1
|
Mazzinari G, Rovira L, Albers-Warlé KI, Warlé MC, Argente-Navarro P, Flor B, Diaz-Cambronero O. Underneath Images and Robots, Looking Deeper into the Pneumoperitoneum: A Narrative Review. J Clin Med 2024; 13:1080. [PMID: 38398395 PMCID: PMC10889570 DOI: 10.3390/jcm13041080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/05/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Laparoscopy offers numerous advantages over open procedures, minimizing trauma, reducing pain, accelerating recovery, and shortening hospital stays. Despite other technical advancements, pneumoperitoneum insufflation has received little attention, barely evolving since its inception. We explore the impact of pneumoperitoneum on patient outcomes and advocate for a minimally invasive approach that prioritizes peritoneal homeostasis. The nonlinear relationship between intra-abdominal pressure (IAP) and intra-abdominal volume (IAV) is discussed, emphasizing IAP titration to balance physiological effects and surgical workspace. Maintaining IAP below 10 mmHg is generally recommended, but factors such as patient positioning and surgical complexity must be considered. The depth of neuromuscular blockade (NMB) is explored as another variable affecting laparoscopic conditions. While deep NMB appears favorable for surgical stillness, achieving a balance between IAP and NMB depth is crucial. Temperature and humidity management during pneumoperitoneum are crucial for patient safety and optical field quality. Despite the debate over the significance of temperature drop, humidification and the warming of insufflated gas offer benefits in peritoneal homeostasis and visual clarity. In conclusion, there is potential for a paradigm shift in pneumoperitoneum management, with dynamic IAP adjustments and careful control of insufflated gas temperature and humidity to preserve peritoneal homeostasis and improve patient outcomes in minimally invasive surgery.
Collapse
Affiliation(s)
- Guido Mazzinari
- Perioperative Medicine Research Group, Health Research Institute la Fe, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain; (P.A.-N.); (O.D.-C.)
- Department of Anesthesiology, La Fe University Hospital, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain
- Department of Statistics and Operational Research, University of Valencia, Calle Doctor Moliner 50, 46100 Burjassot, Spain
| | - Lucas Rovira
- Department of Anesthesiology, Consorcio Hospital General Universitario de Valencia, Av. de les Tres Creus, 2, L’Olivereta, 46014 València, Spain; (L.R.); (B.F.)
| | - Kim I. Albers-Warlé
- Department of Colorectal Surgery, La Fe University Hospital, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain;
- Department of Anesthesiology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Michiel C. Warlé
- Departments of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands;
| | - Pilar Argente-Navarro
- Perioperative Medicine Research Group, Health Research Institute la Fe, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain; (P.A.-N.); (O.D.-C.)
| | - Blas Flor
- Department of Anesthesiology, Consorcio Hospital General Universitario de Valencia, Av. de les Tres Creus, 2, L’Olivereta, 46014 València, Spain; (L.R.); (B.F.)
| | - Oscar Diaz-Cambronero
- Perioperative Medicine Research Group, Health Research Institute la Fe, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain; (P.A.-N.); (O.D.-C.)
