R. S. Bhardwaj

Abnormal collagen I to III distribution in the skin of patients with incisional hernia.

The surgical mesh-free repair of incisional hernias has to face recurrence rates of up to 50%. Apart from technical faults this is probably due to collagen metabolic disorders, known to play an important role in the development of inguinal hernia. In particular an altered ratio of collagen types I and III with an increase in collagen type III has been claimed to reduce the mechanical strength of connective tissues. Therefore, we investigated the content of collagen types I and III in the skin of patients with incisional hernia (n = 7) and recurrent incisional hernia (n = 5) in comparison to controls with healthy skin (n = 7) and normal skin scar (n = 7) both by immunohistochemistry and Western blot analysis. Both immunohistochemistry and Western blot analysis revealed a decrease in the ratio of collagen I/III due to a concomitant increase in collagen III. The patients with incisional hernias and with recurrent incisional hernias showed a ratio of 1.0 ± 0.1 and 0.8 ± 0.1, respectively, whereas the controls exhibit a ratio of 2.1 ± 0.2 in healthy skin and of 1.2 ± 0.2 in normal skin scar, respectively. The decrease was highly significant (p < 0.01) between the patients with either primary or recurrent hernia and the controls or the normal scar, as well as between controls and normal scar, whereas there was not any significant difference between primary and recurrent hernia (p > 0.05). Our data for the first time confirmed that the presence of incisional hernia is accompanied by impaired collagen synthesis in the skin. The decreased tensile strength of collagen type III may play a key role in the development of incisional hernias. Furthermore, it might explain the high recurrence rates of hernia repair by simple closure, as a repetition of the primarily failing technique, and the improvement by the additional use of alloplastic material.

Recurrent inguinal hernia: Disease of the collagen matrix?

The aim of this study was to investigate the collagen matrix in recurrent inguinal hernias. Total ribonucleic acid (RNA) was extracted from skin fibroblasts of three groups (control group I = healthy skin; control group II = plain skin scar; recurrent inguinal hernia group = skin of recurrent inguinal hernias; each n = 5). Reverse transcription-polymerase chain reaction (RT-PCR) and Northern blot analysis were used to investigate the expression of procollagen type I/- III, MMP-1, and MMP-13 mRNAs. Both ratios of procollagen types I to III mRNAs and collagen types I to III were apparently decreased in the recurrent hernia group compared to those of both control groups (p <0.01). Significant differences were caused by the increase of both procollagen type III mRNA and collagen type III protein synthesis. A concomitant increase of MMP-1 and MMP-13 mRNAs and proteins was also observed in the recurrent hernia group and showed significant differences compared to those of both control groups I and II, respectively (p <0.01). In conclusion, the decreased ratio of collagen types I to III seems not only to be the result of a relative increase in the levels of type III procollagen mRNA but also may be the result of an increase of MMP-1 and MMP-13. The data of the present study strongly suggest recurrent inguinal hernias to be a disease of the collagen matrix and result in a clearer understanding of the underlying pathophysiology and may support specific therapeutic strategies in hernia surgery (e.g., surgical meshes).

Expression of the Extracellular Matrix Proteins Collagen I, Collagen III and Fibronectin and Matrix Metalloproteinase-1 and -13 in the Skin of Patients with Inguinal Hernia

Although abnormal collagen metabolism has been ascribed an important role in the high recurrence rates after surgical hernia repair, knowledge on tissue sampled in the region affected by inguinal hernias is poor. In the present study, we determined collagen type I and type III in the skin of adult patients with indirect and direct inguinal hernias by both immunohistochemistry and Western blot analysis. In addition, we quantified the immunohistochemical expression of fibronectin and matrix metalloproteinase (MMP)-1 and -13. The results indicated that the ratio of collagen type I/III was significantly decreased in the skin of patients with either indirect (n = 9) or direct hernia (n = 7), with a concomitant increase in collagen type III (p < 0.001 vs. controls, n = 7, without affection of the inguinal region). There was no significant difference between patients with indirect and direct hernia (p > 0.05). MMP-13 was not expressed in any of the skin samples investigated, whereas MMP-1 was found in the epidermis. Fibronectin was predominantly detected at the epidermal-dermal junction. MMP-1, MMP-13 and fibronectin levels were significantly different between patients and controls (p > 0.05). We conclude that in contrast to the unchanged expression of fibronectin and MMP-1 and MMP-13, the decreased ratios of collagen tpye I/III with the basically increased amount of collagen type III could be of significant importance for the pathophysiology of hernias. The specific ratio collagen I/III probably reflects the altered structural integrity and mechanical stability of the connective tissue in both indirect and direct hernias. Moreover, our findings stress that hernias should be regarded as the manifestation of a systemic disease in the inguinal region with a genetic background, explaining the high recurrence rates after repeated suture repair, as well as the usefulness of surgical meshes in this clinical setting.

