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ABSTRACT: Background. While lightweight (LW) polypropylene (PP) meshes are been used for hernia repair, new prosthetic meshes also of low-density and with largepores have recently been introduced composed of other polymer materials. This study compares the behavior in the short-term of two macroporous LW prosthetic materials, PP and non-expanded PTFE. Methods. Partial defects were created in the lateral wall of the abdomen in New Zealand White rabbits and then repaired using a LW PP mesh or a new monofile, LW PTFE mesh. At 14 days postimplant, shrinkage and tissue incorporation, gene and protein expression of neo-collagens (qRT-PCR/immunofluorescence), macrophage response (immunohistochemistry) and biomechanical strength were determined. Results. Both meshes induced good host tissue ingrowth, yet the macrophage response was significantly greater for the PTFE implants (p⟨0.05). Collagen 1/3 mRNA expression was greater for the PP mesh but differences lacked significance. Similar patterns of collagen I and III protein expression were observed in the neoformed tissue infiltrating the two meshes. After 14 days of implant, tensile strengths were also similar, while elastic modulus values were higher for the PTFE mesh (p⟨0.05). Conclusions. In the short term, host collagen deposition and biomechanical performance seemed unaffected by the polymer structure of the implanted mesh. In contrast, the inflammatory response to mesh implant produced at this early time point was more intense for the PTFE.
Histology and histopathology 02/2013; · 2.48 Impact Factor
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ABSTRACT: The application of bioactive meshes in abdominal surgery for the repair of hernias is an increasing clinic activity in a wide sector of population.The main secondary effect is the appearance of infections from bacteria, specifically Staphylococcus aureus (Sa) and Staphylococcus epidermidis (Se). This work deals with the development and application of low density polypropylene meshes coated with a biocompatible and resorbable polymer as a controlled release system of the antibiotic Vancomycin. The polymeric coating (a non-crosslinked copolymer of 2-hydroxyethyl methacrylate, HEMA and 2-acrylamido-2-methylpropanesulphonic acid AMPS) has a thickness of 14-15 μm, and contains 0.32 mg/cm(2)of the antibiotic Vancomycin. The "in vitro" experiments demonstrate the excellent inhibitory character of the coated meshes loaded with the antibiotic, following the standard protocol of inhibition of halo in agar diffusion test. This inhibitory effect is kept for a relatively long period (at least 14 days) with a low concentration of antibiotic. The acrylic polymer system regulates the release of the antibiotic with rate of 24 μg /hr, due to its slow dissolution in the medium. Experiments "in vivo", based on the implantation of coated meshes demonstrate that the system controls the infection in the animal (rabbits) during at least30 days. The concentration of antibiotic in the blood stream of the implanted rabbits was below the detection limit of the analytical technique (lower than 1-2 μg/mL), which demonstrates that the antibiotic is released in the local area of the implant and remains concentrated in site, without the diffusion to the blood stream. The systems can be applied to other medical devices and implants for the application of new generation antibiotics in a controlled release and targeted applications.
Acta biomaterialia 12/2012; · 3.98 Impact Factor
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ABSTRACT: Surgical procedures for hernia surgery are usually performed using prosthetic meshes. In spite of all the improvements in these biomaterials, the perfect match between the prosthesis and the implant site has not been achieved. Thus, new designs of surgical meshes are still being developed. Previous to implantation in humans, the validity of the meshes has to be addressed, and to date experimental studies have been the gold standard in testing and validating new implants. Nevertheless, these procedures involve long periods of time and are expensive. Thus, a computational framework for the simulation of prosthesis and surgical procedures may overcome some disadvantages of the experimental methods. The computational framework includes two computational models for designing and validating the behaviour of new meshes, respectively. Firstly, the beam model, which reproduces the exact geometry of the mesh, is set to design the weave and determine the stiffness of the surgical prosthesis. However, this implies a high computational cost whereas the membrane model, defined within the framework of the large deformation hyperelasticity, is a relatively inexpensive computational tool, which also enables a prosthesis to be included in more complex geometries such as human or animal bodies.