- Department of Anesthesiology, La Fe University Hospital, Avenida Fernando Abril Martorell 106, 46026 Valencia, Spain
| |
Collapse
|
2
|
Serrano AB, Díaz-Cambronero Ó, Montiel M, Molina J, Núñez M, Mendía E, Mané MN, Lisa E, Martínez-Botas J, Gómez-Coronado D, Gaetano A, Casarejos MJ, Gómez A, Sanjuanbenito A. Impact of Standard Versus Low Pneumoperitoneum Pressure on Peritoneal Environment in Laparoscopic Cholecystectomy. Randomized Clinical Trial. Surg Laparosc Endosc Percutan Tech 2024; 34:1-8. [PMID: 37963307 DOI: 10.1097/sle.0000000000001244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 10/05/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND High CO 2 pneumoperitoneum pressure during laparoscopy adversely affects the peritoneal environment. This study hypothesized that low pneumoperitoneum pressure may be linked to less peritoneal damage and possibly to better clinical outcomes. MATERIALS AND METHODS One hundred patients undergoing scheduled laparoscopic cholecystectomy were randomized 1:1 to low or to standard pneumoperitoneum pressure. Peritoneal biopsies were performed at baseline time and 1 hour after peritoneum insufflation in all patients. The primary outcome was peritoneal remodeling biomarkers and apoptotic index. Secondary outcomes included biomarker differences at the studied times and some clinical variables such as length of hospital stay, and quality and safety issues related to the procedure. RESULTS Peritoneal IL6 after 1 hour of surgery was significantly higher in the standard than in the low-pressure group (4.26±1.34 vs. 3.24±1.21; P =0.001). On the contrary, levels of connective tissue growth factor and plasminogen activator inhibitor-I were higher in the low-pressure group (0.89±0.61 vs. 0.61±0.84; P =0.025, and 0.74±0.89 vs. 0.24±1.15; P =0.028, respectively). Regarding apoptotic index, similar levels were found in both groups and were 44.0±10.9 and 42.5±17.8 in low and standard pressure groups, respectively. None of the secondary outcomes showed differences between the 2 groups. CONCLUSIONS Peritoneal inflammation after laparoscopic cholecystectomy is higher when surgery is performed under standard pressure. Adhesion formation seems to be less in this group. The majority of patients undergoing surgery under low pressure were operated under optimal workspace conditions, regardless of the surgeon's expertise.
Collapse
Affiliation(s)
| | - Óscar Díaz-Cambronero
- Department of Anesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politécnic La Fe, Valencia, Spain
- EuroPeriscope: The ESA-IC Onco-Anaesthesiology Research Group
| | | | | | | | | | | | | | | | | | - Andrea Gaetano
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid
| | | | | | | |
Collapse
|
3
|
Sampurno S, Chittleborough TJ, Carpinteri S, Hiller J, Heriot A, Lynch AC, Ramsay RG. Modes of carbon dioxide delivery during laparoscopy generate distinct differences in peritoneal damage and hypoxia in a porcine model. Surg Endosc 2020; 34:4395-4402. [PMID: 31624943 DOI: 10.1007/s00464-019-07213-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Insufflation with CO2 can employ continuous flow, recirculated gas and/or additional warming and humidification. The ability to compare these modes of delivery depends upon the assays employed and opportunities to minimize subject variation. The use of pigs to train colorectal surgeons provided an opportunity to compare three modes of CO2 delivery under controlled circumstances. METHODS Sixteen pigs were subjected to rectal resection, insufflated with dry-cold CO2 (DC-CO2) (n = 5), recirculated CO2 by an AirSeal device (n = 5) and humidification and warming (HW-CO2) by a HumiGard device (n = 6). Peritoneal biopsies were harvested from the same region of the peritoneum for fixation for immunohistochemistry for hypoxia-inducible factor 1 alpha (HIF-1α) and scanning electron microscopy (SEM) to evaluate hypoxia induction or tissue/cellular damage, respectively. RESULTS DC-CO2 insufflation by both modes leads to significant damage to mesothelial cells as measured by cellular bulging and retraction as well as microvillus shortening compared with HW-CO2 at 1 to 1.5 h. DC-CO2 also leads to a rapid and significant induction of HIF-1α compared with HW-CO2. CONCLUSIONS DC-CO2 insufflation induces substantive cellular damage and hypoxia responses within the first hour of application. The use of HW-CO2 insufflation ameliorates these processes for the first one to one and half hours in a large mammal used to replicate surgery in humans.
Collapse
Affiliation(s)
- Shienny Sampurno
- Peter MacCallum Cancer Centre and The Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Timothy J Chittleborough
- Peter MacCallum Cancer Centre and The Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Sandra Carpinteri
- Peter MacCallum Cancer Centre and The Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Jonathan Hiller
- Peter MacCallum Cancer Centre and The Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Alexander Heriot
- Peter MacCallum Cancer Centre and The Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Andrew Craig Lynch
- Peter MacCallum Cancer Centre and The Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Robert George Ramsay
- Peter MacCallum Cancer Centre and The Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia. .,Differentiation and Transcription Laboratory, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia.
