1
|
Choudhary S, Khanna S, Mantri R, Arora P. Role of Indocyanine Green Angiography in Free Flap Surgery: A Comparative Outcome Analysis of a Single-Center Large Series of 877 Consecutive Free Flaps. Indian J Plast Surg 2023; 56:208-217. [PMID: 37435339 PMCID: PMC10332904 DOI: 10.1055/s-0043-57270] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Purpose This study aims to assess and validate the role and cost-effectiveness of indocyanine green angiography (ICGA) in free flap surgery outcomes. A new intraoperative protocol of whole-body surface warming (WBSW) for all free flap surgeries during the strategic "microbreaks" is also described. Methods A retrospective analysis of 877 consecutive free flaps, performed over 12 years, is presented. The results of the ICGA group ( n = 438) were compared with the historical No-ICGA group ( n = 439), and statistical significance was calculated for three crucial flap-related adverse outcomes and cost-effectiveness. ICGA was also used as a tool to show the effect of WBSW on free flaps. Results ICGA showed a notably strong statistical significance in decreasing two outcome parameters, namely, partial flap loss and re-exploration rate. It was also cost-effective. ICGA also demonstrated the positive role of WBSW in increasing flap perfusion. Conclusions Our study shows that the usage of ICGA for intraoperative assessment of flap perfusion can significantly reduce the partial flap loss and re-exploration rate in free flap surgeries in a cost-effective manner. A new protocol of WBSW is also described and recommended to increase flap perfusion in all free flap surgeries.
Collapse
Affiliation(s)
- Sunil Choudhary
- Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
| | - Soumya Khanna
- Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
| | - Raghav Mantri
- Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
| | - Prateek Arora
- Max Institute of Reconstructive Aesthetic Cleft and Craniofacial Surgery (MIRACLES), Max Super Specialty Hospital, Saket, New Delhi, India
| |
Collapse
|
2
|
Scutigliani EM, Lobo-Cerna F, Mingo Barba S, Scheidegger S, Krawczyk PM. The Effects of Heat Stress on the Transcriptome of Human Cancer Cells: A Meta-Analysis. Cancers (Basel) 2022; 15:cancers15010113. [PMID: 36612111 PMCID: PMC9817844 DOI: 10.3390/cancers15010113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/21/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Hyperthermia is clinically applied cancer treatment in conjunction with radio- and/or chemotherapy, in which the tumor volume is exposed to supraphysiological temperatures. Since cells can effectively counteract the effects of hyperthermia by protective measures that are commonly known as the heat stress response, the identification of cellular processes that are essential for surviving hyperthermia could lead to novel treatment strategies that improve its therapeutic effects. Here, we apply a meta-analytic approach to 18 datasets that capture hyperthermia-induced transcriptome alterations in nine different human cancer cell lines. We find, in line with previous reports, that hyperthermia affects multiple processes, including protein folding, cell cycle, mitosis, and cell death, and additionally uncover expression changes of genes involved in KRAS signaling, inflammatory responses, TNF-a signaling and epithelial-to-mesenchymal transition (EMT). Interestingly, however, we also find a considerable inter-study variability, and an apparent absence of a 'universal' heat stress response signature, which is likely caused by the differences in experimental conditions. Our results suggest that gene expression alterations after heat stress are driven, to a large extent, by the experimental context, and call for a more extensive, controlled study that examines the effects of key experimental parameters on global gene expression patterns.
Collapse
Affiliation(s)
- Enzo M. Scutigliani
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Treatment and Quality of Life, 1081HV Amsterdam, The Netherlands
- Correspondence: (E.M.S.); (P.M.K.)
| | - Fernando Lobo-Cerna
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Treatment and Quality of Life, 1081HV Amsterdam, The Netherlands
| | - Sergio Mingo Barba
- ZHAW School of Engineering, University of Applied Sciences, CH 8401 Winterthur, Switzerland
- Chemistry Department, University of Fribourg, 1700 Fribourg, Switzerland
- Adolphe Merkle Institute, University of Fribourg, Chemin des Verdiers 4, 1700 Fribourg, Switzerland
| | - Stephan Scheidegger
- ZHAW School of Engineering, University of Applied Sciences, CH 8401 Winterthur, Switzerland
| | - Przemek M. Krawczyk
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Treatment and Quality of Life, 1081HV Amsterdam, The Netherlands
- Correspondence: (E.M.S.); (P.M.K.)
| |
Collapse
|
3
|
Maklad M, Emam A. Importance of Postoperative Use of External Warming Devices in Flap Reconstructive Surgery. J Hand Microsurg 2022; 14:271-275. [PMID: 36398153 PMCID: PMC9666074 DOI: 10.1055/s-0041-1727296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Flap failure, partial or complete, can have great negative impact on the patient and the reconstructive outcome. The effect of thermal regulation on flap survival is well recognized. This article focuses on the importance of external warming devices as a standard on postoperative flap care to avoid any temperature-related vascular compromise. PubMed, Medline, and EMBASE search had been performed. More than 60 papers have been reviewed. Out of them, that 29 references have been included in this review. The authors emphasize on the importance of strict postoperative flap temperature control with active warming devices as a standard of practice to minimize any related microcirculatory changes.
