Small intestinal submucosa as a bioscaffold for tissue regeneration in defects of the colonic wall

Optimization of decellularization methods using human small intestinal submucosa for scaffold generation in regenerative medicine

Porcine small intestinal submucosa, despite its successful use as a scaffold in regenerative medicine, has innate biomechanical heterogeneity. In this study, we hypothesized that human small intestinal submucosa could be a viable alternative bio-scaffold. For the first time, we characterize submucosal extraction from human small intestine and examine appropriate decellularization methods. In total, 16 human small intestinal submucosal samples were obtained and decellularized using three reported methods of porcine decellularization: Abraham, Badylak, and Luo. For each method, four specimens were decellularized. The remaining four specimens were designated as non-decellularized. We measured the amount of residual DNA and growth factors in decellularized human intestinal samples. Additionally, decellularized human small intestinal submucosa was co-cultured with mouse bone marrow-derived mesenchymal stem cells to examine mesenchymal stem cell survival and proliferation. The reference value for the amount of residual DNA deemed appropriate in decellularized tissue was established as 50 ng/mg of extracellular matrix dry weight or less. Abraham's method most successfully met this criterion. Measurement of residual growth factors revealed low levels observed in samples decellularized using the Abraham and Badylak methods. Co-culture of each small intestinal submucosal sample with mouse bone marrow-derived mesenchymal stem cells confirmed viable cell survival and proliferation in samples derived using protocols by Abraham and Badylak. Abraham's method most successfully met the criteria for efficient tissue decellularization and cell viability and proliferation. Thus, we consider this method most suitable for decellularization of human small intestinal submucosa.

Porcine Small Intestinal Submucosa (SIS) as a Suitable Scaffold for the Creation of a Tissue-Engineered Urinary Conduit: Decellularization, Biomechanical and Biocompatibility Characterization Using New Approaches

Bladder cancer (BC) is among the most common malignancies in the world and a relevant cause of cancer mortality. BC is one of the most frequent causes for bladder removal through radical cystectomy, the gold-standard treatment for localized muscle-invasive and some cases of high-risk, non-muscle-invasive bladder cancer. In order to restore urinary functionality, an autologous intestinal segment has to be used to create a urinary diversion. However, several complications are associated with bowel-tract removal, affecting patients' quality of life. The present study project aims to develop a bio-engineered material to simplify this surgical procedure, avoiding related surgical complications and improving patients' quality of life. The main novelty of such a therapeutic approach is the decellularization of a porcine small intestinal submucosa (SIS) conduit to replace the autologous intestinal segment currently used as urinary diversion after radical cystectomy, while avoiding an immune rejection. Here, we performed a preliminary evaluation of this acellular product by developing a novel decellularization process based on an environmentally friendly, mild detergent, i.e., Tergitol, to replace the recently declared toxic Triton X-100. Treatment efficacy was evaluated through histology, DNA, hydroxyproline and elastin quantification, mechanical and insufflation tests, two-photon microscopy, FTIR analysis, and cytocompatibility tests. The optimized decellularization protocol is effective in removing cells, including DNA content, from the porcine SIS, while preserving the integrity of the extracellular matrix despite an increase in stiffness. An effective sterilization protocol was found, and cytocompatibility of treated SIS was demonstrated from day 1 to day 7, during which human fibroblasts were able to increase in number and strongly organize along tissue fibres. Taken together, this in vitro study suggests that SIS is a suitable candidate for use in urinary diversions in place of autologous intestinal segments, considering the optimal results of decellularization and cell proliferation. Further efforts should be undertaken in order to improve SIS conduit patency and impermeability to realize a future viable substitute.

Small intestinal submucosa: superiority, limitations and solutions, and its potential to address bottlenecks in tissue repair

Over the past few decades, small intestinal submucosa (SIS), a naturally occurring decellularized extracellular matrix (ECM), has attracted much attention in tissue repair because it can provide plentiful bioactive factors and a biomimetic three-dimensional microenvironment to induce desired cellular functions. In this article, the state-of-the-art research studies on SIS are reviewed, which are mainly centered on three aspects: (1) main superiority such as remarkable bioactivity, low immunogenicity, satisfactory resorbability and promising recellularization; (2) current efforts to overcome its limitations mainly focusing on reducing the naturally occurring heterogeneity, controlling the degradation rate and improving the mechanical properties; (3) great potential in solving the bottleneck problems encountered in repairing various tissues with particular emphasis on cardiovascular, urogenital, abdominal wall, skin, musculotendinous, gastrointestinal, vaginal, and bone tissues. In addition, future research trends are proposed in the conclusion and perspectives section.

