Jakub Szmytkowski

Histologic and immunohistochemical studies of rectus sheath in obese patients

BACKGROUND Obesity is a well-established risk factor for incisional hernia development. The exact causative factors have not been clearly defined, and development may result from structural disruptions in the connective tissue of the fasciae. The goal of this study was to compare the content of elastin in the rectus muscle sheath of obese patients and nonobese controls. MATERIALS AND METHODS The study group consisted of 20 patients with body mass index over 35 kg/m(2) and the control group included 19 patients with normal-range body mass index. The biopsy specimens harvested during surgery were subjected to histologic evaluation, an immunohistochemical reaction with monoclonal anti-elastin antibodies, and the DAB chromatic reaction. The photomicrographs were evaluated using ImageJ software and the percentage of the area affected by the color reaction was assessed. A statistical evaluation was performed. RESULTS The specimens harvested from persons in the control group showed in hematoxylin-eosin staining a high density of fibrous elements, arranged in regular bundles. In specimens obtained from the morbidly obese, the density of the fibers was lower and their architecture was disrupted; the bundles were thinner and less regularly arranged. Most photographs show adipose tissue infiltrating the structure of the fascia. Statistical analysis of the percentage of the area occupied by elastin showed a statistically significant difference in favor of the controls. CONCLUSIONS The quantitative and qualitative changes in the elastin content of rectus abdominis muscle sheath fascia in the obese population may indicate a possible local mechanism influencing the development of incisional hernias.

An analysis of the expression of collagen I and III genes in the fascia of obese patients

BACKGROUND The etiology of incisional hernias in the population of morbidly obese patients remains unclear. Most likely, factors other than purely mechanical are at play; it has been ascertained that nonobese patients suffering from inguinal and incisional hernias display alterations in the architecture of the connective tissue. The goal of this study has been to evaluate and compare the relative expression of collagen type I and III genes in the rectus abdominis muscle sheath (RMS) of obese and nonobese individuals to investigate their possible influence on the quality of the connective tissue. MATERIALS AND METHODS RMS specimens were harvested in the early stages of either bariatric or non-bariatric laparotomies; total RNA was isolated and enzymatically purified from the tissue samples. The resulting material was subjected to a quantitative and qualitative analysis; reverse transcription reactions were then performed and the resulting complementary DNA was used in real-time reverse transcription polymerase chain reactions. The biopsy specimens were also examined by scanning electron microscopy. RESULTS The real-time reverse transcription polymerase chain reactions, performed on complementary DNA, provided specific amplicons for individual genes. The efficacy of the reactions was rather low. An almost twofold decrease of the relative expression level for type I and III collagen was observed between the two patient groups; the results did not reach statistical significance. Scanning electron microscope photographs have documented a marked difference in the ultrastructure of the RMS in both groups. CONCLUSIONS The authors have shown that changes in messenger RNA levels for collagen type I and III genes may be related to the pathogenesis of incisional hernia through alterations in the ultrastructure of the RMS fascia. Our report should be considered preliminary; the results should be verified on a larger group of patients.

Nonvariceal upper gastrointestinal tract bleeding – risk factors and the value of emergency endoscopy

Introduction Upper gastrointestinal tract bleeding (UGIB) remains a valid issue of modern medicine. The mortality and recurrence rates remain high and have not decreased as expected over the past decades. Aim of the study: to assess the treatment outcomes of nonvariceal UGIB depending on the timing of endoscopy (urgent vs. elective) and to perform an analysis of risk factors for death in patients with nonvariceal UGIB. Material and methods Comparative evaluation of treatment outcomes in two groups of patients. Group A consisted of patients undergoing elective endoscopy (n = 187). Group B consisted of patients undergoing emergency endoscopy (n = 295). Moreover, the influence of selected factors on the risk of death and bleeding recurrence was analyzed in the combined population of the two groups. This was done by constructing a logistic regression model and testing dependence hypotheses. Results In group A the mortality rate was 9.1%, and the recurrence rate was 18.2%. In group B the values were 6.8% and 12.2%, respectively. No statistically significant difference was found (p = NS). In group B the number of surgical interventions, blood transfusions and intensive care admissions was significantly lower (p < 0.05). An analysis of the combined material showed that the factors which correlated with an elevated risk of death included: old age, hemodynamic state (shock), elevated Charlson Comorbidity Index score, hemoglobin concentration, bleeding from a malignant lesion, recurrent bleeding and the need for surgery (p < 0.05). Conclusions The use of emergency endoscopy improves the treatment outcomes in patients with UGIB, although no statistically significant decrease in the mortality and recurrence rates could be observed.

Ultrastructural Differences in Rectus Sheath of Hernia Patients and Healthy Controls

BACKGROUND The etiology of inguinal hernia remains unclear. Research data indicate the presence of pathologic alterations within the connective tissue; their exact character remains the subject of dispute. The search for new methods to diagnose connective tissue abnormalities, and thoroughly explain the character of the ultrastructural alterations, continues. MATERIALS AND METHODS The study group included 10 male patients aged 18-60 y (five with primary inguinal hernia and five with acute appendicitis with no history of hernia). A specimen of the rectus muscle sheath was harvested from all of them upon surgery. The tissue samples were fixed and examined by spectrofluorometry and fluorescence microscopy, yielding fluorescence spectra and microscopic fluorescence images. RESULTS Both techniques have demonstrated significant differences between the biopsy samples harvested from hernia patients and healthy controls. The groups of fluorescence spectra were shifted relative to each other and showed maximum emission at different wavelengths after excitation with 350 nm light (arbitrarily chosen for one of the cross-link proteins). The spectra obtained for healthy controls were more homogenous, while the spectra of the hernia samples differed even between each other. In microscopic images, the difference was a more chaotic distribution of fluorophores in the samples obtained from hernia patients. CONCLUSIONS The evidence of significant differences between the samples harvested from the same location from hernia patients and healthy controls, found by fluorescence techniques, indicates the presence of abnormalities in the connective tissue forming the rectus muscle sheath. This area is not a part of the hernial defect, therefore, we can assume that the changes can be attributed to a generalized process.

