Elevated peritoneal soluble endoglin and GDF-15 in infertile women with severe endometriosis and pelvic adhesion.

OBJECTIVES: Chronic inflammation and pelvic adhesion play a critical role in endometriosis-related infertility. Research studies suggest that TGF-ß superfamily members, such as soluble endoglin (sEng), growth differentiation factor 15 (GDF-15) and tumor growth factor-beta (TGF-ß1) contribute to the regulation of inflammation, angiogenesis and cell adhesion. The objective of this study is to investigate the association between the concentrations of these TGF-ß-related members and the clinical parameters of infertile women with endometriosis. MATERIALS AND METHODS: Sixty-five infertile women who underwent laparoscopy were divided into two groups in this study: those who had endometriosis (n = 33) and control subjects with benign gynecologic disorders (n = 32). The levels of TGF-ß- related members in peritoneal fluid and serum were evaluated by the enzyme-linked immunosorbent assay (ELISA). Clinical and hematological parameters were documented and analyzed. RESULTS: Endometriosis cases had significantly higher levels of sEng, GDF-15 and TGF-ß1 in peritoneal fluid (p<0.0005) compared to control subjects, but not in serum. Moreover, serum GDF-15 level was significantly elevated in the late-stage endometriosis compared to the early-stage group. The levels of three TGF-ß related molecules in peritoneal fluid showed positive correlations with rASRM score. Blood neutrophil counts have correlation with the peritoneal sEng concentration. CONCLUSION: Our novel evidence on the elevated concentration of peritoneal sEng and GDF-15 in endometriosis, specifically in the late-stage, may indicate the essential role of TGF-ß-dependent signaling in endometriosis. Serum GDF-15 might serve as a candidate biomarker for endometriosis severity. Further studies are warranted to investigate the role and regulation of these molecules in endometriosis.

Practical considerations in the use of a porcine model (Sus scrofa domesticus) to assess prevention of postoperative peritubal adhesions.

Infertility has been a common postoperative problem caused by peritoneal adhesions. Since several prophylactic agents have recently shown promising preliminary results, more complete studies comparing their real efficacy and safety are needed urgently. The aim of this study was to investigate and describe practical considerations of a porcine model that can be used to assess such prophylactic agents. First, 10 healthy 5½ months old female pigs (24.3-31.3 Kg) underwent a standardized laparoscopy to provoke peritubal adhesion formation without prophylactic agents. After 30 days, a second-look laparoscopy was performed to evaluate adhesions and perform adnexectomy for histopathological evaluation. Adhesions at different sites were classified by grade, for which the scores range from 0 (no adhesion) to 3 (very strong vascularized adhesions), and also by area, with scores ranging from 0 (no adhesion) to 4 (>75% of the injured area). The histopathological evaluation of the distal uterine horns, oviducts and ovaries were compared withthose from a control group of six healthy pigs with no previous surgery. Biological samples were collected to assess vitality, inflammation and renal, hepatic and hematopoietic systems. There were small (but significant) changes in serum albumin (P = 0.07), globulin (P = 0.07), C-reactive protein (P = 0.011), fibrinogen (P = 0.023) and bilirubin (P<0.01) after 30 days, but all values were within the normal range. No inflammation or abscess formation was observed, but different degrees of adhesion were identified. The estimated occurrence of adhesion (scores >0) and of strong / very strong adhesion (scores >1) was 75% (95% CI: 55-94.9) and 65% (95% CI: 45-85), respectively. The porcine model represents a useful animal platform that can be used to test the efficacy and safety of candidate prophylactic agents intended to prevent postoperative peritubal adhesions formation. We present several practical considerations and measures that can help to minimize animal suffering and avoid problems during such experiments.

Correlation of preoperative biomarkers with severity of adhesion in endometriosis.

