Hyperbaric oxygen therapy improves colorectal anastomotic healing

Could hyperbaric oxygen be an effective therapy option for pathological scars? A systematic review and meta-analysis

BACKGROUND

Hyperbaric oxygen (HBO) therapy involves breathing pure oxygen or a high oxygen concentration above atmospheric (ATM) pressure in an enclosed chamber. Studies on pathological scars have demonstrated that HBO can inhibit the formation of pathological scars.

OBJECTIVE

To evaluate the efficacy of HBO in the treatment of pathological scars via meta-analysis.

METHODS

Searches were run on various databases, including the Cochrane, Embase, PubMed, Web of Science, and CNKI databases. A comparative study was conducted on patients with pathological scars treated with or without HBO. We used RevMan 5.4 software to determine the recurrence rate, treatment satisfaction, and Vancouver Scar Scale(VSS) score in the pathological scar.

RESULTS

A total of 543 publications were identified; after screening, four were selected for review, including one randomized controlled trial (RCT), one controlled clinical trial (CCT), and two retrospective cohort studies. Meta-analysis results showed that HBO treatment reduced the pathological scar recurrence rate after surgery and radiotherapy (OR = 0.26, 95% CI: 0.13-0.52, p = 0.0001). Patients had higher satisfaction after HBO therapy (OR = 4.45, 95% CI: 1.49-13.30, p = 0.007). The Vancouver scar scale (VSS) score of patients with pathological scars was significantly improved in the HBO group (SMD: -3.82, 95% CI: -6.07to -0.49, p = 0.02).

CONCLUSIONS

HBO treatment decreased the recurrence rate of pathological scars after surgery and radiotherapy, increased patient satisfaction, and reduced the VSS score, thus providing a new way to treat pathological scar hyperplasia. However, evaluation of the longer-term effects of HBO treatment requires further comprehensive studies, including more RCTs.

Arterial supply to the rat colon

Rats are often used as animal models in studies such as on intestinal transplantation and anastomosis healing, which require colectomy. Although detailed information regarding arterial supply is important to establish accurate and reproducible experimental procedures, this has not been studied in the rat colon. Therefore, we analysed the detailed arterial distribution pattern and its individual variations in the colon of 34 rats. The rat colon received colic branches of the ileocolic artery, and the right, middle and left colic arteries. The single left colic artery constantly arose from the caudal mesenteric artery and was distributed to the descending colon, whereas the others showed variations in number and distribution. The ileocolic artery gave rise to one (12%) or two (88%) colic branches supplying the proximal ascending colon, and these branches formed rich, mesh-like anastomoses along the initial portion of the ascending colon. One (74%) or two (26%) right colic arteries originated from the cranial mesenteric artery and supplied the ascending colon and right colic flexure. Moreover, one (38%), two (56%) or three (6%) middle colic arteries emerged from the cranial mesenteric artery and were distributed to the transverse colon, left colic flexure and proximal descending colon. In total, we categorized the individual variations in arterial branching and anastomosis into 11 patterns. Arterial supply to the rat colon showed a specific pattern and frequent individual variations. These findings thus provide essential information for establishing reproducible models of rat colic surgery.

Inhibition of HIF-prolyl hydroxylases improves healing of intestinal anastomoses

Anastomotic leakage (AL) accounts for a major part of in-house mortality in patients undergoing colorectal surgery. Local ischemia and abdominal sepsis are common risk factors contributing to AL and are characterized by upregulation of the hypoxia-inducible factor (HIF) pathway. The HIF pathway is critically regulated by HIF-prolyl hydroxylases (PHDs). Here, we investigated the significance of PHDs and the effects of pharmacologic PHD inhibition (PHI) during anastomotic healing. Ischemic or septic colonic anastomoses were created in mice by ligation of mesenteric vessels or lipopolysaccharide-induced abdominal sepsis, respectively. Genetic PHD deficiency (Phd1-/-, Phd2+/-, and Phd3-/-) or PHI were applied to manipulate PHD activity. Pharmacologic PHI and genetic PHD2 haplodeficiency (Phd2+/-) significantly improved healing of ischemic or septic colonic anastomoses, as indicated by increased bursting pressure and reduced AL rates. Only Phd2+/- (but not PHI or Phd1-/-) protected from sepsis-related mortality. Mechanistically, PHI and Phd2+/- induced immunomodulatory (M2) polarization of macrophages, resulting in increased collagen content and attenuated inflammation-driven immune cell recruitment. We conclude that PHI improves healing of colonic anastomoses in ischemic or septic conditions by Phd2+/--mediated M2 polarization of macrophages, conferring a favorable microenvironment for anastomotic healing. Patients with critically perfused colorectal anastomosis or abdominal sepsis could benefit from pharmacologic PHI.