| |
Collapse
|
4
|
Makanyengo SO, Carroll GM, Goggins BJ, Smith SR, Pockney PG, Keely S. Systematic Review on the Influence of Tissue Oxygenation on Gut Microbiota and Anastomotic Healing. J Surg Res 2020; 249:186-196. [PMID: 31986361 DOI: 10.1016/j.jss.2019.12.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/04/2019] [Accepted: 12/06/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leak rates have not improved over several decades despite improvements in surgical techniques and patient care. The gut microbiome has been implicated in the development of leaks. The exact mechanisms by which tissue oxygenation affects gut microbial composition and anastomotic healing physiology are unclear. Also, commonly used carbon dioxide (CO2) is a known vasodilator that improves tissue oxygen tension. We performed a systematic review to determine the influence of hyperoxia, hypoxia, and hypercapnia on the gut microbiome and anastomotic healing. METHODS A literature search was performed in MEDLINE, EMBASE, and COCHRANE to identify studies investigating the effects of hyperoxia, hypoxia, and hypercapnia on anastomotic healing and gut microbiota published between 1998 and 2018. Two reviewers screened the articles for eligibility and quality. Fifty-three articles underwent full text review, and a narrative synthesis was undertaken. RESULTS Hyperoxia is associated with better anastomotic healing, increased gastrointestinal oxygen tension, and may reduce gut anaerobes. Hypoxia is associated with poor healing and increased gut anaerobes. However, it is unclear if hypoxia is the most important predictor of anastomotic leaks. Low pressure CO2 pneumoperitoneum and mild systemic hypercapnia are both associated with increased gastrointestinal oxygen tension and may improve anastomotic healing. We found no studies which investigated the effect of hypercapnia on gut microbiota in the context of anastomotic healing. CONCLUSIONS Tissue oxygenation influences gut anastomotic healing, but little evidence exists to demonstrate the influence on the gut microbiome in the context of healing. Further studies are needed to determine if anastomotic microbiome changes with altered tissue oxygenation and if this affects healing and leak rates. If confirmed, altering tissue oxygenation through hyperoxia or hypercapnia could be feasible means of altering the microbiome such that anastomotic leak rates reduce.
Collapse
Affiliation(s)
- Samwel O Makanyengo
- Department of Surgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia; School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia.
| | - Georgia M Carroll
- Department of Surgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia; School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Bridie J Goggins
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Stephen R Smith
- Department of Surgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Peter G Pockney
- Department of Surgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Simon Keely
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| |
Collapse
|
5
|
Wilson RB. Morpheus and the Underworld-Interventions to Reduce the Risks of Opioid Use After Surgery: ORADEs, Dependence, Cancer Progression, and Anastomotic Leakage. J Gastrointest Surg 2019; 23:1240-1249. [PMID: 30937715 DOI: 10.1007/s11605-019-04167-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perioperative pain management is a key element of enhanced recovery after surgery (ERAS) programs. A multimodal approach to analgesia as part of a coordinated ERAS includes the reduction of opioid use. This review aims to discuss opioid-related adverse events, strategies to reduce opioid use after surgery, and the relevance to the present "opioid crisis" in North America. METHODS A literature review of the pharmacology of opioid drugs, perioperative opioid reduction strategies, and the potential public health benefit was performed. This included current ERAS guidelines on multimodal analgesia, randomized controlled trials on perioperative analgesia, and intervention studies to decrease opioid use, misuse, and diversion in North America. RESULTS Reduction of perioperative opioid usage has been endorsed by joint clinical practice guidelines on the management of postoperative pain from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists. Interventions as part of an "opioid bundle" that can be incorporated into ERAS protocols include multimodal analgesia, regional anesthesia, opioid sparing drugs, carbon dioxide humidification during laparoscopy, changing opioid prescription practices, patient and physician education, and proper disposal of unused opioid medications. CONCLUSION There are substantial benefits in incorporating opioid reduction strategies into ERAS and clinical practice guidelines. These include faster return of function and mobility, and decreased opioid-related adverse drug events (ORADEs), postoperative morbidity and mortality, and length of hospital stay. Improved oncological outcomes after cancer surgery may be an additional benefit. Evidence-based interventions can also reduce opioid abuse and diversion in the community.
