Lukasz Krokowicz

Pulsed acoustic cellular treatment induces expression of proangiogenic factors and chemokines in muscle flaps.

BACKGROUND Pulsed Acoustic Cellular Expression (PACE) treatment is a novel technology with potential to improve tissue perfusion, but the mechanism of this action is unknown. We assessed in vivo the effect of PACE therapy on muscle microcirculatory hemodynamics, neovascularization, and proangiogenic and proinflammatory gene expression. METHODS Cremaster muscles were prepared for standard intravital microscopy in 42 Lewis rats divided into five groups: (1) control (n = 10); acute PACE treatment 15 minutes before surgery with (2) 200 impulses (n = 8) and (3) 500 impulses (n = 8); and PACE treatment 24 hours before surgery with (4) 200 impulses (n = 8) and (5) 500 impulses (n = 8).Microcirculatory hemodynamics of red blood cell velocity and capillary perfusion were recorded for 4 hours. Gene expression levels of proinflammatory (inductible nitric oxide synthase [iNOS]) and proangiogenic factors (endothelial nitric oxide synthase [eNOS], vascular endothelial growth factor [VEGF], chemokine (C-X-C motif) ligand 5 [CXCL5], chemokine (C-C motif) ligand 2 [CCL2], and chemokine (C-C motif) receptor 2 [CCR2] were measured using Taqman real-time Polymerase Chain Reaction (PCR). Immunohistochemistry assessed expression of proangiogenic factors: VEGF, von Willebrand factor (vWF), and vessel density by CD31. RESULTS PACE treatment resulted in an increase of arteriolar diameters in acute groups 2 and 3 (p < 0.05). In group 5, vessel densities assessed by CD31, VEGF, and vWF expression increased significantly 24 hours after PACE treatment compared with control (p < 0.05). PACE application downregulated proinflammatory iNOS gene expression and upregulated proangiogenic genes expression of eNOS, VEGF, CXCL5, and CCL2. CONCLUSIONS Application of PACE treatment, applied as short time acting preconditioning and conditioning treatment, resulted in upregulation of proangiogenic chemokines gene expression in the muscle and showed upregulation of expression of proangiogenic factors such as VEGF and vWF on the vessel endothelium.

Pulsed acoustic cellular expression as a protective therapy against I/R injury in a cremaster muscle flap model

BACKGROUND Tissue ischemia and reperfusion (I/R) affects blood flow restoration and oxygen delivery to the damaged tissues contributing to tissue morbidity and microcirculatory compromise. Pulsed acoustic cellular expression (PACE) technology is known to support tissue neovascularization. The aim of this study was to test PACE conditioning mechanism of action on microcirculatory hemodynamics in ischemia-reperfusion injury model. METHODS 34 rat cremaster muscle flaps were monitored under intravital microscopy system in 4 experimental groups: 1) non-ischemic controls (n=10), 2) 5h ischemia without conditioning (n=8), 3) pre-ischemic (5h) PACE conditioning (n=8), 4) post-ischemic (5h) PACE conditioning (n=8). Standard microcirculatory hemodynamics of RBC velocity, vessel diameters and functional capillary perfusion were recorded for 2h after I/R. Immunohistochemistry assessed expression of proangiogenic factors: VEGF and vWF, whereas real-time PCR assessed proangiogenic (VEGF, eNOS) and proinflammatory factors (iNOS; chemokines: CCL2, CXCL5 and chemokine receptor CCR2). RESULTS Pre-ischemic PACE conditioning (group 3) resulted in increased RBC velocity of second (A-2) and third order arterioles (A-3) and venule (V-1) by 40%, 15% and 24% respectively comparing to ischemic group without conditioning (p<0.05). Post-ischemic PACE conditioning (group 4) revealed: 1) increase in RBC velocity in second (A-2) and third order arterioles (A-3) by 65% and 31% respectively comparing to ischemia without conditioning (group 2), 2) 33% increase in first order arterioles diameter (A-1) (p<0.05) compared to ischemic controls, 3) 21% increase in number of functional capillaries compared to ischemia without conditioning (group 2) (P<0.05). Immunostaining assays showed that PACE postconditioning up-regulated proangiogenic factors vWF and VEGF protein expression. This correlated with increased gene expression of VEGF (up to 180%). In contrast, gene expression of proinflammatory factors (iNOS, CCL2, CXCL5) decreased compared to ischemic controls. Pre-ischemic PACE conditioning decreased gene expression of proinflammatory chemokines (CCL2 and CXCL5), compared to ischemic controls without conditioning. CONCLUSIONS As expected 5h ischemia resulted in deterioration of microcirculatory hemodynamics confirmed by decreased vessels diameters and RBC velocities. This was alleviated by pre- and post-ischemic PACE conditioning which improved functional capillary density and stimulated angiogenesis as confirmed by up-regulated VEGF expression. Furthermore, post-ischemic PACE conditioning correlated with decreased expression of early proinflammatory factors (iNOS, CCL2, CXCL5). Both types of PACE conditioning ameliorated deleterious effect of ischemia-reperfusion injury on microcirculatory hemodynamics of muscle flaps.