Computer Methods in Biomechanics and Biomedical Engineering 11/2012; · 0.85 Impact Factor
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ABSTRACT: The aim of this work is to present a methodology to model the passive mechanical behavior of the human abdomen during physiological movements. From a mechanical point of view, it is possible to predict where hernia formation is likely to occur since the areas that support higher stresses can be identified as the most vulnerable ones. For this purpose, a realistic geometry of the human abdomen is obtained from magnetic resonance imaging. The model defines different anatomical structures of the abdomen, including muscles and aponeuroses, and anisotropic mechanical properties are assigned. The finite element model obtained from the geometric human model, which includes initial strains, is used to simulate the anisotropic passive behavior of the healthy human abdomen under intra-abdominal pressure. This study demonstrates that the stiffest structures, namely aponeuroses and particularly the linea alba, are the structures that perform the most work in the abdomen. Thus, the linea alba is the most important unit contributing to the mechanical stability of the abdominal wall.
Annals of biomedical engineering 10/2012; · 2.41 Impact Factor
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ABSTRACT: The viability and immunological response induced by cryopreserved arterial allografts remain unclear. This study examines the post-graft behaviour of this type of vessel substitute.
Both iliac arteries were extracted from Lewis rats (donors) and used to establish groups of allogeneic fresh (group I) or cryopreserved (group II) grafts in Fisher-344 rats (recipients). Cryopreserved segments for grafting were prepared by automated controlled freezing at a cooling rate of 1°C/min followed by storage in liquid nitrogen vapour at -145°C for 30 days. Before grafting, the vessels were slowly thawed. Animals were sacrificed at 14, 30, 90 and 180 days post-surgery when graft specimens were obtained for light and electron microscopy and immunohistochemical detection of inflammatory cells (CD45, ED1, CD4, CD8).
After surgery, 85.71% of the grafts in group I and 82.14% in group II were patent. Following long-term implant, both the fresh and cryopreserved allografts showed complete loss of the muscle compartment of the media. Inflammatory or CD45-positive cells (mainly macrophages and CD8 T-lymphocytes) were detected at earlier time points in suture zones and adventitia. In the fresh allografts, the number of immunolabelled cells steadily increased until they were seen to occupy the entire adventitia at 90 days, with high numbers persisting at 6 months. In the cryopreserved allografts, this adventitial inflammatory infiltrate was significantly reduced.
The cryopreservation/slow thawing protocol used diminished the immune response induced by fresh arterial allografts improving their behaviour after grafting.
Histology and histopathology 07/2012; 27(7):873-84. · 2.48 Impact Factor
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ABSTRACT: PURPOSE: The use prosthetic materials for the surgical repair of abdominal wall defects has become almost standard practice. This study was designed to assess the expression of different growth factors (VEGF/TGF-β1) and macrophages during the early host tissue incorporation of several polypropylene lightweight (PP-LW)-including one partially absorbable-and heavyweight (PP-HW) prosthetic meshes. METHODS: Ventral defects were created in the anterior abdominal wall of New Zealand rabbits and repaired by fixing PP-LW meshes of different pore size and a low porosity PP-HW mesh to the edges of the defect. Following killing 14 days after implant, specimens were taken to examine TGF-β1/VEGF gene and protein expression by qRT-PCR and immunohistochemistry. The macrophage response was also assessed. RESULTS: All the materials showed good host tissue incorporation, with a more severe inflammatory reaction and greater numbers of macrophages recorded in the partially absorbable LW implants. Relative amounts of VEGF mRNA were significantly lower for the LW partially absorbable implants compared with the remaining LW meshes. Protein expression of VEGF showed undetectable or minimum staining in the different groups. TGF-β1 mRNA levels were also lower in the partially absorbable group compared with one of PP-LW type of mesh. Gene expression patterns were consistent with the TGF-β1 protein levels detected. CONCLUSIONS: The results suggest that VEGF and TGF-β1 expression were independent of mesh pore size. The expression of both growth factors and the macrophage response were correlated with the presence of biodegradable material in the mesh. The presence of absorbable material in the LW mesh gave rise to a more intense inflammatory reaction and the reduced synthesis of growth factors known to contribute to neotissue maturation.