Ischemic proctitis 6 months after laparoscopic sigmoidectomy: a case report

Background

Ischemic colitis is a common disease; however, its pathophysiology remains unclear, especially in ischemic proctitis after sigmoidectomy. We present a rare case of ischemic proctitis 6 months after laparoscopic sigmoidectomy.

Case presentation

The patient was a 60-year-old man with hypertension, type 2 diabetes, and hyperlipidemia. He was a smoker. He underwent laparoscopic sigmoidectomy for pathological stage I sigmoid colon cancer and was followed up without any adjuvant therapy. Six months after his surgery, he complained of lower abdominal discomfort, bloody stools, and tenesmus. Colonoscopy showed extensive rectal ulcers between the anastomotic site and the anal canal, which was particularly severe on the anal side several centimeters beyond the anastomosis. We provided non-surgical management, including hyperbaric oxygen therapy. The rectal ulcers had healed 48 days after the therapeutic intervention. He has not experienced any recurrence for 3.5 years.

Conclusions

While performing sigmoidectomy, it is important to consider the blood backflow from the anal side of the bowel carefully, especially for patients with risk factors of ischemic proctitis.

Effect of preconditioning and postoperative hyperbaric oxygen therapy on colonic anastomosis healing with and without ischemia in rats

Purpose

To investigate the effect of hyperbaric oxygen therapy on colonic anastomosis healing with and without ischemia in rats.

Methods

Forty female rats underwent segmental resection of 1 cm of the left colon followed by end-to-end anastomosis. They were randomly assigned to four groups (n=10 each), a sham group; two groups were submitted to Hyperbaric Oxygen therapy (HBOT) with and without induced ischemia and the induced ischemia group without HBOT. The HBOT protocol evaluated was 100% O2 at 2.4 Atmosphere absolute pressure (ATA) for 60 minutes, two sessions before as a preconditioning protocol and three sessions after the operation. Clinical course and mortality were monitored during all experiment and on the day of euthanasia on the fourth day after laparotomy. Macroscopic appearance of the abdominal cavity were assessed and samples for breaking strength of the anastomosis and histopathological parameters were collected.

Results

There was no statistically significant difference in mortality or anastomosis leak between the four experimental groups. Anastomosis breaking strength was similar across groups.

Conclusion

The HBOT protocol tested herein at 2.4 ATA did not affect histopathological and biomechanical parameters of colonic anastomotic healing, neither the clinical outcomes death and anastomosis leak on the fourth day after laparotomy.

Study of the Effect of Hyperbaric Oxygen Therapy on the Viability of Dorsal Cutaneous Flaps in Tobacco-Exposed Rats

BACKGROUND

Smoking causes a threefold increase in the risk of surgical complications in flaps. Hyperbaric oxygen therapy (HBOT) increases the viability of chronic wounds. However, there are few studies concerning the effects of HBOT on surgical flaps in patients who smoke. This study aimed to analyze the effect of HBOT on the viability of cutaneous flaps in tobacco-exposed rats.

METHODS

Twenty Wistar rats were exposed to tobacco smoke for two months. Following this period, all animals underwent a dorsal cutaneous flap (3 × 10 cm) surgery and were divided into two groups: control (n = 10) and HBOT (n = 10). HBOT was performed in seven daily sessions (2 ATA, 90 min). After seven days, the animals were euthanized. The outcomes were total area, viable area, viable area/total area rate, analysis of dermal appendages and angiogenesis (hematoxylin-eosin), and gene expression analysis of iNOS and VEGF-a biomarkers.