This study was undertaken to evaluate the correlation between preoperative Serum markers and pelvic adhesions in endometriosis patients and to explore the markers' clinical value for outcome prediction. Preoperative blood Serum and CA 125 results were obtained and pelvic adhesion scores were calculated. The patient group with adhesion scores less than 28 points was defined as the mild adhesion group, and those with a score of 28 or more were members of the severe adhesion group. The CA 125 level was significantly higher in the severe adhesion group than in the mild adhesion group. The CA 125 level, size of the largest cyst, and WBC count were associated with the level of pelvic adhesion. Adhesion scores were significantly higher in the CA 125 ≥ 35 U/mL group than in the CA 125 < 35 U/mL group. Patients with a preoperative CA 125 level higher than 35 U/mL are at high risk for pelvic adhesion.

TGF-ß and inflammatory blood markers in prediction of intraperitoneal adhesions.

PURPOSE: Intraperitoneal adhesions (IA) develop as a consequence of the healing process in peritoneum injured during surgeries. IA might be formed after all types of surgical interventions regardless the surgical approach with a higher incidence in obese individuals. Here we determine the diagnostic power of TGF-ß and blood inflammatory parameters in the prediction of IA in obese patients undergoing second surgical intervention. MATERIALS AND METHODS: Eighty patients were divided into groups according to body mass index (BMI) values and presence of intraperitoneal adhesions (IA). Evaluation of peritoneal adhesion index (PAI), serum TGF-ß and blood inflammatory parameters was performed. RESULTS: Level of TGF-ß, C-reactive protein (CRP), leukocytes, neutrophil to lymphocyte ratio and platelet to lymphocyte ratio were significantly higher in obese patients while TGF-ß, CRP, and leukocytes were higher in patients with IA. There was a significant correlation between PAI values and TGF-ß concentration (p<0.001; r=0.869) in IA group. CONCLUSIONS: The preoperative TGF-ß concentration, BMI, CRP and NLR could be strong predictors of intraperitoneal adhesions in patients with the history of surgeries.

Peritoneal adhesion prevention with a biodegradable and injectable N,O-carboxymethyl chitosan-aldehyde hyaluronic acid hydrogel in a rat repeated-injury model.

Postoperative peritoneal adhesion is one of the serious issues because it induces severe clinical disorders. In this study, we prepared biodegradable and injectable hydrogel composed of N,O-carboxymethyl chitosan (NOCC) and aldehyde hyaluronic acid (AHA), and assessed its anti-adhesion effect in a rigorous and severe recurrent adhesion model which is closer to clinical conditions. The flexible hydrogel, which gelated in 66 seconds at 37 °C, was cross-linked by the schiff base derived from the amino groups of NOCC and aldehyde groups in AHA. In vitro cytotoxicity test showed the hydrogel was non-toxic. In vitro and in vivo degradation examinations demonstrated the biodegradable and biocompatibility properties of the hydrogel. The hydrogel discs could prevent the invasion of fibroblasts, whereas fibroblasts encapsulated in the porous 3-dimensional hydrogels could grow and proliferate well. Furthermore, the hydrogel was applied to evaluate the anti-adhesion efficacy in a more rigorous recurrent adhesion model. Compared with normal saline group and commercial hyaluronic acid (HA) hydrogel, the NOCC-AHA hydrogel exhibited significant reduction of peritoneal adhesion. Compared to control group, the blood and abdominal lavage level of tPA was increased in NOCC-AHA hydrogel group. These findings suggested that NOCC-AHA hydrogel had a great potential to serve as an anti-adhesion candidate.

Hyperbaric oxygen therapy improves colorectal anastomotic healing.

PURPOSE: Hyperbaric oxygen treatment (HBOT) has been found to improve the healing of poorly oxygenated tissues. This study aimed to investigate the influence of HBOT on the healing in ischemic colorectal anastomosis. METHODS: Forty Wistar rats were randomly divided into a treatment group that received HBOT for 10 consecutive days (7 days before and 3 days after surgery), or in a control group, which did not receive the therapy. Colectomy with an ischemic anastomosis was performed in all rats. In each group, the rats were followed for 3 or 7 days after surgery to determine the influence of HBOT on anastomotic healing. RESULTS: Five rats from each group died during follow-up. No anastomotic dehiscence was seen in the HBOT group, compared to 37.5 % and 28.6 % dehiscence in the control group on postoperative day (POD) 3 and 7, respectively. The HBOT group had a significantly higher bursting pressure (130.9 ± 17.0 mmHg) than the control group (88.4 ± 46.7 mmHg; p = 0.03) on POD 3. On POD 3 and POD 7, the adhesion severity was significantly higher in the control groups than in the HBOT groups (p < 0.005). Kidney function (creatinine level) of the HBOT group was significantly better than of the control group on POD 7 (p = 0.001). Interestingly, a significantly higher number of CD206+ cells (marker for type 2 macrophages) was observed in the HBOT group at the anastomotic area on POD 3. CONCLUSION: Hyperbaric oxygen enhanced the healing of ischemic anastomoses in rats and improved the postoperative kidney function.