Hernia 06/2012; · 1.84 Impact Factor
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ABSTRACT: Routine hernia repair surgery involves the implant of synthetic mesh. However, this type of procedure may give rise to pain and bowel incarceration and strangulation, causing considerable patient disability. The purpose of this study was to compare the long-term behaviour of three commercial meshes used to repair the partially herniated abdomen in New Zealand White rabbits: the heavyweight (HW) mesh, Surgipro(®) and lightweight (LW) mesh, Optilene(®), both made of polypropylene (PP), and a mediumweight (MW) mesh, Infinit(®), made of polytetrafluoroethylene (PTFE). The implanted meshes were mechanical and histological assessed at 14, 90 and 180 days post-implant. This behaviour was compared to the anisotropic mechanical behaviour of the unrepaired abdominal wall in control non-operated rabbits. Both uniaxial mechanical tests conducted in craneo-caudal and perpendicular directions and histological findings revealed substantial collagen growth over the repaired hernial defects causing stiffness in the repair zone, and thus a change in the original properties of the meshes. The mechanical behaviour of the healthy tissue in the craneo-caudal direction was not reproduced by any of the implanted meshes after 14 days or 90 days of implant, whereas in the perpendicular direction, SUR and OPT achieved similar behaviour. From a mechanical standpoint, the anisotropic PP-lightweight meshes may be considered a good choice in the long run, which correlates with the structure of the regenerated tissue.
Journal of the mechanical behavior of biomedical materials. 01/2012; 5(1):257-71.
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ABSTRACT: The material properties of meshes used in hernia surgery contribute to the overall mechanical behaviour of the repaired abdominal wall. The mechanical response of a surgical mesh has to be defined since the haphazard orientation of an anisotropic mesh can lead to inconsistent surgical outcomes. This study was designed to characterize the mechanical behaviour of three surgical meshes (Surgipro®, Optilene® and Infinit®) and to describe a mechanical constitutive law that accurately reproduces the experimental results. Finally, through finite element simulation, the behaviour of the abdominal wall was modelled before and after surgical mesh implant. Uniaxial loading of mesh samples in two perpendicular directions revealed the isotropic response of Surgipro® and the anisotropic behaviour of Optilene® and Infinit®. A phenomenological constitutive law was used to reproduce the measured experimental curves. To analyze the mechanical effect of the meshes once implanted in the abdomen, finite element simulation of the healthy and partially herniated repaired rabbit abdominal wall served to reproduce wall behaviour before and after mesh implant. In all cases, maximal displacements were lower and maximal principal stresses higher in the implanted abdomen than the intact wall model. Despite the fact that no mesh showed a behaviour that perfectly matched that of abdominal muscle, the Infinit® mesh was able to best comply with the biomechanics of the abdominal wall.
Acta biomaterialia 06/2011; 7(11):3905-13. · 3.98 Impact Factor
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ABSTRACT: The aims of this study are to experimentally characterize the passive elastic behaviour of the rabbit abdominal wall and to develop a mechanical constitutive law which accurately reproduces the obtained experimental results. For this purpose, tissue samples from New Zealand White rabbits 2150±50 (g) were mechanically tested in vitro. Mechanical tests, consisting of uniaxial loading on tissue samples oriented along the craneo-caudal and the perpendicular directions, respectively, revealed the anisotropic non-linear mechanical behaviour of the abdominal tissues. Experiments were performed considering the composite muscle (including external oblique-EO, internal oblique-IO and transverse abdominis-TA muscle layers), as well as separated muscle layers (i.e., external oblique, and the bilayer formed by internal oblique and transverse abdominis). Both the EO muscle layer and the IO-TA bilayer demonstrated a stiffer behaviour along the transversal direction to muscle fibres than along the longitudinal one. The fibre arrangement was measured by means of a histological study which confirmed that collagen fibres are mainly responsible for the passive mechanical strength and stiffness. Furthermore, the degree of anisotropy of the abdominal composite muscle turned out to be less pronounced than those obtained while studying the EO and IO-TA separately. Moreover, a phenomenological constitutive law was used to capture the measured experimental curves. A Levenberg-Marquardt optimization algorithm was used to fit the model constants to reproduce the experimental curves.
Journal of the mechanical behavior of biomedical materials. 04/2011; 4(3):392-404.
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ABSTRACT: Extracellular matrix deposition is the main factor inducing stenotic lesions in arterial grafts. Lysyl oxidases (LOX) play a key role in stabilizing collagen and elastin.
To examine the repair response to arterial allografts in terms of LOX expression and collagen/elastin deposition using LOX inhibitors.
Lewis/Fisher-344 rats were used as donors/recipients. Donor segments were grafted to the right iliac artery of recipients and retrieved 14/30 (short-term) or 90/180 days (long-term) after surgery. One group of animals was injected with a potent irreversible LOX inhibitor daily for 30 days.
