Effect of colonic obstruction on the distribution of matrix metalloproteinases during anastomotic healing

Matrix metalloproteinase-9 in relation to patients with complications after colorectal surgery: a systematic review

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.

A multicentre cohort study of serum and peritoneal biomarkers to predict anastomotic leakage after rectal cancer resection

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.

GM6001 Increases Anastomotic Leakage following Colonic Obstruction Possibly by Impeding Epithelialization

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.

The effects of iloprost on colonic anastomotic healing in rats under obstructive ileus conditions

BACKGROUND

The aim of this study was to investigate the effects of iloprost, on colonic anastomotic healing in rats, under obstructive ileus conditions.

MATERIALS AND METHODS

Eighty male Albino rats were randomized into four groups of 20 animals each. They underwent colonic resection followed by an inverted anastomosis. The rats of group 1 (control) and group 2 (ileus) received 3 mL of saline 0.9% intraperitoneally and those of group 3 (iloprost), and group 4 (ileus + iloprost) iloprost (2 μg/kg of body weight), immediately postoperatively and daily until the day of sacrifice. Each group was further divided into two equal subgroups, depending on the day of sacrifice. The animals of subgroup "a" were sacrificed on the fourth postoperative day, whereas those of "b" on the eighth day. Macroscopic and histologic assessment was performed, whereas anastomotic bursting pressures and the tissue concentrations in hydroxyproline and collagenase I were evaluated.

RESULTS

Means of bursting pressure, neoangiogenesis, fibroblast activity, and hydroxyproline concentration were significantly increased in group 4 compared with group 2. In addition, on the fourth postoperative day, the inflammatory cell infiltration and the collagenase I concentration were significantly decreased in group 4 compared with group 2. Moreover, on the eighth postoperative day, collagen deposition was significantly increased in group 4 compared with group 2.

CONCLUSIONS

Iloprost after intraperitoneal administration reverses the negative effect of obstructive ileus. It promotes not only the angiogenic activity but also collagen formation, resulting in increased bursting pressures on the fourth and eighth postoperative days.

Rana catesbeiana, pólvora e modulação supramolecular cicatrização intestinal e prognóstico no câncer de cólon: uma mesma origem biológica para o insucesso?

A cicatrização e remodelação do cólon resultam das modificações do colágeno na matriz extracelular. Algumas condições desequilibram sua renovação, enfraquecendo a resistência mecânica a cicatriz, como resultado da atividade elevada das metaloproteinases locais, e levando a um alto risco de deiscência. As metaloproteinases da matriz extracelular (matrix metalloproteinases, MMPs) constituem uma família de endopeptidases zinco-dependentes - metzincinas. São reconhecidos atualmente, em humanos, cerca de 24 genes responsáveis por cada uma delas. A colagenase (MMP-1) foi identificada por Gross e Lapière (1962) na cauda do girino da rã-touro americana. No câncer as MMPs tem ocupado um lugar especial. Evidências de que a célula neoplásica é capaz de interferir na modulação desta enzima - um co-fator associado à invasividade local e disseminação metastática. As MMP-2 e -7 são observadas com frequência no câncer de cólon, a MMP-12 parece exercer um efeito protetor (melhor prognóstico) e, ao contrário, a MMP-3 o torna pior. A associação entre alta atividade de MMPs, o pior prognóstico do câncer e o maior risco de deiscência de anastomose intestinal já vem sendo considerada, sugerindo uma trilogia consistente. A terapia farmacológica (inibidores MMPs) tem sido investigada, também para o controle do câncer. O artigo discute as informações mais relevantes e atualizadas sobre o assunto.

Zinc deficiency impairs wound healing of colon anastomosis in rats

BACKGROUND

Anastomotic leakage is a relevant surgical complication. The aim of the study was to investigate the influence of a controlled preoperative zinc deficiency on the extracellular matrix composition of colon anastomosis.

MATERIALS AND METHODS

Forty male Wistar rats were randomized to either a zinc deficiency group (n = 20) or a control group (n = 20). In each animal, a transverse colonic end-to-end anastomosis was performed. On postoperative day 7, the surface of the mucosal villi, expression of matrix metalloproteinases (MMP) 2, 8, 9, and 13, and both the number of proliferating cells (Ki67) and apoptotic cells, as well as the collagen types I/III ratio were analyzed. Within the anastomotic area the mesenterial region and the antimesenterial region were analyzed separately.