Effects of alpha lipoic acid on intra-abdominal adhesion: an experimental study in a rat model.

BACKGROUND: This study was performed to determine the effect of alpha lipoic acid, a powerful antioxidant, on intra-abdominal adhesion formation. METHODS: Twenty-four female Wistar Albino rats weighing 250-300 g were used in this study conducted on three groups consisting of the alpha lipoic acid group (Group I, n=8), control group (Group II, n=8), and sham group (Group III, n=8). After performing laparotomy with a midline incision under general anesthesia, the adhesion model was created on the antimesenteric side of the caecum in Group I and Group II. 50 mg/kg alpha-lipoic acid was administered intraperitoneally (IP) in Group I while the surgical procedure was performed but no drugs administered in Group II. Only laparotomy was performed in Group III. Rats were sacrificed at the end of the tenth day. RESULTS: Macroscopic scoring was performed, tissue samples were obtained and subjected to biochemical and histopathological evaluation. The degree of adhesion and malondialdehyde level decreased (p<0.01), and glutathione levels had increased (p<0.01) in Group I compared to Group II in macroscopic scoring. CONCLUSION: Alpha lipoic acid was found to significantly decrease (p<0.01) intra-abdominal adhesion when administered IP compared to the control group.

Locally increased concentrations of inflammatory cytokines in an experimental intraabdominal adhesion model.

BACKGROUND: Peritoneal adhesions may cause bowel obstruction, infertility, and pain. This study investigated cytokines, proteins and growth factors thought to promote formation of adhesions in an experimental intraabdominal adhesion model. METHODS: Male Sprague-Dawley rats were subjected to laparotomy, cecal abrasion, and construction of a small bowel anastomosis and examined at various time points after surgery. Concentrations of cytokines and growth factors in plasma and peritoneal fluid were analyzed using electrochemoluminescence and quantitative sandwich enzyme immunoassay technique. RESULTS: Concentrations of interleukin-6 (IL-6), interleukin-1beta (IL-1ß), and tumor necrosis factor alpha (TNF-α) increased in peritoneal fluid from 6h after incision. Plasma concentrations of IL-6 increased at 6h, but plasma concentrations of IL-1ß and TNF-α remained low. Peritoneal fluid concentrations of platelet-derived growth factor-BB (PDGF-BB), transforming growth factor beta1 (TGF-ß1), vascular endothelial growth factor (VEGF), tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) were below detection levels at all time points. CONCLUSION: Early elevations of IL-6, IL-1ß, and TNF-α concentrations in peritoneal fluid correlated to adhesion formation in this rodent model. Our model is relevant and reproducible, suitable for intervention, and indicates that antiadhesion strategies should be early, local and not systemic.

[Prophylaxis of adhesive process in patients with extended peritonitis].

The results of treatment of 378 patients, suffering extended peritonitis, were analyzed. For prophylaxis of adhesions formation intraoperatively an adequate surgical correction and measures, directed on elimination of endotoxicosis, were applied; postoperatively--the preparations, suppressing the adhesions formation, were applied. Conduction of intracorporeal and extracorporeal therapy extremely high frequency irradiation in complex of treatment have promoted a trustworthy improvement of motor-evacuatory function stomach and intestinal due to impact on system of coagulation and blockade of the oxidative reactions cascade, as well as due to bacteriostatic effect.

Hypothermia decreases postoperative intra-abdominal adhesion formation.