Intimal hyperplasia increased in thickness until 90/180 days postsurgery. Elastin showed great expression in the neointima at 14/30 days and in the media at 90/180 days. LOX/LOXL1 were similarly expressed in the arterial wall during the first month. In the long term, their overexpression was confined to neointimal layers. At 14 days, collagen types I/III were identified in the grafts. The neointima acquired collagen I over time. In the group of animal treated with the LOX inhibitor, intimal hyperplasia was significantly inhibited.
LOX were overexpressed in late stages of intimal hyperplasia in the allografts. LOX inhibitors prevented the development of the neointimal layer, such that their modulation could reduce the excessive extracellular matrix deposition that leads to stenosis.
Journal of Vascular Research 01/2011; 48(1):43-51. · 2.65 Impact Factor
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ABSTRACT: Destruction of the limbal epithelium barrier is the most important mechanism of pterygium formation (conjunctiva proliferation, encroaching onto the cornea). It is thought to arise from activated and proliferating limbal epithelial stem cells. The objective of this study is to evaluate the presence of undifferentiated mesenchymal cells (stem cells) in cultured cells extracted from human pterygium.
Cells from 6 human pterygium were isolated by explantation and placed in cultures with amniomax medium. Once the monolayer was reached the cells were seeded onto 24 well microplates. The cells were studied in the second sub-culture. The immunohistochemical expression of different embryonic stem cell markers, OCT3/4 and CD9, was analysed. The differentiated phenotypes were characterised with the monoclonal antibodies anti-CD31, α-actin and vimentin.
All the cell populations obtained from pterygium showed vimentin expression. Less than 1% of the cells were positive for CD31 and α-actin markers. The majority of the cell population was positive for OCT3/4 and CD9.
The cell population obtained from pterygium expressed mesenchymal cell phenotype and embryonic markers, such us OCT3/4 and CD9. This undifferentiated population could be involved in the large recurrence rate of this type of tissue after surgery.
Archivos de la Sociedad Espanola de Oftalmologia 12/2010; 85(12):400-4.
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American journal of surgery 07/2010; 203(4):553-4. · 2.36 Impact Factor
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ABSTRACT: Expanded polytetrafluoroethylene (ePTFE) is a microporous, laminar, hydrophobic prosthetic material with a negative charge.
It is composed of compact nodules interlinked by fine fibers. The length of these fibers determines the material’s internodal
distance and pore size.
12/2009: pages 393-399;
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ABSTRACT: The aetiology of inguinal hernia involves changes in collagen turnover and metalloproteinase expression; yet it is not known whether the elastic fibre system could also be affected. This study was designed to compare the expression of tropoelastin (TE), lysyl oxidase-like 1 (LOXL-1) and elastase in the transversalis fascia of patients with and without inguinal hernia.
Transversalis fascia (TF) specimens were obtained from patients undergoing surgery for direct or indirect inguinal hernia (n = 20 each) and from multi-organ donors during organ procurement (controls, n = 16). The specimens were divided according to age (20-40/41-60 years). Tissues were immunohistochemically labelled using anti-tropoelastin, anti-LOXL-1 and anti-elastase antibodies and subjected to Western blot analysis. Relative amounts of LOXL-1 and TE mRNA were determined by real time RT-PCR in cultured cells obtained from the TF of patients and controls.
Significantly lower TE and LOXL-1 levels were observed in patients with direct inguinal hernia compared with controls or those with indirect hernia. In contrast, patients with direct inguinal hernia showed significantly higher elastase expression. In fibroblasts isolated from the TF, relative amounts of tropoelastin mRNA were lower for the hernia groups but differences were not significant. LOXL-1 mRNA levels were significantly lower in the direct hernia group compared to controls.
Our findings suggest that impaired elastic fibre function in the transversalis fascia of patients with direct inguinal hernia, reflected by diminished elastin synthesis and its enhanced enzyme degradation, contributes to the development of this type of hernia.