Pre- and postischemic pulsed acoustic cellular expression conditioning modulates expression of inflammation factors in cremaster ischemia/reperfusion injury model.

Pulsed acoustic cellular expression (PACE) is a treatment that applies focused acoustic shock waves to promote tissue healing. The aim of this study was to assess the effect of PACE treatment on inflammatory responses in a cremaster muscle ischemia/reperfusion injury model. Seventeen cremaster muscle flaps were evaluated in four groups: nonischemic controls (n = 5), 5‐hour ischemia controls (n = 4), preischemic (5‐hour) PACE conditioning (n = 4), and postischemic (5‐hour) PACE conditioning (n = 4). The expression of proinflammatory cytokines (TNFα, IL‐6, IL‐1α, IL‐1β, GM‐CSF) and chemokines (CCL3, CCL4, CXCL4) was assessed using TaqMan® real‐time PCR. Expression of ELAM‐1, VCAM‐1, and ICAM‐1 was assessed by immunostaining. Preischemic PACE conditioning upregulated expression of IL‐6, CCL3, CCL4, and CXCL4, and downregulated expression of TNFα, GM‐CSF, and IL‐1α. Postischemic PACE conditioning significantly decreased expression of all evaluated genes. Pre‐ and postischemic PACE conditioning decreased expression of ELAM‐1 and ICAM‐1. Results of the study indicate that application of PACE conditioning may have a beneficial effect on the recovery of tissues subjected to the ischemia/reperfusion injury. Postischemic PACE conditioning revealed anti‐inflammatory effect as confirmed by decreased expression of inflammatory cytokines, chemokines, and cell adhesion molecules (ELAM‐1 and ICAM‐1) that are responsible for leukocyte recruitment into ischemic tissues. Hence, PACE therapy may be used effectively in clinical practice as a convenient therapeutic strategy to protect tissues against ischemia/reperfusion related injury after microsurgical procedures of free tissue transfers.

Iatrogenic Bile Duct Injury. A Significant Surgical Problem. Assessment of Treatment Outcomes in the Department's Own Material

UNLABELLED Iatrogenic bile duct injuries (BDI) are still a challenging diagnostic and therapeutic problem. With the introduction of the laparoscopic technique for the treatment of cholecystolithiasis, the incidence of iatrogenic BDI increased. The aim of the study was a retrospective analysis of 69 patients treated at the department due to iatrogenic BDI in the years 2004-2014. MATERIAL AND METHODS In this paper, we presented the results of a retrospective analysis of 69 patients treated at the Department due to iatrogenic BDI in the years 2004-2014. The data were analysed in terms of age, sex, type of biliary injury, clinical symptoms, the type of repair surgery, the time between the primary surgery and the BDI management, postoperative complications and duration of hospital stay. RESULTS 82.6% of BDI occurred during laparoscopic cholecystectomy, 8.7% occurred during open cholecystectomy, whereas 6 cases of BDI resulted from surgeries conducted for other indications. In order to assess the degree of BDI, Bismuth and Neuhaus classifications were used (for open and laparoscopic cholecystectomy respectively). 84.1% of patients with confirmed BDI, were transferred to the Department from other hospitals. The average time between the primary surgery and reoperation was 6.2 days (SD 4). The most common clinical symptom was biliary fistula observed in 78.3% of patients. In 28 patients, unsuccessful attempts to manage BDI were made prior to the admission to the Department in other centres. The repair procedure was mainly conducted by laparotomy (82.6%) and by the endoscopic approach (15.9%). Hepaticojejunostomy was the most common type of reconstruction following BDI (34.7%). CONCLUSIONS The increase in the rate of iatrogenic bile duct injury remains a challenging surgical problem. The management of BDI should be multidisciplinary treatment. Referring patients with both suspected and confirmed iatrogenic BDI to tertiary centres allows more effective treatment to be implemented.

