Innate Carboxyl Groups and Metallic Ions

This article reports tunable crosslinking, reversible phase transition, and three-dimensional printing (3DP) of hyaluronic acid (HyA) hydrogels via dynamic coordination of Fe³⁺ ions with their innate carboxyl groups for the first time. The concentrations of Fe³⁺ and H⁺ ions and the reaction time determine the tunable ratios of mono-, bi-, and tridentate coordination, leading to the low-to-high crosslinking densities and reversible solid-liquid phase transition of HyA hydrogels. At the monodentate-dominant coordination, the liquid hydrogels have low crosslinking densities (HyA_L). At the mixed coordination of mono-, bi-, and tridentate bonding, the solid hydrogels have medium crosslinking densities (HyA_M). At the tridentate-dominant coordination, the solid hydrogels have high crosslinking densities (HyA_H). The reversible solid-liquid phase transitions among HyA_L, HyA_M, and HyA_H were achieved via controlling the concentrations of Fe³⁺ and H⁺ ions and reaction time. When the crosslinking densities are between HyA_L and HyA_M, the hydrogels become 3D printable (HyA_P). HyA_P hydrogels were 3D-printed successfully using cold-stage or direct writing methods, and the 3D constructs achieved better structural stability using the latter method. In the direct exposure culture with bone marrow-derived mesenchymal stem cells, the 3D-printed HyA_H (HyA_H_3D) and HyA_H hydrogels showed higher average cell adhesion densities than the HyA_M, HyA_P, and HyA_L hydrogel groups under both direct and indirect contact conditions. For all hydrogel groups, cell adhesion densities under direct contact conditions were statistically lower than the same groups under indirect contact conditions. In this article, we elucidated the mechanisms of dynamic coordination and the relationships among the key parameters in controlling the tunable crosslinking, reversible phase transition, and 3DP of HyA hydrogels without blending with other polymers or adding functional groups. This approach can be potentially adapted to crosslink and 3D print other polymeric hydrogels with carboxyl groups, which is promising for a wide range of applications.

Fabrication of an injectable iron (III) crosslinked alginate-hyaluronic acid hydrogel with shear-thinning and antimicrobial activities

The combination of alginate, hyaluronic acid and multivalent ions have been reported to form alginate-hyaluronic acid ionic-crosslinking hydrogels for biomedical applications. However, injectable alginate-hyaluronic acid ionic-crosslinking hydrogels with satisfactory shear-thinning property have rarely been reported. In this study, we successfully developed an ionic-crosslinked alginate-hyaluronic acid hydrogel by simple assembly of alginate-hyaluronic acid mixture and Fe³⁺ complex. This hydrogel could fully recover within seconds after damaged, while displayed shear thinning behavior and good injectability which were contributed by the reversible and dynamic metal-ligand interactions formed via ferric ions and carboxyl groups of the polymers. Moreover, the local degradation of this hydrogel giving the hydrogel sustained ferric ions release property, of which led to potential long-term antibacterial activities against multiple types of bacteria including gram-negative Escherichia coli and gram-positive Staphylococcus aureus, as well as representative oral pathogenic bacteria Streptococcus mutans and Porphyromonas gingivalis.

Advancement of Biomaterial-Based Postoperative Adhesion Barriers

Postoperative peritoneal adhesion (PPA) is a prevalent incidence that generally happens during the healing process of traumatized tissues. It causes multiple severe complications such as intestinal obstruction, chronic abdominal pain, and female infertility. To prevent PPA, several antiadhesion materials and drug delivery systems composed of biomaterials are used clinically, and clinical antiadhesive is one of the important applications nowadays. In addition to several commercially available materials, like film, spray, injectable hydrogel, powder, or solution type have been energetically studied based on natural and synthetic biomaterials such as alginate, hyaluronan, cellulose, starch, chondroitin sulfate, polyethylene glycol, polylactic acid, etc. Moreover, many kinds of animal adhesion models, such as cecum abrasion models and unitary horn models, are developed to evaluate new materials' efficacy. A new animal adhesion model based on hepatectomy and conventional animal adhesion models is recently developed and a new adhesion barrier by this new model is also developed. In summary, many kinds of materials and animal models are studied; thus, it is quite important to overview this field's current progress. Here, PPA is reviewed in terms of the species of biomaterials and animal models and several problems to be solved to develop better antiadhesion materials in the future are discussed.