Collapse
Affiliation(s)
- Robert Beaumont Wilson
- Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Suite 6, Level 2, 171 Bigge St, Liverpool, Sydney, NSW, 2170, Australia.
| |
Collapse
|
6
|
Wilson RB, Solass W, Archid R, Weinreich FJ, Königsrainer A, Reymond MA. Resistance to anoikis in transcoelomic shedding: the role of glycolytic enzymes. Pleura Peritoneum 2019; 4:20190003. [PMID: 31198853 PMCID: PMC6545877 DOI: 10.1515/pp-2019-0003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 02/26/2019] [Indexed: 02/07/2023] Open
Abstract
Detachment of cells from the extracellular matrix into the peritoneal cavity initiates a cascade of metabolic alterations, leading usually to cell death by apoptosis, so-called anoikis. Glycolytic enzymes enable the switch from oxidative phosphorylation to aerobic glycolysis and allow resistance to anoikis of shed tumour cells. These enzymes also have moonlighting activities as protein kinases and transcription factors. Phosphoglycerate kinase (PGK) and pyruvate kinase are the only glycolytic enzymes generating ATP in the hexokinase pathway. Hypoxia, EGFR activation, expression of K-Ras G12V and B-Raf V600E induce mitochondrial translocation of phosphoglycerate kinase 1 (PGK1). Mitochondrial PGK1 acts as a protein kinase to phosphorylate pyruvate dehydrogenase kinase 1 (PDHK1), reducing mitochondrial pyruvate utilization, suppressing reactive oxygen species production, increasing lactate production and promoting tumourigenesis. PGK1 also plays a role as a transcription factor once transported into the nucleus. Resistance to anoikis is also facilitated by metabolic support provided by cancer-associated fibroblasts (CAFs). Our series of experiments in-vitro and in the animal model showed that PGK1 knock-out or inhibition is effective in controlling development and growth of peritoneal metastasis (PM) of gastric origin, establishing a causal role of PGK1 in this development. PGK1 also increases CXCR4 and CXCL12 expression, which is associated with a metastatic phenotype and plays a role in the metastatic homing of malignant cells. Thus, PGK1, its modulators and target genes may be exploited as therapeutic targets for preventing development of PM and for enhancing cytotoxic effects of conventional systemic chemotherapy.
Collapse
Affiliation(s)
- Robert B. Wilson
- Department of Surgery, University of South New Wales, Sydney, Australia
- Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Elizabeth St, Liverpool, Sydney, New South Wales, Australia
| | - Wiebke Solass
- Institute of Pathology, University of Tübingen, Tübingen, Germany
| | - Rami Archid
- Department of General and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | | | - Alfred Königsrainer
- Department of General and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Marc A. Reymond
- Department of General and Transplant Surgery, University of Tübingen, Tübingen, Germany
| |
Collapse
|
7
|
Michel R, Poirier L, van Poelvoorde Q, Legagneux J, Manassero M, Corté L. Interfacial fluid transport is a key to hydrogel bioadhesion. Proc Natl Acad Sci U S A 2019; 116:738-743. [PMID: 30602456 PMCID: PMC6338857 DOI: 10.1073/pnas.1813208116] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Attaching hydrogels to soft internal tissues is a key to the development of a number of biomedical devices. Nevertheless, the wet nature of hydrogels and tissues renders this adhesion most difficult to achieve and control. Here, we show that the transport of fluids across hydrogel-tissue interfaces plays a central role in adhesion. Using ex vivo peeling experiments on porcine liver, we characterized the adhesion between model hydrogel membranes and the liver capsule and parenchyma. By varying the contact time, the tissue hydration, and the swelling ratio of the hydrogel membrane, a transition between two peeling regimes is found: a lubricated regime where a liquid layer wets the interface, yielding low adhesion energies (0.1 J/m2 to 1 J/m2), and an adhesive regime with a solid binding between hydrogel and tissues and higher adhesion energies (1 J/m2 to 10 J/m2). We show that this transition corresponds to a draining of the interface inducing a local dehydration of the tissues, which become intrinsically adhesive. A simple model taking into account the microanatomy of tissues captures the transition for both the liver capsule and parenchyma. In vivo experiments demonstrate that this effect still holds on actively hydrated tissues like the liver capsule and show that adhesion can be strongly enhanced when using superabsorbent hydrogel meshes. These results shed light on the design of predictive bioadhesion tests as well as on the development of improved bioadhesive strategies exploiting interfacial fluid transport.