RESULTS

The HBOT group showed an increase in viable area compared with the control group (84% versus 47%, p = 0.009, respectively). The HBOT group also showed an increase in appendage units (1.69 ± 0.54 versus 1.87 ± 0.58, p = 0.04) and angiogenesis density (1.29 ± 0.45 versus 1.82 ± 0.64, p < 0.001) compared to the control group. There was a difference between the control and HBOT groups in iNOS levels (0.926 ± 1.4 versus 0.04 ± 0.1 p = 0.002, respectively). However, this study did not show a difference between the groups concerning the gene expression of VEGF-a.

CONCLUSION

The use of hyperbaric oxygen therapy increased the viability of cutaneous flaps in tobacco-exposed rats and decreased iNOS mRNA levels; however, it did not change VEGF-a levels. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Experimental fortification of intestinal anastomoses with nanofibrous materials in a large animal model

Anastomotic leakage is a severe complication in gastrointestinal surgery. It is often a reason for reoperation together with intestinal passage blockage due to formation of peritoneal adhesions. Different materials as local prevention of these complications have been studied, none of which are nowadays routinely used in clinical practice. Nanofabrics created proved to promote healing with their structure similar to extracellular matrix. We decided to study their impact on anastomotic healing and formation of peritoneal adhesions. We performed an experiment on 24 piglets. We constructed 3 hand sutured end-to-end anastomoses on the small intestine of each pig. We covered the anastomoses with a sheet of polycaprolactone nanomaterial in the first experimental group, with a sheet of copolymer of polylactic acid with polycaprolactone in the second one and no fortifying material was used in the Control group. The animals were sacrificed after 3 weeks of observation. Clinical, biochemical and macroscopic signs of anastomotic leakage or intestinal obstruction were monitored, the quality of the scar tissue was assessed histologically, and a newly developed scoring system was employed to evaluate the presence of adhesions. The material is easy to manipulate with. There was no mortality or major morbidity in our groups. No statistical difference was found inbetween the groups in the matter of level of peritoneal adhesions or the quality of the anastomoses. We created a new adhesion scoring system. The material appears to be safe however needs to be studied further to prove its' positive effects.

Systematic Review on the Influence of Tissue Oxygenation on Gut Microbiota and Anastomotic Healing

BACKGROUND

Anastomotic leak rates have not improved over several decades despite improvements in surgical techniques and patient care. The gut microbiome has been implicated in the development of leaks. The exact mechanisms by which tissue oxygenation affects gut microbial composition and anastomotic healing physiology are unclear. Also, commonly used carbon dioxide (CO₂) is a known vasodilator that improves tissue oxygen tension. We performed a systematic review to determine the influence of hyperoxia, hypoxia, and hypercapnia on the gut microbiome and anastomotic healing.

METHODS

A literature search was performed in MEDLINE, EMBASE, and COCHRANE to identify studies investigating the effects of hyperoxia, hypoxia, and hypercapnia on anastomotic healing and gut microbiota published between 1998 and 2018. Two reviewers screened the articles for eligibility and quality. Fifty-three articles underwent full text review, and a narrative synthesis was undertaken.

RESULTS

Hyperoxia is associated with better anastomotic healing, increased gastrointestinal oxygen tension, and may reduce gut anaerobes. Hypoxia is associated with poor healing and increased gut anaerobes. However, it is unclear if hypoxia is the most important predictor of anastomotic leaks. Low pressure CO₂ pneumoperitoneum and mild systemic hypercapnia are both associated with increased gastrointestinal oxygen tension and may improve anastomotic healing. We found no studies which investigated the effect of hypercapnia on gut microbiota in the context of anastomotic healing.

CONCLUSIONS

Tissue oxygenation influences gut anastomotic healing, but little evidence exists to demonstrate the influence on the gut microbiome in the context of healing. Further studies are needed to determine if anastomotic microbiome changes with altered tissue oxygenation and if this affects healing and leak rates. If confirmed, altering tissue oxygenation through hyperoxia or hypercapnia could be feasible means of altering the microbiome such that anastomotic leak rates reduce.