Collapse
Affiliation(s)
- Mohamed Maklad
- Department of Hand and Plastic Surgery, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Ahmed Emam
- Department of Plastic Surgery, Welsh Centre of Burns and Plastic Surgery, United Kingdom
| |
Collapse
|
4
|
SOGORSKI ALEXANDER, DOSTIBEGIAN MARYNA, LEHNHARDT MARCUS, WALLNER CHRISTOPH, WAGNER JOHANNESM, DADRAS MEHRAN, GLINSKI MAXIVON, KOLBENSCHLAG JONAS, BEHR BJÖRN. Postoperative Remote Ischemic Conditioning (RIC) significantly improves entire flap microcirculation beyond 4 hours. J Plast Reconstr Aesthet Surg 2022; 75:4003-4012. [DOI: 10.1016/j.bjps.2022.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 05/28/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022]
|
5
|
Effects of Preconditioning With Transcutaneous Electrical Nerve Stimulation Monitored by Infrared Thermography on the Survival of Pedicled Perforator Flaps in a Rat Model. Ann Plast Surg 2022; 89:444-450. [PMID: 35703222 DOI: 10.1097/sap.0000000000003238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pedicled perforator partial or complete necrosis with a rate of 13.7%. This study was undertaken to test whether preconditioning with transcutaneous electrical nerve stimulation (TENS) monitored by infrared thermography protect against partial necrosis by converting the choke anastomoses to the true anastomoses via inducing heme oxygenase-1 (HO-1) in a rat pedicled perforator flap model. METHODS Seventy-two Sprague-Dawley rats were randomly assigned to the control, the TENS, the TENS + SnPP (tin protoporphyrin; HO-1 activity inhibitor; 50 μmol/kg) and the TENS +0.9% saline groups. On the unilateral dorsum of the rats, a rectangular flap donor site of 11 × 3 cm was marked out, which contained three perforator angiosomes and two choke zones. On days 1, 3 and 4, 1 hour of TENS (biphasic pulses, 25 mA, 80 Hz, 200 μs) was applied to the flap donor sites, respectively. On day 5, after the flap donor sites were assessed by infrared thermography, the flaps were harvested based on the deep circumflex iliac artery perforator. RESULTS Infrared thermography showed that the choke zones in the flap donor sites presented white in the TENS and the TENS +0.9% saline groups, whereas they presented red in the control and the TENS + SnPP groups. Postmortem arteriography showed that the number of arterioles across each choke zone significantly increased in the TENS and the TENS +0.9% saline groups compared with the control and the TENS + SnPP groups. Immunohistochemistry and western blot showed a significant increase in HO-1 in the choke zones after TENS preconditioning. The necrotic area percentage of the flaps was significantly decreased in the TENS (4.3% ± 2.6%) and the TENS +0.9% saline groups (4.5% ± 2.3%) compared with the control (24.8% ± 5.0%) (P < 0.001); there was no significant difference between the TENS and the TENS + SnPP (24.4% ± 7.3%) groups. CONCLUSIONS These data show that TENS preconditioning monitored by infrared thermography might be a promising strategy to prevent pedicled perforator flaps from partial necrosis.
Collapse
|
6
|
Zheng YH, Yin LQ, Xu HK, Gong X. Non-invasive physical therapy as salvage measure for ischemic skin flap: A literature review. World J Clin Cases 2021; 9:3227-3237. [PMID: 34002132 PMCID: PMC8107891 DOI: 10.12998/wjcc.v9.i14.3227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/26/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
This review focuses on the available evidence regarding the molecular mechanisms and treatment potential of several non-surgical physical therapies for managing flap ischemia to propose a non-invasive, economical, and simple treatment to improve flap survival. A review of the literature was conducted on the topics of various non-invasive methods for the treatment of ischemic necrosis of the distal end of the flap between 1988 and 2019. A total of 52 published studies were reviewed on the applications of hyperbaric oxygen therapy, electrical stimulation therapy, heat stress pretreatment, phototherapy, and vibration therapy to manage skin flap necrosis. The underlying molecular mechanisms of these physical therapies on revitalizing the dying skin flaps were discussed and preliminary clinical uses of these therapies to salvage the necrotic skin flaps were pooled and summarized for clarifying the safety and feasibility of these methods. Various physical therapy regimens have been ushered to manage necrotic development in cutaneous flaps. With the refinement of these new technologies and enhancement of related basic science research on vascular revitalization, the prevention and treatment of flap ischemia will enter a new era.
Collapse
Affiliation(s)
- Yin-Hua Zheng
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Li-Quan Yin
- Department of Rehabilitation Medicine, The Third Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Hai-Kun Xu
- Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Xu Gong
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| |
Collapse
|
7
|
Zheng Y, Li Z, Yin M, Gong X. Heme oxygenase‑1 improves the survival of ischemic skin flaps (Review). Mol Med Rep 2021; 23:235. [PMID: 33537805 PMCID: PMC7893698 DOI: 10.3892/mmr.2021.11874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/12/2021] [Indexed: 01/17/2023] Open
Abstract
Heat shock protein 32 (Hsp32), also known as heme oxygenase‑1 (HO‑1), is an enzyme that exists in microsomes. HO‑1 can be induced by a variety of stimuli, including heavy metals, heat shock, inflammatory stimuli, heme and its derivatives, stress, hypoxia, and biological hormones. HO‑1 is the rate‑limiting enzyme of heme catabolism, which splits heme into biliverdin, carbon monoxide (CO) and iron. The metabolites of HO‑1 have anti‑inflammatory and anti‑oxidant effects, and provide protection to the cardiovascular system and transplanted organs. This review summarizes the biological characteristics of HO‑1 and the functional significance of its products, and specifically elaborates on its protective effect on skin flaps. HO‑1 improves the survival rate of ischemic skin flaps through anti‑inflammatory, anti‑oxidant and vasodilatory effects of enzymatic reaction products. In particular, this review focuses on the role of carbon monoxide (CO), one of the primary metabolites of HO‑1, in flap survival and discusses the feasibility and existing challenges of HO‑1 in flap surgery.
Collapse
Affiliation(s)
- Yinhua Zheng
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Zhenlan Li
- Department of Rehabilitation Medicine, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Min Yin
- Department of Nephrology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Xu Gong
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| |
Collapse
|
8
|
Kankam HKN, Mehta S, Jain A. Thermal Preconditioning for Surgery: A Systematic Review. J Plast Reconstr Aesthet Surg 2020; 73:1645-1664. [PMID: 32505626 DOI: 10.1016/j.bjps.2020.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/07/2020] [Accepted: 05/09/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Optimising patients pre-operatively reduces the chance of complications. This may be achieved by preconditioning. Thermal preconditioning refers to the supraphysiological heating of organisms or specific organs prior to an environmental insult. This review explores the current application and efficacy of thermal preconditioning for surgery. METHODS A comprehensive search of Medline (via PubMed), Embase and the Cochrane library was performed. Only articles evaluating the use of supraphysiological heating prior to a surgical intervention were included. Qualitative syntheses of data were undertaken due to the heterogeneity of the studies. The quality of each article was appraised using risk of bias tools (Cochrane and SYRCLE). RESULTS The primary literature search returned 3175 articles. After screening and reviewing reference lists, 28 papers met the inclusion criteria. The majority of studies were performed in animals, with only three clinical trials. Although there was broad coverage of different surgical techniques, flap transfer was the most commonly performed procedure. Most studies demonstrated a beneficial effect of thermal preconditioning, ranging from increased joint mobility to improved flap or organ transplant survival rates. The quality of evidence was variable, with experimental animal studies limited by a lack of methodological detail. CONCLUSIONS Thermal preconditioning for surgery has been primarily investigated using animal models. A beneficial effect has been demonstrated in most cases, across specialties ranging from plastic to general surgery. Future studies should aim to assess the clinical significance through large multicentre randomised controlled trials.