Collapse
Affiliation(s)
- Raphaël Michel
- Ecole Supérieure de Physique et Chimie Industrielle de la Ville de Paris (ESPCI Paris), Paris Sciences et Lettres Research University, Laboratoire Matière Molle et Chimie, CNRS UMR 7167, 75005 Paris, France;
- MINES ParisTech, Paris Sciences et Lettres Research University, Centre des Matériaux, CNRS UMR 7633, 91003 Evry, France
| | - Léna Poirier
- Ecole Supérieure de Physique et Chimie Industrielle de la Ville de Paris (ESPCI Paris), Paris Sciences et Lettres Research University, Laboratoire Matière Molle et Chimie, CNRS UMR 7167, 75005 Paris, France
| | - Quentin van Poelvoorde
- Ecole Supérieure de Physique et Chimie Industrielle de la Ville de Paris (ESPCI Paris), Paris Sciences et Lettres Research University, Laboratoire Matière Molle et Chimie, CNRS UMR 7167, 75005 Paris, France
| | - Josette Legagneux
- Ecole de Chirurgie, Agence Générale des Équipements et Produits de Santé, Assistance Publique-Hôpitaux de Paris, 75005 Paris, France
| | - Mathieu Manassero
- Service de Chirurgie, Ecole Nationale Vétérinaire d'Alfort, 94700 Maisons-Alfort, France
- Laboratoire de Bioingénierie et Bioimagerie Ostéo-Articulaire, CNRS UMR 7052, 75010 Paris, France
| | - Laurent Corté
- Ecole Supérieure de Physique et Chimie Industrielle de la Ville de Paris (ESPCI Paris), Paris Sciences et Lettres Research University, Laboratoire Matière Molle et Chimie, CNRS UMR 7167, 75005 Paris, France;
- MINES ParisTech, Paris Sciences et Lettres Research University, Centre des Matériaux, CNRS UMR 7633, 91003 Evry, France
| |
Collapse
|
8
|
Wilson RB. Hypoxia, cytokines and stromal recruitment: parallels between pathophysiology of encapsulating peritoneal sclerosis, endometriosis and peritoneal metastasis. Pleura Peritoneum 2018; 3:20180103. [PMID: 30911653 PMCID: PMC6405013 DOI: 10.1515/pp-2018-0103] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/01/2018] [Indexed: 02/06/2023] Open
Abstract
Peritoneal response to various kinds of injury involves loss of peritoneal mesothelial cells (PMC), danger signalling, epithelial-mesenchymal transition and mesothelial-mesenchymal transition (MMT). Encapsulating peritoneal sclerosis (EPS), endometriosis (EM) and peritoneal metastasis (PM) are all characterized by hypoxia and formation of a vascularized connective tissue stroma mediated by vascular endothelial growth factor (VEGF). Transforming growth factor-β1 (TGF-β1) is constitutively expressed by the PMC and plays a major role in the maintenance of a transformed, inflammatory micro-environment in PM, but also in EPS and EM. Persistently high levels of TGF-β1 or stimulation by inflammatory cytokines (interleukin-6 (IL-6)) induce peritoneal MMT, adhesion formation and fibrosis. TGF-β1 enhances hypoxia inducible factor-1α expression, which drives cell growth, extracellular matrix production and cell migration. Disruption of the peritoneal glycocalyx and exposure of the basement membrane release low molecular weight hyaluronan, which initiates a cascade of pro-inflammatory mediators, including peritoneal cytokines (TNF-α, IL-1, IL-6, prostaglandins), growth factors (TGF-α, TGF-β, platelet-derived growth factor, VEGF, epidermal growth factor) and the fibrin/coagulation cascade (thrombin, Tissue factor, plasminogen activator inhibitor [PAI]-1/2). Chronic inflammation and cellular transformation are mediated by damage-associated molecular patterns, pattern recognition receptors, AGE-RAGE, extracellular lactate, pro-inflammatory cytokines, reactive oxygen species, increased glycolysis, metabolomic reprogramming and cancer-associated fibroblasts. The pathogenesis of EPS, EM and PM shows similarities to the cellular transformation and stromal recruitment of wound healing.
Collapse
Affiliation(s)
- Robert Beaumont Wilson
- Upper GI Surgery Department, Liverpool Hospital, Elizabeth St, Liverpool, 2170, NSW, Australia
| |
Collapse
|