Effect of oxygen-producing suture material on hypoxic colonic anastomoses in an experimental model

Background

Anastomotic leak remains a significant cause of morbidity and mortality after colorectal surgery. Among multiple risk factors considered, hypoxia–ischaemia is considered to be a primary cause of intestinal anastomotic leakage. The aim of this experimental study was to assess safety, usability for surgical tasks, and efficacy of a newly developed oxygen‐producing suture material in the healing of colonic anastomoses under critical conditions.

Methods

An oxygen‐producing suture material was produced that is capable of releasing oxygen directly into the surrounding tissue. Off‐the‐shelf sutures loaded with calcium peroxide nano‐crystals and covered with poly(d,l‐lactide‐co‐glycolide) were assessed in vitro and in a rat model of hypoxic colonic anastomosis.

Results

In vitro assessment showed that these sutures can increase oxygen levels in a hypoxic environment. Potential oxygen byproducts did not seem to have a negative impact on the viability of intestinal cells. The use of oxygen‐producing sutures in vivo resulted in increased tissue oxygen saturation, measured by visible light spectroscopy, and increased mechanical stability of the anastomosis.

Conclusion

Oxygen‐producing suture material increased tissue oxygen saturation and mechanical stability of colonic anastomosis in a rat model.

Meta-analysis on the effect of hyperbaric oxygen as adjunctive therapy in the outcome of anastomotic healing of experimental colorectal resections in rats

BACKGROUND

Colorectal cancer is the third most common form of cancer and colorectal surgery is the treatment of choice in local disease. Anastomotic leakage following colorectal surgery is a major complication with a high incidence and mortality. Adjuvant hyperbaric oxygen treatment (HBOT) may be associated with reduction of anastomotic leakage. A systematic review was conducted regarding HBOT as an adjunctive therapy to colorectal surgery.

METHODS

Systematic review (1900-2017) using PubMed, Cochrane, EMBASE, Web of Science and EMCARE. All original published studies on the effect of HBOT as an adjunctive therapy for colorectal surgery with the creation of an anastomosis were considered.

RESULTS

Thirteen small animal trials were included for qualitative synthesis. We found no human trials. Eleven trials used bursting pressure whilst eight used hydroxyproline levels as a marker for collagen synthesis as primary outcome to assess the strength of the anastomosis. A meta-analysis performed for normal and ischaemic anastomoses showed that postoperative HBOT improves bursting pressure and hydroxyproline levels significantly in both normal (p ≤ 0.001 and p = 0.02) and ischaemic anastomoses (p ≤ 0.001 and p = 0.04).

CONCLUSION

Postoperative HBOT has a positive effect on colorectal anastomoses in rats. Further research should focus on a larger systematic animal study.

The triune of intestinal microbiome, genetics and inflammatory status and its impact on the healing of lower gastrointestinal anastomoses

Gastrointestinal resections are a common operation and most involve an anastomosis to rejoin the ends of the remaining bowel to restore gastrointestinal (GIT) continuity. While most joins heal uneventfully, in up to 26% of patients healing fails and an anastomotic leak (AL) develops. Despite advances in surgical technology and techniques, the rate of anastomotic leaks has not decreased over the last few decades raising the possibility that perhaps we do not yet fully understand the phenomenon of AL and are thus ill-equipped to prevent it. As in all complex conditions, it is necessary to isolate each different aspect of disease for interrogation of its specific role, but, as we hope to demonstrate in this article, it is a dangerous oversimplification to consider any single aspect as the full answer to the problem. Instead, consideration of important individual observations in parallel could illuminate the way forward towards a possibly simple solution amidst the complexity. This article details three aspects that we believe intertwine, and therefore should be considered together in wound healing within the GIT during postsurgical recovery: the microbiome, the host genetic make-up and their relationship to the perioperative inflammatory status. Each of these, alone or in combination, has been linked with various states of health and disease, and in combining these three aspects in the case of postoperative recovery from bowel resection, we may be nearer an answer to preventing anastomotic leaks than might have been thought just a few years ago.