Collapse
Affiliation(s)
- Hadyn K N Kankam
- Department of Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Saahil Mehta
- Department of Plastic Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, UK; Department of Plastic Surgery, Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Abhilash Jain
- Department of Plastic and Reconstructive Surgery, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Botnar Research Centre Institute of Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| |
Collapse
|
9
|
Scheel-Sailer A, Aliyev N, Jud D, Annaheim S, Harder Y, Krebs J, Wildisen A, Wettstein R. Changes in skin-physiology after local heat application using two different methods in individuals with complete paraplegia: a feasibility and safety trial. Spinal Cord 2020; 58:667-674. [PMID: 31911622 DOI: 10.1038/s41393-019-0408-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 12/10/2019] [Accepted: 12/19/2019] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Interventional feasibility study. OBJECTIVES To evaluate safety and effects of local heat preconditioning on skin physiology using water-filtered infrared-A radiation (wIRA) or warm water therapy (wWT) in individuals with spinal cord injury (SCI). SETTING Acute and rehabilitation center, specialized in SCI. METHODS A convenience sample of 15 individuals (3 women, 12 men) with complete paraplegia from thoracic levels ranging between T2 and T12 received local heat applications either with wIRA or wWT on the thigh (paralyzed area) and on the upper arm (non-paralyzed area). Local heat was applied during three 30-min cycles, each separated by 30 min rest; thus, the treatment lasted for 180 min. Temperature, blood perfusion, and skin redness were measured at baseline, before and after heat application and 24 h after the last application. RESULTS Heat applications with wIRA and wWT were well-tolerated. No burns or any other side effects were detected. Skin temperature (p ≤ 0.008) and blood perfusion (p ≤ 0.013) significantly increased after heat application. Local skin temperature (arm p = 0.004/leg p < 0.001) and blood perfusion (arm p = 0.011/leg p = 0.001) after the first and the second application cycle, respectively, were significantly higher during heat application with wIRA than with wWT. However, skin redness did not change significantly (p = 0.1). No significant differences were observed between the paralyzed and non-paralyzed areas for all parameters immediately, as well as 24 h after the treatment. CONCLUSIONS Although both heating methods have been confirmed as safe treatments in this study, further investigations with regard to their efficacy in the context of preconditioning are warranted. SPONSORSHIP The use of the instruments Hydrosun® 750 Irradiator (Hydrosun Medizintechnik, Germany) and Hilotherm-Calido 6 (Hilotherm GmbH, Germany) was sponsored by the Dr. med. h. c. Erwin Braun Foundation and by Hilotherm GmbH, respectively.
Collapse
Affiliation(s)
| | | | - Dominique Jud
- Swiss Paraplegic Centre, 6207, Nottwil, Switzerland.,Faculty of Medicine, University of Basel, 4056, Basel, Switzerland
| | - Simon Annaheim
- Empa, Swiss Federal Laboratories for Biomimetic Membranes and Textiles, Laboratory for Protection and Physiology, 9014, St. Gallen, Switzerland
| | - Yves Harder
- Division of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano (ORL), Ente Ospedaliero Cantonale (EOC), 6500, Viganello-Lugano, Switzerland.,Faculty of Medicine, University of Zurich, 8091, Zurich, Switzerland
| | - Jörg Krebs
- Swiss Paraplegic Centre, 6207, Nottwil, Switzerland
| | - Alessia Wildisen
- Swiss Paraplegic Centre, 6207, Nottwil, Switzerland.,Faculty of Medicine, University of Basel, 4056, Basel, Switzerland
| | - Reto Wettstein
- Swiss Paraplegic Centre, 6207, Nottwil, Switzerland.,Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, 4031, Basel, Switzerland
| |
Collapse
|
10
|
Schmauss D, Weinzierl A, Weiss F, Egaña J, Rezaeian F, Hopfner U, Schmauss V, Machens HG, Harder Y. Long-term pre- and postconditioning with low doses of erythropoietin protects critically perfused musculocutaneous tissue from necrosis. J Plast Reconstr Aesthet Surg 2019; 72:590-599. [DOI: 10.1016/j.bjps.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 11/12/2018] [Accepted: 01/06/2019] [Indexed: 12/11/2022]
|
11
|
Mehta S, Cro SC, Coomber B, Rolph R, Cornelius V, Farhadi J. A randomised controlled feasibility trial to evaluate local heat preconditioning on wound healing after reconstructive breast surgery: the preHEAT trial. Pilot Feasibility Stud 2019; 5:5. [PMID: 30656059 PMCID: PMC6329155 DOI: 10.1186/s40814-019-0392-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/03/2019] [Indexed: 11/10/2022] Open
Abstract
Objective preHEAT was a randomised controlled feasibility trial to determine how best to measure skin necrosis in breast reconstruction to inform the design of a larger multicentre trial. Background Mastectomy skin flap necrosis (MSFN) is a serious complication resulting in prolonged wound healing. Local heat preconditioning of the MSF before surgery has been shown to reduce skin necrosis in immediate breast reconstruction patients (IBR). Method preHEAT was a single-centre, randomised control two-arm single-blind parallel arm feasibility trial of local heat preconditioning in breast cancer patients undergoing SSM and NSM at Guy’s and St Thomas’ Hospital, London, UK. All patients undergoing IBR above the age of 18 were included. Intervention patients heated breast skin to 43 °C in three, 30-min cycles interrupted by spontaneous cooling using hot water bottles. The primary aim was to compare measurement of skin necrosis using binary ‘yes/no’ assessment, the SKIN score, and wound area. Results One hundred forty-one patients were randomised over a 2-year period (71 heated group, 70 controls). There was near perfect agreement between assessors using the “yes/no” measurement of necrosis. The proportion of patients experiencing necrosis in controls was 35% (n = 23/66) in the heated 26% (n = 18/68]). In the control group, 17% (n = 4/23) patients experiencing necrosis required surgical intervention for necrosis compared to 11% (n = 2/18) in the heated group. Conclusion The binary outcome of MSFN “yes/no” is a suitable and reliable primary outcome measure of necrosis and was superior to the SKIN Score or necrosis area. The trial study design is feasible for a larger definitive trial. Trial registration ISRCTN15744669. Date of registration: 25/02/2018 Electronic supplementary material The online version of this article (10.1186/s40814-019-0392-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Saahil Mehta
- 1Department of Plastic Surgery, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK.,3Department of Plastic Surgery, Faculty of Medicine, University of Basel, Klingelbergstrasse 61, CH - 4046 Basel, Switzerland
| | - Suzie Cro Cro
- 2Imperial College Trials Unit, 1st Floor, Stadium House, 68 Wood Lane, London, W12 7RH UK
| | - Billie Coomber
- 1Department of Plastic Surgery, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Rachel Rolph
- 1Department of Plastic Surgery, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Victoria Cornelius
- 2Imperial College Trials Unit, 1st Floor, Stadium House, 68 Wood Lane, London, W12 7RH UK
| | - Jian Farhadi
- 1Department of Plastic Surgery, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK.,3Department of Plastic Surgery, Faculty of Medicine, University of Basel, Klingelbergstrasse 61, CH - 4046 Basel, Switzerland
| |
Collapse
|
12
|
Grambow E, Augustin VA, Strüder D, Kundt G, Klar E, Vollmar B. The effects of hydrogen sulfide on microvascular circulation in the axial pattern flap ear model in hairless mice. Microvasc Res 2018; 120:74-83. [PMID: 29991448 DOI: 10.1016/j.mvr.2018.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/27/2018] [Accepted: 06/27/2018] [Indexed: 01/30/2023]
Affiliation(s)
- Eberhard Grambow
- Institute for Experimental Surgery, University Medical Center Rostock, Rostock, Germany; Department for General, Thoracic-, Vascular- and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany.