Altered collagen synthesis in fascia transversalis of patients with inguinal hernia

SummaryThe aim of this study was to substantiate the hypothesis as to whether an altered metabolism of type I and type III collagen should be included as pathophysiological considerations of inguinal hernia development or not. Therefore, fascia transversalis derived from patients with indirect hernias (n=9), direct hernias (n=7) and from controls (n=7) were investigated both by immunohistochemistry and protein analysis (Western Blot). Both immunohistochemical analysis and Western Blot analysis showed that the ratio of the relative amounts of type I to type III collagen was significantly decreased in the fascia transversalis of patients with indirect and direct inguinal hernias compared with controls (p<0.001). The relative reduction of the collagen I/III ratio may be explained by a concomitant increase in collagen type III synthesis in both hernia-families. In contrast to the control group there was no significant difference between patients with direct and indirect hernia. It is concluded that the change in collagen type I / III ratio, with the resulting altered physical properties, might essentially predispose individuals to the development of inguinal hernia. Thus, an altered collagen metabolism would provide an additional theoretical basis for the use of alloplastic materials, such as surgical meshes, and an explanation for the disappointing high recurrence rates after appropriate primary hernia repair, particularly if mesh-free techniques have been used.

Morphologische Korrelation der funktionellen Bauchwandmechanik nach Mesh-Implantation

Modern surgical hernia repair depends increasingly on synthetic meshes for reconstruction of the abdominal wall. Despite the undisputed advantages of the synthetic meshes currently available, reports of late complications after implantation are accumulating. It is essential that the synthetic meshes be improved, but this makes a standardized animal model necessary for evaluation of their biocompatibility on both functional and morphological levels. In the present study, commercially available polypropylene and polyester meshes were implanted in a rat model, and detailed morphological and morphometric analysis were carried out. Correlations between the morphological and morphometric data and the function of the artificial abdominal wall were then sought. In summary, the data show that the mesh constructions currently available are oversized and definitely restrict the function of the artificial abdominal wall. The degree of inflammation and fibrosis, the pattern of fibrosis, and the composition of the extracellular matrix exert decisive influences on the function. Fibrosis and inflammation are caused less by the material itself, however, than by its density, the way it is processed, and its surface. Future, that is to say second-generated, mesh constructions should be designed with the aims of reducing the amount of material used and finding material-specific processing methods in mind, to improve the functionally and morphologically defined biocompatibility.ZusammenfassungDie moderne Hernienchirurgie bedient sich zunehmend Kunstnetzkonstruktionen zur Bauchwandrekonstruktion. Trotz der unbestrittenen Vorteile der z.Z. verfügbaren Kunstnetze mehren sich Berichte über Spätkomplikationen nach der Implantation. Eine Optimierung der Kunstnetze ist notwendig, bedingt aber ein standardisiertes Tiermodell zur Evaluierung der Biokompatibilität auf funktioneller und morphologischer Ebene. In der vorliegenden Studie werden z.T. handelübliche Polypropylen-und Polyesternetze in einem standardisierten Rattenmodell implantiert und detailliert morphologisch und morphometrisch analysiert. Die morphologisch-morphometrischen Daten werden in Anschluß mit der Funktion der künstlichen Bauchwand korreliert. Zusammenfassend zeigen die Daten, daß die z.Z. gebräuchlichen Netzkonstruktionen überdimensioniert sind und zu einer deutlichen Funktionseinschränkung der künstlichen Bauchwand führen. Die Funktion wird dabei entscheidend durch den Entzündungs- und Fibrosegrad, durch das Fibrosemuster und durch die Zusammensetzung der Extrazellularmatrix beeinflußt. Fibrose und Entzündung werden jedoch weniger durch das Material an sich bestimmt, sondern durch die Materialdichte,-verarbeitung und-ober-fläche. Zukünftige Netzkonstruktionen der 2. Generation sollten zur Verbesserung der funktionell-morphologisch definierten Biokompatibilität eine Reduzierung der Materialmenge und eine materialspezifische Verarbeitung anstreben.