BACKGROUND: Hypothermia may decrease postoperative intra-abdominal adhesion. We sought to determine the most suitable temperature for hypothermia for decreasing postoperative adhesion formation. METHODS: One hundred and twenty male BALB/c mice weighing 25 to 30 g were randomized into 5 groups: adhesion model with infusion of cold saline at (I) 15°C; (II) 10°C; or (III) 4°C; (IV) adhesion model without infusion of saline; and (V) sham operation without infusion of saline. Adhesion scores, incidence of adhesion, and serum cytokine levels were measured at postoperative days 1, 3, 7, and 14. RESULTS: Adhesion scores among groups I, II, and III did not differ significantly. Interleukin-6 was significantly decreased in groups I, II, and III, compared to the levels in groups IV and V (P < .05). Tumor necrosis factor-α levels in groups I and II were significantly decreased compared to those in groups III, IV, and V (P < .05). CONCLUSION: We suggest that 15°C is the appropriate temperature for induction of hypothermia to decrease postoperative intra-abdominal adhesion formation.

Addition of nitrous oxide to the carbon dioxide pneumoperitoneum strongly decreases adhesion formation and the dose-dependent adhesiogenic effect of blood in a laparoscopic mouse model.

OBJECTIVE: To evaluate the effect of addition of nitrous oxide (N2O) to the carbon dioxide (CO2) pneumoperitoneum (PP) and the effect of blood, plasma, or red blood cells (RBCs) on postoperative adhesions in a laparoscopic mouse model. DESIGN: Prospective randomized controlled trial. SETTING: University laboratory research center. ANIMAL(S): BALB/c female mice. INTERVENTION(S): The effect of adding to the 60-minute CO2 PP 5%, 10%, 25%, 50%, or 100% N2O on adhesion formation was evaluated. Subsequently the effect of adding 1 mL blood, or RBCs, or plasma and the effect of adding different concentrations of blood were studied. Finally, the effect of adding 10% N2O, 4% O2, or both to the CO2 was evaluated in a control group and after addition of blood. MAIN OUTCOME MEASURE(S): Postoperative adhesions after 7 days. RESULT(S): N2O strongly reduces adhesion formation with a full effect at a concentration of 5% or 10%. Adhesions increase linearly with 0.125 mL to 1 mL blood. In both the control group and after adding blood, 10% N2O is the most effective factor in prevention of adhesions. CONCLUSION(S): N2O, from concentrations of 5% upward, strongly prevents adhesion formation. Blood, mainly the plasma, increases adhesion formation. These data extend the concept of the role of acute inflammation and support the importance of good surgical practice with little bleeding and peritoneal cavity conditioning in adhesion prevention.

Matrix metaloproteinase-2 and -9 serum levels as potential markers of intraperitoneal adhesions.

OBJECTIVE: To assess the value of matrix metalloproteinases-2 (MMP-2) and -9 (MMP-9) as prognostic serum markers for intraperitoneal adhesions. BACKGROUND: Postoperative adhesions are associated with serious complications responsible for increased patient's morbidity. METHODS: Forty-eight rabbits were used and randomized into groups A, B, C, and D. Abdominal laparotomy and experimental adhesion formation model was carried out. In group A, 60 mL of N/S 0.9% were instilled intraperitoneally, in group B 60 mL of icodextrin 4% were instilled intraperitoneally, in group C 0.1 mL/kg of dimetindene maleate were administered intravenously, and in group D both agents were administered. Prior to euthanasia 0.5 mL of blood was obtained. The type, the surface area of adhesions, and serum concentration of MMPs were assessed. RESULTS: The mean surface area and Zuhlke classification of adhesions of groups B, C, and D has been proved to be significantly lower compared to group A. Serum MMP-2 levels were significantly higher in groups B and D than in group A, while group D was higher when compared to group C. Serum MMP-9 levels were significantly higher in group D compared to groups A, B, and C. Serum MMP-9 was the most accurate test to differentiate between animals with and without adhesions with a sensitivity of 81.8% and a specificity of 100% at a cut-off point of 21.5 (AUC = 0.934). CONCLUSIONS: The administration of icodextrin 4% and dimetindene maleate seems to prevent postoperative adhesion formation. Serum levels of MMP-2 and MMP-9 may serve as prognostic markers to identify postoperative adhesions.