| | - Vicky A Augustin
- Institute for Experimental Surgery, University Medical Center Rostock, Rostock, Germany
| | - Daniel Strüder
- Institute for Experimental Surgery, University Medical Center Rostock, Rostock, Germany; Department of Otorhinolaryngology, Head and Neck Surgery, Rostock University Medical Center, Rostock, Germany
| | - Günther Kundt
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, Rostock University Medical Center, Rostock, Germany
| | - Ernst Klar
- Department for General, Thoracic-, Vascular- and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany
| | - Brigitte Vollmar
- Institute for Experimental Surgery, University Medical Center Rostock, Rostock, Germany
| |
Collapse
|
13
|
Cro S, Mehta S, Farhadi J, Coomber B, Cornelius V. Measuring skin necrosis in a randomised controlled feasibility trial of heat preconditioning on wound healing after reconstructive breast surgery: study protocol and statistical analysis plan for the PREHEAT trial. Pilot Feasibility Stud 2018; 4:34. [PMID: 29375891 PMCID: PMC5773051 DOI: 10.1186/s40814-017-0223-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 12/21/2017] [Indexed: 11/10/2022] Open
Abstract
Background Essential strategies are needed to help reduce the number of post-operative complications and associated costs for breast cancer patients undergoing reconstructive breast surgery. Evidence suggests that local heat preconditioning could help improve the provision of this procedure by reducing skin necrosis. Before testing the effectiveness of heat preconditioning in a definitive randomised controlled trial (RCT), we must first establish the best way to measure skin necrosis and estimate the event rate using this definition. Methods PREHEAT is a single-blind randomised controlled feasibility trial comparing local heat preconditioning, using a hot water bottle, against standard care on skin necrosis among breast cancer patients undergoing reconstructive breast surgery. The primary objective of this study is to determine the best way to measure skin necrosis and to estimate the event rate using this definition in each trial arm. Secondary feasibility objectives include estimating recruitment and 30 day follow-up retention rates, levels of compliance with the heating protocol, length of stay in hospital and the rates of surgical versus conservative management of skin necrosis. The information from these objectives will inform the design of a larger definitive effectiveness and cost-effectiveness RCT. Discussion This article describes the PREHEAT trial protocol and detailed statistical analysis plan, which includes the pre-specified criteria and process for establishing the best way to measure necrosis. This study will provide the evidence needed to establish the best way to measure skin necrosis, to use as the primary outcome in a future RCT to definitively test the effectiveness of local heat preconditioning. The pre-specified statistical analysis plan, developed prior to unblinded data extraction, sets out the analysis strategy and a comparative framework to support a committee evaluation of skin necrosis measurements. It will increase the transparency of the data analysis for the PREHEAT trial. Trial registration ISRCTN ISRCTN15744669. Registered 25 February 2015 Electronic supplementary material The online version of this article (10.1186/s40814-017-0223-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Suzie Cro
- 1Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Saahil Mehta
- 2Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Jian Farhadi
- 2Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | | | - Victoria Cornelius
- 1Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| |
Collapse
|
14
|
Kolbenschlag J, Sogorski A, Timmermann C, Harati K, Daigeler A, Hirsch T, Goertz O, Lehnhardt M. Ten minutes of ischemia is superior to shorter intervals for the remote ischemic conditioning of human microcirculation. Clin Hemorheol Microcirc 2017; 66:239-248. [DOI: 10.3233/ch-170268] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- J. Kolbenschlag
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther-Hospital Berlin, Berlin, Germany
| | - A. Sogorski
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
- Department of Surgery, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - C. Timmermann
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - K. Harati
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - A. Daigeler
- Department of Plastic, Reconstructive, Hand and Burn Surgery, BG-Trauma Center, Eberhard Karls University Tübingen, Tübingen, Germany
| | - T. Hirsch
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - O. Goertz
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther-Hospital Berlin, Berlin, Germany
| | - M. Lehnhardt
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| |
Collapse
|
15
|
Remote Ischemic Conditioning Improves Blood Flow and Oxygen Saturation in Pedicled and Free Surgical Flaps. Plast Reconstr Surg 2017; 138:1089-1097. [PMID: 27391830 DOI: 10.1097/prs.0000000000002664] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Surgical flaps have become safe and reliable reconstructive tools, but total flap loss rates as high as 25 percent and partial flap loss rates as high as 36 percent have been reported due to insufficient perfusion. Therefore, a reliable, noninvasive, and effective way to improve the microcirculation of surgical flaps is desirable. The aim of this study was to assess the effect of remote ischemic conditioning on the microcirculation of pedicled and free surgical flaps. METHODS Thirty patients undergoing free (n = 20) and pedicled (n = 10) tissue transfer were included in this study. Remote ischemic conditioning was applied on the upper extremity for three cycles on postoperative days 1, 5, and 12. Blood flow, tissue oxygen saturation, and relative hemoglobin content were measured by means of a combination of laser Doppler and spectroscopy (O2C device) in the flap and the surrounding tissue. The relative increase compared with baseline measurements was assessed. RESULTS Blood flow increased significantly in controls on all 3 postoperative days (p < 0.05 for all). In free flaps, tissue oxygen saturation improved significantly on postoperative days 1 and 12 and blood flow improved significantly on postoperative days 5 and 12 (p < 0.05). In pedicled flaps, blood flow and tissue oxygen saturation increased on postoperative day12, but not significantly. CONCLUSIONS Remote ischemic conditioning is a safe, inexpensive, fast, and reliable method to improve the microcirculation of surgical flaps. Further research is warranted to see whether such an improvement translates into improved flap survival, but it is likely. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
|
16
|
Harder Y, Schmauss D, Wettstein R, Egaña JT, Weiss F, Weinzierl A, Schuldt A, Machens HG, Menger MD, Rezaeian F. Ischemic tissue injury in the dorsal skinfold chamber of the mouse: a skin flap model to investigate acute persistent ischemia. J Vis Exp 2014:e51900. [PMID: 25489743 PMCID: PMC4354003 DOI: 10.3791/51900] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Despite profound expertise and advanced surgical techniques, ischemia-induced complications ranging from wound breakdown to extensive tissue necrosis are still occurring, particularly in reconstructive flap surgery. Multiple experimental flap models have been developed to analyze underlying causes and mechanisms and to investigate treatment strategies to prevent ischemic complications. The limiting factor of most models is the lacking possibility to directly and repetitively visualize microvascular architecture and hemodynamics. The goal of the protocol was to present a well-established mouse model affiliating these before mentioned lacking elements. Harder et al. have developed a model of a musculocutaneous flap with a random perfusion pattern that undergoes acute persistent ischemia and results in ~50% necrosis after 10 days if kept untreated. With the aid of intravital epi-fluorescence microscopy, this chamber model allows repetitive visualization of morphology and hemodynamics in different regions of interest over time. Associated processes such as apoptosis, inflammation, microvascular leakage and angiogenesis can be investigated and correlated to immunohistochemical and molecular protein assays. To date, the model has proven feasibility and reproducibility in several published experimental studies investigating the effect of pre-, peri- and postconditioning of ischemically challenged tissue.