Ringer's lactate solution enhances the inflammatory response during fluid resuscitation of experimentally induced haemorrhagic shock in rats

Introduction Hemorrhagic shock leads to systemic oxygen deficit (hypoxaemia) that results in systemic inflammatory response syndrome (SIRS), a recognised cause of late mortality in this case. The aim of this study was to analyse the impact of fluid resuscitation, using two Ringer solutions, on the microcirculation changes that take place during experimentally induced haemorrhagic shock. Material and methods A model of the rat cremaster muscle was used to assess microcirculation in vivo. The experimental groups (n = 10 each) included: control (CTRL); shock (HSG); Ringer’s acetate (RAG); and Ringer’s lactate (RLG). Microhaemodynamic parameters were measured during the experiment. Results A statistically significantly higher level of leukocytes, both those attached to the endothelium and those located in the extravascular space (p < 0.05), was reported in the lactate Ringer (LR) group compared with the AR group. There were significant differences in the activity of A3 arterioles compared with A1 and A2 arterioles. Ringer’s lactate solution seemed to the inflammation response during fluid resuscitation from haemorrhagic shock. A3 arterioles are likely to play a role as a pre-capillary sphincter in the skeletal muscle. Conclusions The present study revealed that fluid resuscitation with Ringer’s lactate solution exacerbates inflammation in the skeletal muscle. It is worth noting that Ringer’s acetate solution reduces local inflammation and could therefore be recommended as the “first line” crystalloid of the fluid resuscitation during haemorrhagic shock.

''Sandwich technique'' with bridging, a modification of negative pressure wound therapy for anal fistulas

The surgical treatment of anal fistulas is a complex problem, associated with high relapse rates. Wounds frequently heal by the secondary intention. The process is time-consuming and frequently causes discomfort to the patient. Negative pressure wound therapy seems to be one of the methods which might accelerate the healing process in patients who have undergone surgery for anal fistula. Nevertheless, this approach is seldom used. The principal challenge in applying negative pressure wound therapy (NPWT) in the anal and perineal regions remains appropriate application of particular elements forming the negative pressure dressing and above all tight pasting of the foil.

Large bowel mucosal neoplasia in the original specimen may increase the risk of ileal pouch neoplasia in patients following restorative proctocolectomy for ulcerative colitis

PurposeRestorative proctocolectomy is a current gold standard procedure for patients who require a colectomy for ulcerative colitis. The incidence of ileal pouch neoplasia is low. The aims of this study were to assess the prevalence of neoplasia in ileal pouch and investigate the risk factors for ileal pouch neoplasia.MethodsA total of 276 patients who underwent restorative proctocolectomy for ulcerative colitis between 1984 and 2009 were analyzed. Results of histological examinations of both original specimen and biopsies from the J-pouch taken during routine pouch endoscopy were evaluated. Patients’ records were analyzed for ulcerative colitis duration, the time from pouch creation to pouch neoplasia, presence of pouchitis, as well as the concurrent primary sclerosing cholangitis.ResultsAnalyzing the original specimen of large bowel, fifty-six lesions of low-grade dysplasia, twenty-five high-grade dysplasia, and five adenocarcinoma were revealed. All patients with dysplasia (n = 8) or adenocarcinoma (n = 1) of the J-pouch were positive for dysplasia in the original specimen. Duration of ulcerative colitis before surgery and duration time following restorative proctocolectomy were found as risk factors for J-pouch neoplasia with a significant difference (p = 0.01 and p = 0.0003, respectively). Patients with pouch neoplasia developed significantly more severe pouchitis (p = 0.00001).ConclusionsNeoplasia of the J-pouch is rare. Patients with neoplasia in the original specimen are more susceptible to develop neoplasia in the J-pouch. Precise follow-up in patients with neoplasia lesions in the original specimen should be recommended. Moreover, in patients with risk factors, the exact surveillance pouch endoscopy should be recommended.

Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis.

To the Editor—recently, Musters et al published a very interesting review on perineal wound healing after abdominoperineal resection (APr) for rectal cancer. the authors discussed various methods of perineal wound closure, as well as treatment options for potential complications of primary closure. We did not find any information in the article about the implementation of negative pressure wound therapy (NPWt). NPWt has been demonstrated to be an effective method for the management of complicated and chronic wounds. Perianal wounds, both postoperative and posttraumatic, remain a challenging problem. Because of an impaired healing process (radiation therapy), as well as difficulty in dressing and nursing, we strongly recommend implementing NPWt after an APr procedure. Based on our experience, we found NPWt to be a helpful method for management of this type of wound. the crucial aspect of NPWt is to apply the dressing in the appropriate manner, particularly in the anal and genital regions. Keeping the entire system sealed is challenging and usually requires the use of a stoma paste or silicone plate. our results are consistent with other publications that have reported good results when using NPWt after an APr procedure. NPWt has been used to support the healing process from complicated perineal wounds after APr procedures, as well as for gracilis muscle flap transposition and an omentoplasty technique after an APr procedure. Promising results were also demonstrated concerning incisional NPWt used postoperatively. Although the application of NPWt for a perineal wound is not considered a goldstandard procedure, in our opinion NPWt is an effective method for primary wound closure and a method of choice during impaired healing of perineal wounds after an APr procedure.

Microcirculation and Pace Therapy

Pulsed Acoustic Cellular Expression (PACE) is a novel technology utilizing Extracorporeal Shock Waves (ESW) in as a source of acoustic energy in a pulsed manner capable of delivering a cellular expression response. It has multiple indications in medicine but exact mechanism of PACE remains unknown. In our experiment in a large group of animals we checked influence of PACE on microcirculation in a well-known model of rats’ cremaster muscle. Results revealed that PACE therapy increases circulation in cremaster muscle and causes neovascularization and angiogenesis. It also has anti-inflammatory effect on the muscle. To achieve desired results PACE therapy has to be used periodically.

Management of traveller’s diarrhoea with a combination of sodium butyrate, organic acids, and A-300 silicon dioxide

Introduction Travellers diarrhoea (TD), defined by UNICEF/WHO as three or more unformed stools with or without other symptoms, imposes a considerable burden on travellers from developed countries. Various efforts have focused on decreasing the prevalence and severity of this condition. Aim To assess the efficacy of a combination of sodium butyrate, organic acids, and A-300 silicon dioxide in treatment providing symptomatic relief of TD. Material and methods The study was conducted in accordance with a protocol presented to the Bioethical committee of Poznan University of Medical Sciences. A total of 278 patients travelling to countries with higher risk of diarrhoea for at least 10 days were divided into a study arm being administered, in case of TD, a combination of sodium butyrate, organic acids, and A-300 silicon dioxide (n = 139) and a placebo arm (n = 139) with placebo administration. Results Forty-seven patients completed the study (22 in the study arm and 25 in the placebo arm). The diarrhoea occurrence after initiation of treatment at first symptoms was significantly lower in the study arm as compared to the placebo arm (9% vs. 36%, p = 0.041). Also, subjects from the study arm more frequently reported that the regimen administered had been efficient for their symptoms in comparison to the placebo arm (72.7% vs. 32%, p = 0.008). No adverse effects of the administered medication were noted during the study. Conclusions Sodium butyrate, organic acids, and A-300 silicon dioxide can be successful in decreasing symptoms of TD. Because of its efficacy and lack of observed side effects it has a strong potential in the treatment of patients with TD.