Reduction of post-surgical pericardial adhesions using a pig model.

BACKGROUND: Post-surgical pericardial adhesions pose an increased risk of complications during redo sternotomies. Adhesive tissue formation is a normal response to tissue injury and involves complex patho-physiological processes including the actions of prostaglandins to cause plasma leakage and fibrin formation. The purpose of this study was to assess the ability of two non-steroidal anti-inflammatory agents (Indomethacin and Rofecoxib) and a barrier (Coseal, a polyethylene glycol) to limit adhesion formation following cardiac surgery in a pig model. METHODS: Forty-four piglets were allocated equally to four treatment groups: Group 1: Control, Group 2: intramuscular Indomethacin, Group 3: oral Rofecoxib and Group 4: Coseal sprayed on the heart. A full median sternotomy was performed on each animal and the heart exposed. Adhesions were induced by rubbing tissues with gauze, applying sutures and leaving blood in the pericardial sac before chest closure. Plasma inflammatory markers including prostaglandin E(2) and thromboxane B(2) were measured preoperatively and on Days 2, 5 and 10 after surgery. Eight animals from each group were slaughtered after 12 weeks and 3 after 25 weeks. Adhesions were assessed macroscopically and microscopically. RESULTS: Compared to the Control group, the extent of adhesions was significantly less in all other groups whilst adhesion density was least in the Indomethacin and Coseal groups. Indomethacin and less so Rofecoxib, inhibited the synthesis of prostaglandin E(2) and thromboxane B(2) but there were no significant changes in other inflammatory markers. CONCLUSIONS: We conclude that systemic Indomethacin, and locally applied Coseal are suitable methods to markedly reduce pericardial and retrosternal adhesions.

Pathogenesis of postoperative adhesion formation.

BACKGROUND: Current views on the pathogenesis of adhesion formation are based on the 'classical concept of adhesion formation', namely that a reduction in peritoneal fibrinolytic activity following peritoneal trauma is of key importance in adhesion development. METHODS: A non-systematic literature search (1960-2010) was performed in PubMed to identify all original articles on the pathogenesis of adhesion formation. Information was sought on the role of the fibrinolytic, coagulatory and inflammatory systems in the disease process. RESULTS: One unifying concept emerged when assessing 50 years of studies in animals and humans on the pathogenesis of adhesion formation. Peritoneal damage inflicted by surgical trauma or other insults evokes an inflammatory response, thereby promoting procoagulatory and antifibrinolytic reactions, and a subsequent significant increase in fibrin formation. Importantly, peritoneal inflammatory status seems a crucial factor in determining the duration and extent of the imbalance between fibrin formation and fibrin dissolution, and therefore in the persistence of fibrin deposits, determining whether or not adhesions develop. CONCLUSION: Suppression of inflammation, manipulation of coagulation as well as direct augmentation of fibrinolytic activity may be promising antiadhesion treatment strategies.

Surgery-induced changes in red blood cell and plasma lipid peroxidation, enzymatic and non-enzymatic antioxidants, and blood hematology of female rats: protective role of methylene blue and vitamin E.