European Journal of Clinical Investigation 05/2009; 39(4):328-37. · 3.02 Impact Factor
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ABSTRACT: New generation prosthetic biomaterials for abdominal wall repair have been designed to be less dense, by having larger pores than that of the standard polypropylene meshes, to improve abdominal wall compliance. The aim of the present study was to analyze the functional and morphologic properties of these new meshes. For this purpose, 7 x 5 cm(2) defects were created in the anterior abdominal wall of 36 male New Zealand White rabbits and repaired using different polypropylene meshes: a heavyweight mesh (HW), Surgipro, and two lightweight meshes (LW), Parietene and Optilene. Six animals each implanted with biomaterial were sacrificed on postoperative days 14 and 90. Histological and morphometric analysis, adhesion assessment, and biomechanical resistance tests were performed. Similar behavior was shown by the LW and HW meshes in terms of the adhesions and macrophage response induced. After 14 days, the tensile strength of Optilene was greater than the strengths recorded for the other two biomaterials, probably because of its high elasticity. By 90 days, however, the tensile strengths of the three biomaterials were comparable. In conclusion, despite an initial tensile strength advantage shown by the mesh with larger pores, at 90 days postimplant, tensile strengths were similar. Compared with HW, LW prostheses have the benefit that less foreign material was implanted, preserving the elasticity of the recipient host tissue.
Journal of Biomedical Materials Research Part B Applied Biomaterials 11/2008; 89(2):448-55. · 2.15 Impact Factor
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ABSTRACT: Elastin expression is higher in tissues where elastic fibres are essential for the correct maintenance of function such as blood vessels. Elastin expression usually diminishes with age, however, it may be re-expressed in response to injury or repair processes. Some authors attribute the characteristic loss of elasticity of the varicose vein to a drop in the population of smooth muscle cells in the media layer. A reduction in elastin has been observed in chronic venous insufficiency, but little is known about some of the factors involved in elastin synthesis such as lysyl oxidases. The aim of this study was to examine the in vivo expression of the elastin precursor, tropoelastin (TE), and lysyl oxidase-like 1 (LOXL1), a cross-linking enzyme responsible for elastin polymer deposition. The effects of age on these expression patterns were also evaluated.
Saphenous vein segments were obtained during surgery from organ donors (controls, n=20) and subjects with venous insufficiency (varicose veins, n=20). Both these groups were subdivided according to subject age into <50 years (n=10) and >or=50 years (n=10). Control and varicose vein tissue specimens were immunolabelled using anti-tropoelastin and anti-LOXL1 antibodies and also subjected to Western blot analysis.
Our results indicate that the levels of these markers of elastin synthesis (LOXL/tropoelastin) in the vein wall diminish in a significant way (p<0.05) with the age factor. Excluding the age factor, LOXL1 was significantly decreased in the varicose condition (p<0.05). In the younger pathological population they showed an inverse relationship (LOXL decreased, tropoelastin increased).
The already established reduction in elastin in the varicose condition may be related, at least in part, to the decreased LOXL1 levels observed here. These events could reduce spontaneous reticulation of elastin and the partial loss of tissue elasticity in this group of patients.
Histology and histopathology 02/2008; 23(2):179-86. · 2.48 Impact Factor
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ABSTRACT: The aetiology of inguinal hernia includes changes in collagen turnover and metalloproteinase (MMP) expression, and direct hernia has been linked to increased MMP-2 expression. Since transforming growth factor beta1 (TGFbeta1) plays a role in tissue remodelling, this growth factor could directly affect metalloproteinase secretion and thus the proteolytic activity of these enzymes. We hypothesized that TGFbeta1 expression could also be altered in direct inguinal hernias.
Tissue specimens were obtained from the transversalis fascia (TF) of organ donors (controls; n = 10) and patients with inguinal hernia (indirect; n = 20/direct; n = 20), who were also divided into two groups according to age (20-40/41-60 years). Tissue sections were immunohistochemically labelled using anti-LAP TGFbeta1 (latent form) and anti-TGFbeta1 (active form) antibodies, and fragments of tissue were subjected to Western blot analysis.
No significant differences in LAP-TGFbeta1 expression were detected between specimens from control and hernia patients. However, significantly higher levels of active TGFbeta1 were detected in the TF of patients with direct hernia (P < 0.05). Age affected the expression of the growth factor in its active form, and significant differences emerged between direct hernias and controls/indirect hernias only in the younger age groups.
Our findings indicate overexpression of the active form of TGFbeta1 in the TF of young patients with direct hernia. This overexpression reflects an attempt to counterbalance the enhanced matrix degradation process observed in these patients, identifying a subset of patients requiring the use of a prosthetic material for primary hernia repair.