Expression of heat shock protein 70 (HSP70) at the interface of polymer–implants in vivo

Synthetic polymer meshes are widely applied in the modern surgical approach for repairing abdominal wall defects. The implanted material is often observed leading to post-operative complications such as deficient abdominal wall mobility and adhesion formation with the abdominal cavity and/or abdominal organs. However, the functioning of the implant is primarily affected by the wound healing process guided by inflammatory events occurring at the tissue–material interface. This could presumably be influenced by the physicochemical properties of the polymer. With regard to it, the cellular and molecular processes involved in the successful restoration of the abdominal wall function are poorly understood. The present in vivo study, therefore, exemplary investigated in a rat model, the commercially available polymer-meshes Prolene® (polypropylene, PP), Mersilene® (polyester, PE) and Vicryl® (polyglactin 910), as well as new mesh variants consisting either of PP (EB) or a combination of PP and polyglactin 910 (A plus or Vypro®). The implanted material was evaluated by light and electron microscopy, immunohistochemistry as well as morphometry over an implantation period of 90 days. The data show that polymers induce heat shock protein (HSP)70, and its expression at the interface correlates inversely with the activity of the inflammatory reaction in vivo. Further, an ascent in HSP70 expression parallels the increasing implantation period and evolving foreign-body granulomas. Accordingly, a major role for HSP70 in modulating the local acceptance of polymers and as an additional marker for in vivo testing of polymers is suggestive. ©©2000 Kluwer Academic Publishers

Role of HSP70i in regulation of biomaterial-induced activation of human monocytes-derived macrophages in culture.

The functioning of an implant depends on the material properties and the wound-healing process. The latter is led by an inflammatory reaction guided mainly by monocyte/macrophage activity. This in vitro study investigated human monocytes/macrophages in culture from 2 h to 10 days on silicone, polyurethane, teflon and TCPS. Analysis of cytokine release by ELISA showed that maturing macrophages have different capacities to produce cytokines TNFα, IL10, IL8 and GM-CSF. The long culture-mature macrophages on all polymers produced comparable low levels of TNFα, IL10 and IL8. Monocytes/macrophages on polyurethane and teflon, and those on silicone only in long culture-time produced high GM-CSF amounts, where as those on TCPS exhibited low levels of GM-CSF. FACS analysis revealed that HSP70i was highly inducible after short time culture yet this high level was maintained in long culture-mature macrophages on TCPS only, whereas on other polymers the mature macrophages showed a high reduction in HSP70i level, which demonstrated a high stress-response by cells on TCPS. Accordingly, CLSM-analysis revealed low nuclear NF-κB in cells on TCPS and high nuclear NF-κB in mature macrophages on silicone and polyurethane, showing a high cellular activation on the latter two polymers. This corresponded also to the high mitochondrial activity by XTT metabolism displayed by the mature macrophages on polyurethane ≥ silicone > teflon > TCPS. These data show a correlation of (1) cytokines (TNFα, GM-CSF) and HSP70i, (2) NF-κB and HSP70i by monocytes/macrophages after contact with polymers. Thus, HSP70i might be a useful molecular candidate for exploring biomaterial-induced inflammatory reaction.

Pathologie der Implantate

Jedes chirurgische Implantat stellt einen Fremdkorper dar und provoziert eine mehr oder minder starke Abwehrreaktion des Organismus. In einer gemeinschaftlichen Anstrengung der Facher Chirurgie und Pathologie sowie von technischingenieurwissenschaftlichen Disziplinen soll die Implantatforschung neue Impulse erhalten durch: 1. Sorgfaltige Registrierung und Aufarbeitung von explantierten (nicht funktionierenden oder funktionierenden) Devices. Stichwort: „Schadensanalyse“. 2. Weiterentwicklung eines DNA-Chips „Implantat/chronische Wunde“ zur Erforschung der Transkriptionsaktivitat von Zellen im Kontakt mit Fremdstoffoberflachen. 3. Orchestrierung einer optimalen fur Patienten und Chirurgen gleichermasen befriedigenden Zellreaktion auf Implantate durch pradiktives Zeil-Engineering.