OBJECTIVE: The aim was to determine the effects on red blood cell (RBC) and plasma lipid peroxidation, antioxidants and blood hematology of intraperitoneally administered vitamin E (VE) and 1% methylene blue (MB) solutions for prevention of adhesions in rats. STUDY DESIGN: Thirty-seven female Sprague-Dawley rats were randomized into four groups. An adhesion model was constituted on the left uterine horn in three of the groups. They were then given intraperitoneally 0.9% saline (C group), 10 mg VE (VE group) and 1% MB (MB group) solutions, respectively. A sham group (Sh group), on which laparotomy was performed, received 2 ml of 0.9% saline solution. RESULTS: In the C group, the adhesion scores were significantly higher than in the VE (p<0.01), MB (p<0.01) and Sh groups (p<0.005). Results showed that adhesion formation significantly induced nitric oxide (NO) (p<0.01) and malondialdehyde (MDA) in plasma (p<0.01). The levels of RBC glutathione (GSH) (p<0.05) and plasma VE (p<0.01) significantly increased after VE administration, whereas the levels of MDA (RBC and plasma) (p<0.01), plasma NO (p<0.01), blood lymphocyte count (p<0.05) and blood white blood cell (WBC) counts (p<0.01) decreased. Treatment with MB caused a significant increase in plasma VE (p<0.01). On the other hand, results showed that MB significantly decreased blood WBC counts (p<0.01), plasma paraoxonase (PON1) (p<0.001) and NO (p<0.01), and RBC glutathione peroxidase (GPx) activity (p<0.05) and MDA levels (p<0.01). CONCLUSION: Intraperitoneal administration of MB and VE is significantly effective in preventing intraabdominal adhesion formation in a rat model. Further investigations are necessary, however, to better understand the underlying biochemical mechanisms on lipid peroxidation and antioxidants of MB.

Hormonal, biochemical, and hematological profiles in female camels (Camelus dromedarius) affected with reproductive disorders.

The aim of this study was to assess the blood profiles in female camels affected with common reproductive disorders. Estradiol-17beta (E(2)), progesterone (P(4)), thyroxin (T(4)), zinc (Zn), copper (Cu), calcium (Ca), phosphorus (P), magnesium (Mg), cholesterol, glucose, triglycerides, total protein, albumin, globulin, hematocrite, and total and differential white blood cell counts (WBC) were determined in blood of female camels affected with endometritis (n=15), vaginal adhesions (n=15), and ovarian cysts (n=15). Normal cyclic animals were used as controls (n=15). Diagnosis of reproductive disorders was based on transrectal palpation, ultrasonographic examination, and exploration of the vagina. Increased WBC counts (P=0.03) and a tendency for neutrophelia (P=0.05) were noted in female camels with vaginal adhesions. These animals were also characterized by having higher concentration of serum P(4) (P=0.0001), T(4) (P=0.001) and total protein (P=0.007), in comparison with female camels with endometritis, ovarian cysts, or controls. Animals having ovarian cysts with thin walls and homogenous hypoechogenic contents had greater serum E(2) (P=0.001) and P(4) (P=0.0001) than those having ovarian cysts with thick walls and non-homogenous echogenic contents. Animals with endometritis, vaginal adhesions, and ovarian cysts revealed lower serum Zn concentration than that of control group (P=0.003). Other blood parameters did not differ significantly compared to controls. In conclusion, this is the first report characterizing blood constituents in female camels with various reproductive disorders. These profiles may be valuable in clarifying the etio-pathogenesis of these disorders.

Serum estradiol levels in infants with and without labial adhesions: the role of estrogen in the etiology and treatment.

No strong evidence has been found that estrogen levels in girls with labial adhesions are lower than in girls without. Therefore, this study was based on the determination of estradiol levels in girls with and without labial adhesions in order to show whether a considerable difference exists between these two groups. Serum estradiol levels were measured in 59 infants with labial adhesions and in 60 healthy infants. No significant age difference was seen between affected infants and controls, with a mean age of 12.7 and 12.4 months, respectively. Serum estradiol levels ranged from 6.5 to 14.3 pg/ml (10.27 +/- 1.897) in those with labial adhesions and from 6.4 to 15.1 pg/ml (10.47 +/- 2.006) in controls, a statistically insignificant difference (p = 0.5764). When taking into consideration the effect of estrogen on wound healing and the fact that the difference in estrogen levels between the infants with and without labial adhesion is not significant, it is concluded that hypoestrogenism does not take place in the development of labial adhesions, but that creams containing estrogen might have a beneficial effect on healing after mechanical separation of the adhesion by enhancing wound reepithelialization.

[The changes of natural resistance of the patients with acute adhesive ileus].

The state of an organism natural resistance before and after the operative intervention for an acute adhesive ileus (AAI) was investigated. There was established, that the natural resistance of organism persisting after the operative intervention conduction constitutes the diagnostic criterion of the adhesive process progression in abdominal cavity and of the AAI recurrence occurrence.