Collapse
Affiliation(s)
- Yves Harder
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München;
| | - Daniel Schmauss
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München
| | - Reto Wettstein
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel
| | - José T Egaña
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München
| | - Fabian Weiss
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München
| | - Andrea Weinzierl
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München
| | - Anna Schuldt
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München
| | - Hans-Günther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, University of Saarland
| | - Farid Rezaeian
- Division of Plastic and Hand Surgery, University Hospital Zurich
| |
Collapse
|
17
|
Edmunds MC, Czopek A, Wigmore SJ, Kluth DC. Paradoxical effects of heme arginate on survival of myocutaneous flaps. Am J Physiol Regul Integr Comp Physiol 2013; 306:R10-22. [PMID: 24089372 DOI: 10.1152/ajpregu.00240.2013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ischemia reperfusion injury (IRI) contributes to partial flap and solid organ transplant failure. Heme-oxygenase 1 (HO-1) is an inducible, cytoprotective enzyme which protects against IRI in solid organ transplant models. Heme arginate (HA), a HO-1 inducer, is a promising, translatable, preconditioning agent. This study investigated the effects of preconditioning with HA on the clinical outcome of a myocutaneous IRI model. Forty male Lewis rats were randomized to intravenously receive 1) Control-NaCl, 2) HA, 3) HA and tin mesoporphyrin (SnMP), a HO-1 inhibitor; and 4) SnMP alone. Twenty-four hours later, an in situ transverse rectus abdominis myocutaneous flap was performed under isoflurane anesthesia. Viability of flaps was measured clinically and by laser-Doppler perfusion scanning. In vitro work on human epidermal keratinocytes (HEKa) assessed the effects of HA, SnMP, and the iron chelator desferrioxamine on 1) cytotoxicity, 2) intracellular reactive oxygen species (ROS) concentration, and 3) ROS-mediated DNA damage. In contrast to our hypothesis, HA preconditioning produced over 30% more flap necrosis at 48 h compared with controls (P = 0.02). HA-containing treatments produced significantly worse flap perfusion at all postoperative time points. In vitro work showed that HA is cytotoxic to keratinocytes. This cytotoxicity was independent of HO-1 and was mediated by the generation of ROS by free heme. In contrast to solid organ data, pharmacological preconditioning with HA significantly worsened clinical outcome, thus indicating that this is not a viable approach in free flap research.
Collapse
Affiliation(s)
- Marie-Claire Edmunds
- Medical Research Council Centre for Inflammation Research, Queen's Medical Research Institute, Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; and
| | | | | | | |
Collapse
|
18
|
Tobalem M, Wettstein R, Pittet-Cuénod B, Vigato E, Machens HG, Lohmeyer JA, Rezaeian F, Harder Y. Local shockwave-induced capillary recruitment improves survival of musculocutaneous flaps. J Surg Res 2013; 184:1196-204. [DOI: 10.1016/j.jss.2013.03.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 02/26/2013] [Accepted: 03/13/2013] [Indexed: 02/06/2023]
|
19
|
Mehta S, Rolph R, Cornelius V, Harder Y, Farhadi J. Local heat preconditioning in skin sparing mastectomy: a pilot study. J Plast Reconstr Aesthet Surg 2013; 66:1676-82. [PMID: 24011908 DOI: 10.1016/j.bjps.2013.07.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 06/05/2013] [Accepted: 07/30/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Experimental data has shown an association with a reduction of flap necrosis after local heat-application to a supraphysiological level resulting from the up-regulation of heat shock proteins, such as HSP-32. The proteins maintained capillary perfusion and increased tissue tolerance to ischaemia. The purpose of this translational study was to evaluate the effect of local heat preconditioning before skin sparing mastectomy and immediate breast reconstruction. METHODS A prospective non-randomised trial was performed from July 2009-April 2010. 50 consecutive patients at risk of skin flap necrosis (BMI >30, sternal-to-nipple distance>26 cm or breast size>C-cup) were included. Twenty-five patients were asked to heat-precondition their breast 24-h prior to surgery using a hot water bottle with a water temperature of 43 °C (thermometers provided), in three 30-min cycles interrupted by spontaneous cooling to room temperature. Skin flap necrosis was defined by the need for surgical debridement. LDI images were taken pre- and post-mastectomy to demonstrate an increase in tissue vascularity. RESULTS 36% of women (n=25) without local heat-treatment developed skin flap necrosis, 12% developed skin flap necrosis in the treatment group, resulting in a 24% difference (n=25; p=0.047 (95%CI 1%-47%)). LDI scanning of the heated breast demonstrated an increase in vascularity compared to the contralateral non-heated breast. Median length of inpatient stay for treatment group was 4 days (95%CI(4, 7)), controls 8 days (95%CI(8, 9) (p=<0.001)). CONCLUSIONS The data suggests that in selected cases, local heat preconditioning is a simple and non-invasive method of reducing skin necrosis and length of hospital stay following skin sparing mastectomy. CLINICAL TRIAL REGISTRATION NUMBER ACTRN12612001197820. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Saahil Mehta
- Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom.