Peritoneal adhesions: Occurrence, prevention and experimental models

Peritoneal adhesions (PA) are a postoperative syndrome with high incidence rate, which can cause chronic abdominal pain, intestinal obstruction, and female infertility. Previous studies have identified that PA are caused by a disordered feedback of blood coagulation, inflammation, and fibrinolysis. Monocytes, macrophages, fibroblasts, and mesothelial cells are involved in this process, and secreted signaling molecules, such as tumor necrosis factor alpha (TNF-α), interleukin-10 (IL-10), tissue plasminogen activator (tPA), and type 1 plasminogen activator inhibitor (PAI-1), play a key role in PA development. There have been many attempts to prevent PA formation by anti-PA drugs, barriers, and other therapeutic methods, but their effectiveness has not been widely accepted. Treatment by biomaterial-based barriers is believed to be the most promising method to prevent PA formation in recent years. In this review, the pathogenesis, treatment approaches, and animal models of PA are summarized and discussed to understand the challenges faced in the biomaterial-based anti-PA treatments.

Dual dynamically crosslinked thermosensitive hydrogel with self-fixing as a postoperative anti-adhesion barrier

Tissue adhesion is a severe postoperative complication. Various strategies have been developed to minimize postoperative adhesion, but the clinical efficacy is still far from satisfactory. Herein, we present a dual dynamically crosslinked hydrogel to serve as a physical postoperative anti-adhesion barrier. The hydrogel was generated by dynamic chemical oxime bonding from alkoxyamine-terminated Pluronic F127 (AOP127) and oxidized hyaluronic acid (OHA), as well as hydrophobic association of AOP127. Rheological analysis demonstrated that the hydrogel exhibits temperature sensitivity. At 37 °C, it shows much higher modulus and higher stability than the Pluronic F127 hydrogel. Hemolytic assays suggested that the hydrogel undergoes low hemolysis. In addition, it exhibited anti-adhesion to blood cells in blood cell adhesion tests. It also showed an anti-attachment effect to fibroblasts and biocompatibility in vitro cell studies. Macroscopic evaluation and lap-shear tests revealed that the hydrogel has a moderate adhesive capacity to tissue, which is important for self-fixation. A rat model of sidewall defect-bowel abrasion was established to evaluate the anti-adhesion effect in vivo. The gross observation and pathological analysis revealed a significant reduction in postoperative peritoneal adhesion in the AOP127/OHA hydrogel-treated group than those treated with normal saline or Pluronic F127 hydrogel. Hence, the dual dynamically crosslinked hydrogel with self-fixable capacity may be suitable as a physical barrier for postoperative adhesion prevention. STATEMENT OF SIGNIFICANCE: Despite the development of numerous postoperative anti-adhesion barriers, their anti-adhesion efficacy is still limited in clinical trials due to poor tissue adhesion and rapid clearance from injured areas. Herein, we have developed a dual dynamic crosslinked hydrogel, generated by dynamic oxime bonds and hydrophobic interactions. The hydrogel is temperature-sensitive and demonstrates moderate tissue adhesion capacity, which allows for self-fixation when applied to defects. The introduction of dynamic covalent bonds improves the stability of the hydrogel. Moreover, the hydrogel not only displays appropriate hemocompatibility, cytocompatibility and anti-adhesion of blood cells and fibroblasts, but it also effectively contributes to preventing postoperative peritoneal adhesions in vivo. Hence, this dual dynamic crosslinked hydrogel may have potential applications as a physical barrier in clinical practice.

Thermal stimuli-responsive hyaluronic acid loaded cellulose based physical hydrogel for post-surgical de novo peritoneal adhesion prevention

Effective strategies for post-surgical adhesion prevention have increasingly focused on injectable adhesion barriers due to their minimal invasiveness and wider applicability. In this study, a thermo-reversible hydrogel was developed by combining high molecular weight hyaluronic acid (HA) at various concentrations (0.05, 0.25, and 0.45% w/v) with tempo-oxidized nanocellulose (TOCN), methyl cellulose (MC) and polyethylene glycol (PEG) for anti-adhesion application. The hydrogel preparation time was short and did not require any chemical modification. TOCN ensured the mechanical stability of the hydrogel. MC confirmed thermo-sensitive feature. Higher amounts of HA increased the rate of hydrogel degradation. The HA 0.25 hydrogel was free-flowing, injectable at ambient temperature, capable of faster (40 ± 2 s), and reversible sol-gel (4 °C-37 °C) transition. A rat side-wall cecum abrasion model was used to confirm the complete de novo adhesion prevention efficacy of optimized HA 0.25 hydrogel, where the scratched abdominal wall of animals treated with HA 0.25 hydrogel healed after 14 days. During in vivo experiment, PEG in the hydrogel played a crucial role in adhesion prevention by minimizing friction between the surgical site and nearby organs. In a nutshell, HA 0.25 hydrogel, fabricated without crosslinking agent, is a potential candidate for tissue adhesion prevention strategies.