RESULTS

In each group, one anastomotic leakage was detected. Expression of both MMP 2, 9, and 13 was significantly higher, and expression of Ki67 was significantly reduced in the zinc deficient group both mesenterial and antimesenterial. The collagen types I/III ratio was reduced in the zinc deficiency group by trend, without statistical significance neither mesenterial nor antimesenterial. Likewise, zinc deficiency affected neither the expression of MMP 8 nor the rate of apoptotic cells, respectively. Analyses of the surface of the mucosal villi revealed no significant differences comparing the groups with neither mesenterial nor antimesenterial.

CONCLUSIONS

Our study constitutes the known negative effect of zinc deficiency on wound healing. Zinc deficiency significantly increased the activity of MMPs (2, 9, and 13), caused a reduced collagen type I/III ratio, and delayed cell proliferation and quality of intestinal wound healing.

Intraperitoneally applied gentamicin increases collagen content and mechanical stability of colon anastomosis in rats

BACKGROUND

Anastomotic leakage remains a serious complication in colorectal surgery, and is being caused by a multitude of factors. Recent reports reveal changes of the extracellular matrix as risk factors as well as gentamicin as a potential agent to influence wound healing. This experimental study was initiated to investigate the influence of intraperitoneally applied gentamicin on colonic anastomotic wound healing and in particular on mechanical stability, overall collagen content and collagen type I/III ratio.

MATERIALS AND METHODS

Sixty Sprague Dawley rats were randomized to one of two groups. In each animal, a standard transverse colonic end-to-end anastomosis was performed. Immediately postoperative, either 5 ml gentamicin (1 ml/kg bodyweight) or NaCl 0.9% was applied intraperitoneally. On postoperative days 3, 5, and 14, ten of the animals in each group were sacrificed. Measurements of the anastomosis bursting pressure were performed on postoperative days 3 and 5. At each explantation time, the collagen per protein ratio, the collagen types I/III ratio, and both the expression of MMP-2, -9, and Ki67 were analyzed.

RESULTS

None of the animals died. None of the rats exhibited clinical evidence of anastomotic leakage. The bursting strength in the gentamicin group was significantly elevated on postoperative day 5. Both the overall collagen content and the collagen type I/III ratio in the gentamicin group were significantly increased 3, 5, and 14 days postoperatively compared to the control group. The expression of MMP-9 was significantly elevated in the gentamicin group both 3 and 5 days postoperatively. In contrast, there were no significant differences in the expression of MMP-9 14 days postoperatively. All investigated samples demonstrated positive staining for MMP-2 and Ki67 without statistically significant differences at any term, respectively.

CONCLUSIONS

The present data confirm that intraperitoneally applied gentamicin is able to enhance healing and stability of colonic anastomosis due to an increase of both the overall collagen content and collagen type I/III ratio.

Do low-molecular-weight heparins influence the healing process in colon anastomosis?

Anastomosis leakage is one of the most serious complications of colorectal surgery. A role for extracellular matrix remodelling in the healing process of the colon wall has been recently postulated. Changes in matrix metalloproteinase (MMP) activity in the intestinal wall occurring prior to elective resection and primary anastomosis appear to be responsible for dehiscence leading to anastomosis. Thrombophylaxis using low-molecular-weight heparins is routinely administered to all patients during the perioperative period. However, adverse antiproliferative and proapoptotic effects such as limitation of bioavailability of growth factors and angiogenesis inhibition have been characterized in various cell types as a result of heparin administration. It is also likely that relationships exist between extracellular matrix homeostasis and the coagulation/fibrinolysis system. We hypothesize that subcutaneous administration of LMWHs (low-molecular-weight heparins) may influence matrix metalloproteinase activity in the colon wall and increase the risk of postoperative leakage.

Increased concentration of tissue-degrading matrix metalloproteinases and their inhibitor in complicated diverticular disease

OBJECTIVE

Complicated diverticular disease is associated with extensive structural changes of the colonic wall. Turnover of extracellular matrix (ECM) plays a pivotal role in this process. Proteolytic enzymes, including matrix metalloproteinases (MMPs), are capable of degrading most components of ECM. Their activity is regulated by inhibitors, tissue inhibitors of metalloproteinases (TIMPs). Disturbances of the MMP-TIMP balance can cause tissue degradation or fibrosis. The aim of this study was to assess the concentration and distribution of MMPs and TIMPs in colonic biopsies.

MATERIAL AND METHODS

Twenty-seven patients who had undergone sigmoid colectomy were included in the study. Full-thickness biopsies from affected and non-affected parts of each resected specimen were collected. Expressions of the proteins MMP-1, -2, -3, -9, TIMP-1 and TIMP-2 were quantified by ELISA and localized by immunohistochemistry.