| | | | | | | | | |
Collapse
|
20
|
Rezaeian F, Wettstein R, Scheuer C, Bäumker K, Bächle A, Vollmar B, Menger MD, Harder Y. Ghrelin protects musculocutaneous tissue from ischemic necrosis by improving microvascular perfusion. Am J Physiol Heart Circ Physiol 2012; 302:H603-10. [DOI: 10.1152/ajpheart.00390.2010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Persistent ischemia in musculocutaneous tissue may lead to wound breakdown and necrosis. The objective of this experimental study was to analyze, whether the gastric peptide ghrelin prevents musculocutaneous tissue from necrosis and to elucidate underlying mechanisms. Thirty-two C57BL/6 mice equipped with a dorsal skinfold chamber containing ischemic musculocutaneous tissue were allocated to four groups: 1) ghrelin; 2) Nω-nitro-l-arginine methyl ester (l-NAME); 3) ghrelin and l-NAME; and 4) control. Microcirculation, inflammation, angiogenesis, and tissue survival were assessed by fluorescence microscopy. Inducible and endothelial nitric oxide synthase (iNOS I and eNOS), vascular endothelial growth factor (VEGF), as well as nuclear factor κB (NF-κB) were assessed by Western blot analysis. Ghrelin-treated animals showed an increased expression of iNOS and eNOS in critically perfused tissue compared with controls. This was associated with arteriolar dilation, increased arteriolar perfusion, and a sustained functional capillary density. Ghrelin further upregulated NF-κB and VEGF and induced angiogenesis. Finally, ghrelin reduced microvascular leukocyte-endothelial cell interactions, apoptosis, and overall tissue necrosis ( P < 0.05 vs. control). Inhibition of nitric oxide by l-NAME did not affect the anti-inflammatory and angiogenic action of ghrelin but completely blunted the ghrelin-induced tissue protection by abrogating the arteriolar dilation, the improved capillary perfusion, and the increased tissue survival. Ghrelin prevents critically perfused tissue from ischemic necrosis. Tissue protection is the result of a nitric oxide synthase-mediated improvement of the microcirculation but not due to induction of angiogenesis or attenuation of inflammation. This might represent a promising, noninvasive, and clinically applicable approach to protect musculocutaneous tissue from ischemia.
Collapse
Affiliation(s)
- F. Rezaeian
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technische Universität, Munich
| | - R. Wettstein
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - C. Scheuer
- Institute for Clinical and Experimental Surgery, University of Saarland, Homburg/Saar; and
| | - K. Bäumker
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - A. Bächle
- Institute for Clinical and Experimental Surgery, University of Saarland, Homburg/Saar; and
| | - B. Vollmar
- Institute for Experimental Surgery, University of Rostock, Rostock, Germany
| | - M. D. Menger
- Institute for Clinical and Experimental Surgery, University of Saarland, Homburg/Saar; and
| | - Y. Harder
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technische Universität, Munich
| |
Collapse
|
21
|
Rana M, von See C, Rücker M, Schumann P, Essig H, Kokemüller H, Lindhorst D, Gellrich NC. Increase in periosteal angiogenesis through heat shock conditioning. Head Face Med 2011; 7:22. [PMID: 22098710 PMCID: PMC3253043 DOI: 10.1186/1746-160x-7-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 11/18/2011] [Indexed: 11/10/2022] Open
Abstract
Objective It is widely known that stress conditioning can protect microcirculation and induce the release of vasoactive factors for a period of several hours. Little, however, is known about the long-term effects of stress conditioning on microcirculation, especially on the microcirculation of the periosteum of the calvaria. For this reason, we used intravital fluorescence microscopy to investigate the effects of heat shock priming on the microcirculation of the periosteum over a period of several days. Methods Fifty-two Lewis rats were randomized into eight groups. Six groups underwent heat shock priming of the periosteum of the calvaria at 42.5°C, two of them (n = 8) for 15 minutes, two (n = 8) for 25 minutes and two (n = 8) for 35 minutes. After 24 hours, a periosteal chamber was implanted into the heads of the animals of one of each of the two groups mentioned above. Microcirculation and inflammatory responses were studied repeatedly over a period of 14 days using intravital fluorescence microscopy. The expression of heat shock protein (HSP) 70 was examined by immunohistochemistry in three further groups 24 hours after a 15-minute (n = 5), a 25-minute (n = 5) or a 35-minute (n = 5) heat shock treatment. Two groups that did not undergo priming were used as controls. One control group (n = 8) was investigated by intravital microscopy and the other (n = 5) by immunohistochemistry. Results During the entire observation period of 14 days, the periosteal chambers revealed physiological microcirculation of the periosteum of the calvaria without perfusion failures. A significant (p < 0.05) and continuous increase in functional capillary density was noted from day 5 to day 14 after 25-minute heat shock priming. Whereas a 15-minute exposure did not lead to an increase in functional capillary density, 35-minute priming caused a significant but reversible perfusion failure in capillaries. Non-perfused capillaries in the 35-minute treatment group were reperfused by day 10. Immunohistochemistry demonstrated an increase in cytoprotective HSP70 expression in the periosteum after a 15-minute and a 35-minute heat shock pretreatment when compared with the control group. The level of HSP70 expression that was measured in the periosteum after 25 minutes of treatment was significantly higher than the levels observed after 15 or 35 minutes of heat shock exposure. Conclusion A few days after heat shock priming over an appropriate period of time, a continuous increase in functional capillary density is seen in the periosteum of the calvaria. This increase in perfusion appears to be the result of the induction of angiogenesis.