Naturally-Derived Biomaterials for Tissue Engineering Applications

Naturally-derived biomaterials have been used for decades in multiple regenerative medicine applications. From the simplest cell microcarriers made of collagen or alginate, to highly complex decellularized whole-organ scaffolds, these biomaterials represent a class of substances that is usually first in choice at the time of electing a functional and useful biomaterial. Hence, in this chapter we describe the several naturally-derived biomaterials used in tissue engineering applications and their classification, based on composition. We will also describe some of the present uses of the generated tissues like drug discovery, developmental biology, bioprinting and transplantation.

Extracellular Matrix Bioscaffolds for Building Gastrointestinal Tissue

Regenerative medicine is a rapidly advancing field that uses principles of tissue engineering, developmental biology, stem cell biology, immunology, and bioengineering to reconstruct diseased or damaged tissues. Biologic scaffolds composed of extracellular matrix have shown great promise as an inductive substrate to facilitate the constructive remodeling of gastrointestinal (GI) tissue damaged by neoplasia, inflammatory bowel disease, and congenital or acquired defects. The present review summarizes the preparation and use of extracellular matrix scaffolds for bioengineering of the GI tract, identifies significant advances made in regenerative medicine for the reconstruction of functional GI tissue, and describes an emerging therapeutic approach.

Use of small intestinal submucosal and acellular dermal matrix grafts in giant omphaloceles in neonates and a rabbit abdominal wall defect model

BACKGROUND

The described surgical strategies for the management of omphalocele include primary closure, staged closure, and delayed closure. A primary repair is not suitable for all giant omphaloceles. We implanted two grafts, small intestinal submucosal (SIS) and acellular dermal matrix (ADM) onto abdominal wall defects in neonates to study the safety and efficacy of SIS and ADM graft techniques for initial closure of giant omphaloceles in infants, and we also implanted these grafts onto abdominal wall defects in an animal model.

METHODS

Twenty-four patients with giant omphaloceles were divided into two groups (ADM group, 12 patients; SIS group, 12 patients). The operative time, skin healing time postoperatively, and the incidence of skin infections, and abdominal wall hernias were observed. In the rabbit animal model, bilateral full-thickness incisions were made through the rabbit rectus abdominus muscles and a 2×4cm longitudinal whole layer defect was created on either the left or right lateral anterior abdominal wall. A four-layered variant of the SIS graft was used to repair the right abdominal defect; ADM was used to repair the left. Tensile strength was measured using an Instron tensiometer. Electron scanning and light microscopy were used to evaluate neovascularization, collagen deposition, and muscle fibers at 2, 4, 8, and 16weeks postimplantation.

RESULTS

In the neonatal patients, there was no statistically significant difference between the two groups with respect to operative time, skin healing time postoperatively, the incidence of skin infections, or abdominal wall hernias. In the SIS group, only one patient developed a skin infection, which led to skin necrosis and sloughing. In the ADM group, four patients developed skin infection postoperatively, and the patch was gradually removed. In the animal study, there was no significant difference between the mean breaking strength of ADM versus SIS repairs. Scanning electron and light microscopy showed collagen deposition, increased vascularization, fibroblasts, and muscular regeneration in both SIS and ADM repairs. SEM showed that the SIS graft was absorbed, while ADM was not. Light microscopy showed foreign body macrophages in ADM, but not in the SIS repairs.

CONCLUSION

SIS and ADM grafts adequately enhance healing with a low complication rate. Compared with ADM grafts, SIS is absorbable, induces less inflammation, and is more biocompatible, and therefore might be more useful and suitable for closure of abdominal wall defects.