RESULTS

The concentrations of MMP-1, MMP-2 and TIMP-1 were significantly higher in affected tissue than concentrations in non-affected tissue (MMP-1 p=0.005, MMP-2 p=0.0003 and TIMP-1 p<0.0001). In affected segments in general, there was an increased expression in the entire bowel wall, predominantly for MMP-2, MMP-3 and TIMP-1.

CONCLUSIONS

Concentrations of MMP-1, MMP-2 and TIMP-1 were increased in intestinal segments affected by complicated diverticular disease and distributed throughout the entire bowel wall, which may explain the structural changes.

[Anastomotic leakage in the gastrointestinal tract-repair and prognosis]

Anastomotic leakage is still a serious complication in surgery, resulting in increased morbidity and mortality. The reasons for its onset are various and due to two main reasons: general risk factors of the individual patient and technical surgical factors influencing the outcome after gastrointestinal anastomoses. Changes in the extracellular matrices, particularly due to collagen metabolism, and related disturbances are assumed to be important factors influencing wound healing processes. The technique chosen and the surgical skill are important with regard to inflammation and tissue necroses at the anastomotic line. Analysis of data obtained by clinical studies that concern clinical risk factors for anastomotic leakage reveal an inhomogeneous picture. Attempts to develop risk profiles or scores based on these results have failed until now. Problems encompass the complexity of wound healing processes, and it is questionable whether our current knowledge about them is complete. Therefore, profound understanding of anastomotic leakage requires in-depth analysis of the interaction of extracellular matrix components. Preliminary results indicate the presence of a risk population with collagen metabolism disturbances that have a major effect on wound healing after gastrointestinal anastomosis.

Colonic anastomotic strength and matrix metalloproteinase activity in an experimental model of bacterial peritonitis

BACKGROUND

Clinical studies report conflicting results on the safety of primary intestinal anastomoses in the presence of peritonitis, and comprehensive experimental data are lacking. The present study investigated whether the strength of experimental colonic anastomoses is affected if surgery is performed in the presence of pre-existing bacterial peritonitis.

METHODS

Colonic anastomoses were constructed in Wistar rats 24 h after caecal ligation and puncture or a sham procedure. Anastomotic strength was assessed by measuring breaking strength and bursting pressure during the first 5 days after operation. Anastomotic hydroxyproline levels were measured and matrix metalloproteinase (MMP) activity was analysed by quantitative gelatin zymography.

RESULTS

Anastomotic strength was lowered in the presence of bacterial peritonitis but in a minor and transient way. The breaking strength was lower only immediately after construction of the anastomosis (- 15 per cent, P = 0.011) and the bursting pressure only on the third postoperative day (- 33 per cent, P = 0.038); no anastomotic dehiscence was observed. At 3 days after operation increased levels of MMP activity were observed but anastomotic hydroxyproline content was not affected by bacterial peritonitis.

CONCLUSION

The influence of bacterial peritonitis on the development of anastomotic strength is limited. This experimental finding lends support to recent clinical studies that have demonstrated the feasibility of constructing a primary anastomosis under these conditions.

Repair of full-thickness bowel injury

OBJECTIVE

Colon surgery is more and more often performed in complex situations such as after trauma, under immunosuppression, or in the elderly. Even under optimal conditions, anastomosis fails in certain situations. The objective of this study was to demonstrate the normal phases of bowel healing and to review the local and systemic factors affecting healing with special attention to critical care variables such as major surgery, acute hemorrhage, and infections.

DATA SOURCE

MEDLINE cited and/or published articles.

DESIGN

Review analysis.

RESULTS

Colon healing is a structured cascade of different phases that can be affected by a multitude of local (infection, ischemia) and systemic (diabetes, malnutrition, anemia, hypothermia, trauma) factors. The normal phases of repair, the resulting bursting pressure as an experimental index of healing, and the available published data on local and systemic factors affecting healing are summarized.

CONCLUSION

Several local and systemic factors negatively affect bowel healing; there is still a small portion of patients who fail to heal, suggesting that intrinsic factors need to be analyzed.

Understanding endoluminal gastroplications: a histopathologic analysis of intraluminal suture plications

BACKGROUND

Endoluminal gastroplication is used to treat GERD, with modest results. Little is known of the histologic reaction to endosutures. Thus, the histologic response to intraluminal plications at different penetration depths within the gastric wall was studied in an animal model.