European Journal of Clinical Investigation 06/2007; 37(6):516-21. · 3.02 Impact Factor
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ABSTRACT: When a biomaterial is used to repair an abdominal wall defect, wound contraction can cause the prosthesis to shrink, and the tension generated can provoke recurrence of the defect. This study was designed to determine whether the structure of a prosthesis can directly influence prosthetic shrinkage. Abdominal wall defects (7 x 5 cm) in rabbits were repaired using the laminar prosthesis DualMesh (DM), the composites Sepramesh (Se) and Vypro II (Vy), and the reticular prosthesis Surgipro (PP). The animals were sacrificed 14 and 90 days after surgery, at which time implant specimens were morphologically and immunohistochemically examined to establish the presence of myofibroblasts and macrophages. The size of each prosthesis was measured at the end of the study through image analysis. Morphometric measurements revealed greatest prosthesis shrinkage for Se, PP, and Vy (16.05% +/- 5.08%; 13.75% +/- 4.22%; 16.16% +/- 6.34%), while the DM prostheses only showed a 7.57% +/- 0.62% decrease in size (p < 0.05). In the DM implants, the macrophage response and myofibroblast labeling were reduced. Both biomaterial structure and the macrophage reaction induced at the implant site modulate prosthetic shrinkage, laminar prostheses of the ePTFE type undergoing less shrinkage than reticular meshes. Reduced DM shrinkage was linked to decreased myofibroblast numbers 2 weeks postimplant.
Journal of Biomedical Materials Research Part B Applied Biomaterials 08/2006; 78(2):340-6. · 2.15 Impact Factor
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ABSTRACT: This study was designed to evaluate the extent of adhesion formation to prostheses fixed with spiral tacks and to establish whether the use of Ringer's lactate or icodextrin could prevent these adhesions.
24 New Zealand white rabbits weighing around 3,000 g were implanted with a 7 x 5 cm patch of ePTFE (DualMesh) through a midline laparotomy. The prosthesis was fixed to the intact peritoneum using spiral tacks. Three study groups were established according to whether the animals were: implanted with ePTFE fixed with spiral tacks or implanted with ePTFE fixed with spiral tacks and simultaneously administered Ringer's lactate or 4% icodextrin in the peritoneal cavity. Adhesion formation and prosthetic behavior at the prosthesis/peritoneal interface were evaluated and quantified by sequential laparoscopy performed at 3, 7 and 14 days.
Adhesions generally formed on the tacks and were classified as the fully integrated type. No significant differences were observed in terms of the extent of adhesions or of neoperitoneal thickness between control animals and those receiving Ringer's lactate or icodextrin.
(a) Prosthesis-fixing tacks induced adhesions; (b) the use of substances such as icodextrin or Ringer's lactate does not seem to diminish adhesion formation, and (c) the use of icodextrin offered no benefits over that of Ringer's lactate solution.
European Surgical Research 02/2006; 38(5):458-63. · 0.93 Impact Factor
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ABSTRACT: The component of a composite prosthesis, which makes contact with the visceral peritoneum, can be reabsorbable or non-reabsorbable, and laminar or reticular. This study was designed to determine whether the composition of this second, barrier component could improve its behavior at this interface. Abdominal wall defects in rabbits were repaired using a polypropylene prosthesis (PP), or the composites Sepramesh (PP + h) or Vicryl (PP + v). Fourteen days after surgery, the implants were evaluated by light and scanning electron microscopy, and immunohistochemistry. Prosthetic areas occupied by adhesions (PP: 71.08 +/- 5.09, PP + h: 18.55 +/- 4.96, P + v: 69.69 +/- 16.81%), neoperitoneal thickness (PP: 256.17 +/- 21.68, PP + h: 83.11 +/- 19.63, PP + v:213.72 +/- 35.90 microm) and macrophage counts (PP: 8.73 +/- 1.16, PP + h: 27.33 +/- 4.13, PP + v: 31.24 +/- 3.08%) showed significant differences (P < 0.05). The tested biomaterials induced an optimal recipient tissue infiltration. Least adhesion formation was observed on the PP + h implants. This suggests that the second component, although reabsorbable, should be smooth in structure.
Hernia 12/2005; 9(4):338-43. · 1.84 Impact Factor