Activity of metalloproteinases and adiponectin in obese patients— a possible factor of incisional hernias after bariatric procedures

PurposeMetalloproteinases are a key component of the pathogenesis of abdominal hernias. Obesity is considered a risk factor in herniogenesis and hernia recurrence. The aim of this study was to evaluate the serum concentrations of metalloproteinase-2 (MMP-2), MMP-9, MMP-13, and adiponectin in morbidly obese and nonoverweight controls.Materials and methodsThe participants were recruited from among patients undergoing bariatric and non-bariatric surgery and divided into two groups: I (body mass index (BMI)≥35 kg/m2, n=40) and II (BMI<25 kg/m2, n=30). Serum concentrations of MMP-2, MMP-9, MMP-13, and adiponectin were measured using enzyme-linked immunosorbent assay (ELISA).ResultsA statistically significant difference between groups was observed for MMP-2 concentration. The median MMP-9 concentration was higher in the obese group, but the difference was not statistically significant. Median MMP-13 concentrations did not differ between groups. Serum adiponectin concentration was insignificantly higher in the non-obese group.ConclusionsThe elevated serum MMP-2 and MMP-9 concentrations in obese individuals may be related to the higher incidence of incisional hernias in this population.摘要目的主要研究病态肥胖患者与正常人血清中金属蛋白 酶2(MMP-2)、MMP-9、MMP-13 和脂联素的 浓度。创新点建立血清中MMP-2、MMP-9、MMP-13 和脂联 素的浓度与肥胖和切口疝的关系。方法参与实验的人员为进行肥胖手术的患者和不进行 肥胖手术的患者,并将他们分为两组:I(体重 指数(BMI)≥35 kg/m2,n=40)和II (BMIlt;25 kg/m2, n=30),并使用酶联免疫吸附实验测定受试人员 体内血清中MMP-2、MMP-9、MMP-13 和脂联 素的浓度。结论MMP-2 的浓度在肥胖组中更高,且在两组血清 中有显著性差异。虽然MMP-9 的浓度在肥胖组 中更高,但是两组之间没有显著性差异。MMP-13 在两组间没有差异。血清中脂联素的浓度在非肥 胖组更高,但无显著性差异。因此,血清中 MMP-2和MMP-9的浓度在肥胖人群中与更高的 切口疝发病率有关。

Asymptomatic infection of a surgical mesh implant

Zakazenie obejmujące implantat jest jednym z najpowazniejszych powiklan towarzyszących stosowaniu biomaterialow w chirurgii przepuklin. Zakazenie implantatu moze miec rozny przebieg kliniczny. W pracy przedstawiono przypadek bezobjawowego zakazenia siatki chirurgicznej zastosowanej do zaopatrzenia przepukliny okolopepkowej. Zakazenie zostalo rozpoznane przypadkowo podczas operacji z powodu nawrotu przepukliny. Badania metodą jakościową z uzyciem chlorku 2,3,5-trojfenylotetrazoliowego (TTC), metodą ilościową oraz z uzyciem skaningowego mikroskopu elektronowego wykazaly obecnośc biofilmu bakteryjnego na powierzchni implantatu zastosowanego do pierwotnego zaopatrzenia przepukliny. Jego obecnośc na powierzchni implantatu uchronila drobnoustroje przez dzialaniem ukladu odpornościowego pacjenta i byla odpowiedzialna za bezobjawowy przebieg zakazenia biomaterialu. Zdaniem autorow wszystkie implantaty usuwane podczas operacji z powodu nawrotu przepukliny nalezy poddac badaniu mikrobiologicznemu, nawet gdy nie stwierdza sie makroskopowych cech zakazenia. Do badan diagnostycznych powinna zostac wlączona metoda redukcji TTC, co pozwala ograniczyc liczbe wynikow falszywie ujemnych.

The Ultrastructure of the Fascia Lata in Hernia Patients and Healthy Controls

BACKGROUND Current research data indicate that a hernia is a manifestation of a generalized polyethiological connective tissue pathology. The goal of this study was to demonstrate ultrastructural differences in tissues distant from the hernial defect. MATERIALS AND METHODS Biopsy specimens harvested upon thigh surgery from 12 males aged 25-65 y were compared. Seven of these men had an inguinal hernia or a history thereof. Scanning electron microphotograms taken at a magnification of 50× were analyzed with the use of Image J software. For every patient, 100 thickness measurements were performed of the fibrous elements (cross-sections) visible in five consecutive photograms. The person performing the measurements had no means of identifying the patient from whom the specimen had been harvested. RESULTS The authors have found the thickness of the fibers to fall in the range from 23.441 u (ImageJ intrinsic units) to 94.878 u in the hernia group and 22.067 u to 303.681 u for the control group. A statistically significant difference was found between the mean values of thickness measurements of the fibrous elements in the study and control groups. CONCLUSIONS The study has shown that in patients with an inguinal hernia, the mean diameter of fibers within the fascia lata is significantly smaller. This appears to indicate that the process is generalized and that one can expect the structural alterations to occur within the connective tissue of the entire organism. The authors speculate that they may result from a combination of external and internal factors.