METHODS

Intraluminal gastroplications were performed through a laparotomy in 18 New Zealand rabbits. Three sets of everted plications were placed at different penetration depths in each stomach: submucosa (SMpl), muscularis propria (Mpl), and serosa (Spl). Animals were randomized to survival times of 3, 10, or 60 days (respectively, Groups I, II, and III). Plications were compared with a grade scale for each histologic healing phase and gross inspection.

RESULTS

Fusion between folds was absent in all groups. Serosa differed from muscularis propria with respect to the proportion of samples with microscopic ischemia (67% vs. 8%; p = 0.015), remaining sutures in Group III (33% vs. 3%; p < 0.05 in a single test of significance, but correction for multiple testing removes this significance), and remaining plications in Group II (96% vs. 54%; p < 0.05 in a single test of significance, but correction for multiple testing removes this significance). All of the total and partial histologic scores for the corresponding healing phase in each group escalated with penetration depth. Overall comparison of the histologic scores showed a significant difference among the plications in the proliferation (Group II, p = 0.004) and maturation (Group II, p = 0.009) phases. Total scores also differed among the plications in Groups II (p < 0.001) and III (p < 0.001). Plications were absent in all of Group III, with Spl resulting only in a flat scar.

CONCLUSION

Everted intraluminal gastroplications do not result in fusion between folds irrespective of suture-penetration depth. A flat scar is the final outcome and appears proportional to the amount of ischemia, foreign body reaction, and suture depth.

Doxycycline improves wound strength after intestinal anastomosis in the rat

BACKGROUND

The strength of intestinal anastomoses is relatively low in the first days after operation, possibly as a result of localized degradation of the supporting matrix by enzymes from the matrix metalloproteinase (MMP) family. The aim of this study was to examine whether doxycycline, a drug known to inhibit MMP activity, could enhance anastomotic strength.

METHODS

Male Wistar rats received anastomoses in both ileum and colon. From the day before operation onwards, animals were treated daily with doxycycline (orally or subcutaneously) in a dose of 10 mg/day or with saline only. Rats were killed 1, 3, or 5 days after operation, and anastomotic bursting pressure and breaking strength were measured. At day 3, anastomotic hydroxyproline levels were measured, MMP (gelatinase) activity was analyzed by gelatin zymography, and anastomotic histology was examined.

RESULTS

Doxycycline enhanced wound strength, but only at day 3, when it was at its lowest. Subcutaneous administration of 10 mg/day increased median colonic and ileal breaking strength by 27% (P =.0019) and 104% (P =.0376), respectively. Colonic bursting pressure was increased by 93% (P =.0002). Wound histology was similar in experimental and control groups.

CONCLUSIONS

Administration of doxycycline enhances anastomotic strength and should be investigated further as a means to preserve anastomotic integrity.

Regulation of matrix metalloproteinases in a model of colonic wound healing in a rabbit

PURPOSE

Matrix metalloproteinases occur in the colon at an anastomosis but not in the normal colon. Matrix metalloproteinase synthesis can be regulated by cytokines, for example interleukin-1 beta and growth factors, such as transforming growth factor beta and basic fibroblast growth factor. The aim of this study was to investigate the regulation of matrix metalloproteinases at an anastomosis by identifying the cell types that synthesize matrix metalloproteinases, examining factors that might regulate their synthesis, determining whether they occur in an active form, and assessing the effect of suture type on these parameters.

METHODS

An anastomosis was formed in the distal colon of rabbits using either polyglactin or polydioxanone and the animals were killed six hours or seven days later. The distribution of matrix metalloproteinases and cytokines and the cell types were assessed by immunohistochemistry. Matrix metalloproteinase-2, matrix metalloproteinase-3, and matrix metalloproteinase-9 were detected also by zymography.

RESULTS

Immunohistochemistry showed that matrix metalloproteinases were restricted to the suture line. Although zymography demonstrated that matrix metalloproteinase-2 was present mainly in an active form, matrix metalloproteinase-9 and matrix metalloproteinase-3 were present in the pro-form. The active form of matrix metalloproteinase-3 occurred more often in the polydioxanone-sutured rabbits. With the exception of matrix metalloproteinase-9, the matrix metalloproteinases were synthesized by fibroblasts. Interleukin-1 beta and transforming growth factor beta were more widespread than in the normal colon and were localized adjacent to the matrix metalloproteinases. Basic fibroblast growth factor was also more widespread postoperatively but occurred deeper in the anastomosis than the matrix metalloproteinases.

CONCLUSIONS

This study has shown that interleukin-1 beta and transforming growth factor beta may regulate the synthesis of the matrix metalloproteinases by fibroblasts and that minor differences that occur in the matrix metalloproteinase profile are dependent on the suture type.