Collapse
Affiliation(s)
- Majeed Rana
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Staton CA, Reed MWR, Brown NJ. A critical analysis of current in vitro and in vivo angiogenesis assays. Int J Exp Pathol 2009; 90:195-221. [PMID: 19563606 DOI: 10.1111/j.1365-2613.2008.00633.x] [Citation(s) in RCA: 334] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The study of angiogenesis has grown exponentially over the past 40 years with the recognition that angiogenesis is essential for numerous pathologies and, more recently, with the advent of successful drugs to inhibit angiogenesis in tumours. The main problem with angiogenesis research remains the choice of appropriate assays to evaluate the efficacy of potential new drugs and to identify potential targets within the angiogenic process. This selection is made more complex by the recognition that heterogeneity occurs, not only within the endothelial cells themselves, but also within the specific microenvironment to be studied. Thus, it is essential to choose the assay conditions and cell types that most closely resemble the angiogenic disease being studied. This is especially important when aiming to translate data from in vitro to in vivo and from preclinical to the clinic. Here we critically review and highlight recent advances in the principle assays in common use including those for endothelial cell proliferation, migration, differentiation and co-culture with fibroblasts and mural cells in vitro, vessel outgrowth from organ cultures and in vivo assays such as chick chorioallantoic membrane (CAM), zebrafish, sponge implantation, corneal, dorsal air sac, chamber and tumour angiogenesis models. Finally, we briefly discuss the direction likely to be taken in future studies, which include the use of increasingly sophisticated imaging analysis systems for data acquisition.
Collapse
Affiliation(s)
- Carolyn A Staton
- Microcirculation Research Group, Academic Unit of Surgical Oncology, School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, UK.
| | | | | |
Collapse
|
23
|
Harder Y, Amon M, Schramm R, Contaldo C, Metzkow E, Matzen A, Rücker M, Vollmar B, Menger MD. Erythropoietin reduces necrosis in critically ischemic myocutaneous tissue by protecting nutritive perfusion in a dose-dependent manner. Surgery 2009; 145:372-83. [PMID: 19303985 DOI: 10.1016/j.surg.2008.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Accepted: 06/12/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Erythropoietin (Epo), the primary regulator of erythropoiesis, has recently been shown to exert antiinflammatory and antiapoptotic properties in neuronal and myocardial tissue. We herein studied whether Epo pretreatment can reduce cell death and ischemic necrosis in a chronic in vivo model. METHODS C57BL/6 mice were treated daily for 3 consecutive days with either 500 IU EPO/kg body weight (bw) (group Epo 500, n = 8) or 5000 IU EPO/kg bw (group Epo 5000, n = 8) administered intraperitoneally 24 hours before surgery. Thereafter, a random pattern myocutaneous flap subjected to acute persistent ischemia was elevated and fixed into a dorsal skinfold chamber. Flap elevation in animals receiving the water-soluble vitamin E analog Trolox (6-hydroxy-2, 5, 7, 8-tetramethylchroman-2-carboxylic acid) served as a nonspecific antiinflammatory agent control group (Tro); untreated control animals (Con) received saline only. Capillary perfusion, leukocyte-endothelial cell interaction, apoptotic cell death, and tissue necrosis were determined over a 10-day observation period using intravital multifluorescence microscopy. RESULTS Epo 5000 (44 +/- 26 cm/cm(2)) but, more noticeably, Epo 500 (116 +/- 32 cm/cm(2)) improved capillary perfusion compared with the two control groups, particularly the Con group (9 +/- 7 cm/cm(2); P < .05). The ischemia-associated leukocytic inflammation was found drastically attenuated in both Epo-pretreatment groups. Epo 500 further decreased apoptotic cell death and was effective in significantly reducing tissue necrosis (16% +/- 4% vs Tro: 48% +/- 7% and Con: 52% +/- 4%; P < .001). No angiogenic blood vessel formation could be observed in either of the Epo groups. Of interest, Epo 5000-but not Epo 500-increased systemic hematocrit. CONCLUSION Despite the lack of neovascularization, Epo pretreatment was capable of reducing ischemic tissue necrosis by protecting capillary perfusion, ie, nutrition of the tissue. Low-dose pretreatment was more effective, a result that was most likely due to the better perfusion conditions without an increase of the hematocrit values. Thus, low-dose Epo pretreatment might represent a promising strategy to protect critically perfused ischemic tissue.
Collapse
Affiliation(s)
- Yves Harder
- Institute for Clinical and Experimental Surgery, University of Saarland, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Tight Spatial and Temporal Control in Dynamic Basal to Distal Migration of Epithelial Inflammatory Responses and Infiltration of Cytoprotective Macrophages Determine Healing Skin Flap Transplants in Mice. Ann Surg 2009; 249:519-34. [DOI: 10.1097/sla.0b013e31819a8d6c] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
25
|
Abstract
Ischemia/reperfusion (I/R) is inevitable in many vascular and musculoskeletal traumas, diseases, free tissue transfers, and during time-consuming reconstructive surgeries in the extremities. Salvage of a prolonged ischemic extremity or flap still remains a challenge for the microvascular surgeon. One of the common complications after microsurgery is I/R-induced tissue death or I/R injury. Twenty years after the discovery, ischemic preconditioning has emerged as a powerful method for attenuating I/R injury in a variety of organs or tissues. However, its therapeutic expectations still need to be fulfilled. In this article, the author reviews some important experimental evidences of I/R injury and preconditioning-induced protection in the fields relevant to microsurgery.
Collapse
Affiliation(s)
- Wei Zhong Wang
- Department of Surgery, Division of Plastic Surgery, University of Nevada School of Medicine, Las Vegas, NV 89102, USA.
| |
Collapse
|
26
|
Desmons S, Delfosse C, Rochon P, Buys B, Devos P, Falgayrac G, Penel G, Mordon S. Préconditionnement laser en site osseux membraneux : mise au point d’un modèle d’étude. Ing Rech Biomed 2008. [DOI: 10.1016/j.rbmret.2008.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
27
|
An old dream revitalised: preconditioning strategies to protect surgical flaps from critical ischaemia and ischaemia-reperfusion injury. J Plast Reconstr Aesthet Surg 2008; 61:503-11. [DOI: 10.1016/j.bjps.2007.11.032] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Revised: 04/11/2007] [Accepted: 11/22/2007] [Indexed: 10/22/2022]
|
28
|
Klass MG, Gavrikov V, Krishnamoorthy M, Csete M. Heat shock proteins, endothelin, and peripheral neuronal injury. Neurosci Lett 2008; 433:188-93. [DOI: 10.1016/j.neulet.2008.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Revised: 12/16/2007] [Accepted: 01/03/2008] [Indexed: 11/28/2022]
|
29
|
Ischemia-induced up-regulation of heme oxygenase-1 protects from apoptotic cell death and tissue necrosis. J Surg Res 2008; 150:293-303. [PMID: 18262556 DOI: 10.1016/j.jss.2007.12.773] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 11/12/2007] [Accepted: 12/06/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tissues are endowed with protective mechanisms to counteract chronic ischemia. Previous studies have demonstrated that endogenous heme oxygenase (HO)-1 may protect parenchymal tissue from inflammation- and reoxygenation-induced injury. Nothing is known, however, on whether endogenous HO-1 also plays a role in chronic ischemia to protect from development of tissue necrosis. The aim of this study is, therefore, to evaluate in vivo whether endogenous HO-1 exerts protection on chronically ischemic musculocutaneous tissue, and whether this protection is mediated by an attenuation of the microcirculatory dysfunction. MATERIALS AND METHODS In C57BL/6-mice, a chronically ischemic flap was elevated and fixed into a dorsal skinfold chamber. In a second group, tin-protoporphyrin-IX was administrated to competitively block the action of HO-1. Animals without flap elevation served as controls. With the use of intravital fluorescence microscopy, microcirculation, apoptotic cell death, and tissue necrosis were analyzed over a 10-day observation period. The time course of HO-1 expression was determined by Western blotting. RESULTS Chronic ischemia induced an increase of HO-1 expression, particularly at day 1 and 3. This was associated with arteriolar dilation and hyperperfusion, which was capable of maintaining an adequate capillary perfusion density in the critically perfused central part of the flap, demarcating the distal necrosis. Inhibition of endogenous HO-1 by tin-protoporphyrin-IX completely abrogated arteriolar dilation (44.6 +/- 6.2 microm versus untreated flaps: 71.3 +/- 7.3 microm; P < 0.05) and hyperperfusion (3.13 +/- 1.29 nL/s versus 8.55 +/- 3.56 nL/s; P < 0.05). This resulted in a dramatic decrease of functional capillary density (16 +/- 16 cm/cm(2)versus 84 +/- 31 cm/cm(2); P < 0.05) and a significant increase of apoptotic cell death (585 +/- 51 cells/mm(2)versus 365 +/- 53 cells/mm(2); P < 0.05), and tissue necrosis (73% +/- 5% versus 51% +/- 5%; P < 0.001). CONCLUSION Thus, our results suggest that chronic ischemia-induced endogenous HO-1 protects ischemically endangered tissue, probably by the vasodilatory action of the HO-1-associated carbon monoxide.
Collapse
|
30
|
Contaldo C, Harder Y, Plock J, Banic A, Jakob SM, Erni D. The influence of local and systemic preconditioning on oxygenation, metabolism and survival in critically ischaemic skin flaps in pigs. J Plast Reconstr Aesthet Surg 2007; 60:1182-92. [PMID: 17428750 DOI: 10.1016/j.bjps.2007.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2006] [Accepted: 02/20/2007] [Indexed: 11/16/2022]
Abstract
Stress proteins represent a group of highly conserved intracellular proteins that provide adaptation against cellular stress. The present study aims to elucidate the stress protein-mediated effects of local hyperthermia and systemic administration of monophosphoryl lipid A (MPL) on oxygenation, metabolism and survival in bilateral porcine random pattern buttock flaps. Preconditioning was achieved 24h prior to surgery by applying a heating blanket on the operative site (n = 5), by intravenous administration of MPL at a dosage of 35 microg/kg body weight (n = 5) or by combining the two (n = 5). The flaps were monitored with laser Doppler flowmetry, polarographic microprobes and microdialysis until 5h postoperatively. Semiquantitative immunohistochemistry was performed for heat shock protein 70 (HSP70), heat shock protein 32 (also termed haem oxygenase-1, HO-1), and inducible nitrc oxide synthase (iNOS). The administration of MPL increased the impaired microcirculatory blood flow in the proximal part of the flap and partial oxygen tension in the the distal part by approximately 100% each (both P<0.05), whereas both variables remained virtually unaffected by local heat preconditioning. Lactate/pyruvate (L/P) ratio and glycerol concentration (representing cell membrane disintegration) in the distal part of the flap gradually increased to values of approximately 500 mmol/l and approximately 350 micromol/l, respectively (both P<0.01), which was substantially attenuated by heat application (P<0.01 for L/P ratio and P<0.05 for glycerol) and combined preconditioning (P<0.01 for both variables), whereas the effect of MPL was less marked (not significant). Flap survival was increased from 56% (untreated animals) to 65% after MPL (not significant), 71% after heat application (P<0.05) and 78% after both methods of preconditioning (P<0.01). iNOS and HO-1 were upregulated after each method of preconditioning (P<0.05), whereas augmented HSP70 staining was only observed after heat application (P<0.05). We conclude that local hyperthermia is more effective in preventing flap necrosis than systemic MPL administration because of enhancing the cellular tolerance to hypoxic stress, which is possibly mediated by HSP70, whereas some benefit may be obtained with MPL due to iNOS and HO-1-mediated improvement in tissue oxygenation.
Collapse
Affiliation(s)
- C Contaldo
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Inselspital University Hospital, CH 3010 Berne, Switzerland.
| | | | | | | | | | | |
Collapse
|
31
|
Ryter SW, Kim HP, Hoetzel A, Park JW, Nakahira K, Wang X, Choi AMK. Mechanisms of cell death in oxidative stress. Antioxid Redox Signal 2007; 9:49-89. [PMID: 17115887 DOI: 10.1089/ars.2007.9.49] [Citation(s) in RCA: 876] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Reactive oxygen or nitrogen species (ROS/RNS) generated endogenously or in response to environmental stress have long been implicated in tissue injury in the context of a variety of disease states. ROS/RNS can cause cell death by nonphysiological (necrotic) or regulated pathways (apoptotic). The mechanisms by which ROS/RNS cause or regulate apoptosis typically include receptor activation, caspase activation, Bcl-2 family proteins, and mitochondrial dysfunction. Various protein kinase activities, including mitogen-activated protein kinases, protein kinases-B/C, inhibitor-of-I-kappaB kinases, and their corresponding phosphatases modulate the apoptotic program depending on cellular context. Recently, lipid-derived mediators have emerged as potential intermediates in the apoptosis pathway triggered by oxidants. Cell death mechanisms have been studied across a broad spectrum of models of oxidative stress, including H2O2, nitric oxide and derivatives, endotoxin-induced inflammation, photodynamic therapy, ultraviolet-A and ionizing radiations, and cigarette smoke. Additionally ROS generated in the lung and other organs as the result of high oxygen therapy or ischemia/reperfusion can stimulate cell death pathways associated with tissue damage. Cells have evolved numerous survival pathways to counter proapoptotic stimuli, which include activation of stress-related protein responses. Among these, the heme oxygenase-1/carbon monoxide system has emerged as a major intracellular antiapoptotic mechanism.
Collapse
Affiliation(s)
- Stefan W Ryter
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
| | | | | | | | | | | | | |
Collapse
|