Colorectal tissue engineering: A comparative study between porcine small intestinal submucosa (SIS) and chitosan hydrogel patches

OBJECTIVE

Tissue engineering may provide new operative tools for colorectal surgery in elective indications. The aim of this study was to define a suitable bioscaffold for colorectal tissue engineering.

METHODS

We compared 2 bioscaffolds with in vitro and in vivo experiments: porcine small intestinal submucosa (SIS) versus chitosan hydrogel matrix. We assessed nontoxicity of the scaffold in vitro by using human adipose-derived stem cells (hADSC). In vivo, a 1 × 2-cm colonic wall defect was created in 16 rabbits. Animals were divided randomly into 2 groups according to the graft used, SIS or chitosan hydrogel. Graft area was explanted at 4 and 8 weeks. The end points of in vivo experiments were technical feasibility, behavior of the scaffold, in situ putative inflammatory effect, and the quality of tissue regeneration, in particular smooth muscle layer regeneration.

RESULTS

In vitro, hADSC attachment and proliferation occurred on both scaffolds without a substantial difference. After proliferation, hADSCs kept their mesenchymal stem cell characteristics. In vivo, one animal died in each group. Eight weeks after implantation, the chitosan scaffold allowed better wound healing compared with the SIS scaffold, with more effective control of inflammatory activity and an integral regeneration of the colonic wall including the smooth muscle cell layer.

CONCLUSION

The outcomes of in vitro experiments did not differ greatly between the 2 groups. Macroscopic and histologic findings, however, revealed better wound healing of the colonic wall in the chitosan group suggesting that the chitosan hydrogel could serve as a better scaffold for colorectal tissue engineering.

Small intestinal submucosa segments as matrix for tissue engineering: review

Tissue engineering (TE) is an emerging interdisciplinary field aiming at the restoration or improvement of impaired tissue function. A combination of cells, scaffold materials, engineering methods, and biochemical and physiological factors is employed to generate the desired tissue substitute. Scaffolds often play a pivotal role in the engineering process supporting a three-dimensional tissue formation. The ideal scaffold should mimic the native extracellular environment providing mechanical and biological properties to allow cell attachment, migration, and differentiation, as well as remodeling by the host organism. The scaffold should be nonimmunogenic and should ideally be resorbed by the host over time, leaving behind only the regenerated tissue. More than 40 years ago, a preparation of the small intestine was introduced for the replacement of vascular structures. Since then the small intestinal submucosa (SIS) has gained a lot of interest in TE and subsequent clinical applications, as this material exhibits key features of a highly supportive scaffold. This review will focus on the general properties of the SIS and its applications in therapeutical approaches as well as in generating tissue substitutes in vitro. Furthermore, the main problem of TE, which is the insufficient nourishment of cells within three-dimensional, artificial tissues exceeding certain dimensions is addressed. To solve this issue the implementation of another small intestine-derived preparation, the biological vascularized matrix (BioVaM), could be a feasible option. The BioVaM comprises in addition to SIS the arterial and venous mesenteric pedicles and exhibits thereby a perfusable vessel bed that is preserved after decellularization.

Quantification of MSCs involved in wound healing: use of SIS to transfer MSCs to wound site and quantification of MSCs involved in skin wound healing

Mesenchymal stem cells (MSCs) are known to be effective in wound healing, but not much has been reported on quantitative correlations between MSCs injected into the wound site and MSCs that actually participate in wound healing. This study traced MSCs participating in wound healing by using small intestinal submucosa (SIS) as a cell carrier, identified their moving path and calculated the number of MSCs involved in wound healing. First, MSCs were isolated from the nude mouse and 1 × 10(6) cells were seeded onto the centre of the SIS. MSC-seeded SIS complexes were injected onto full-thickness skin wounds made on the dorsum of nude mice. Tracing of MSC-seeded SIS complex transplanted to the wound site revealed that 27.6% of the MSCs were migrated to the wound site at the first attempt. Second, repeated injection of additional MSCs did not increase the number of MSCs participating in wound healing beyond a certain constant maximum amount. The number of MSCs present in the wound site remains constant in the range 2-3 × 10(5) from day 1 to day 10. The expression of skin regeneration-related growth factors was confirmed by real-time polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA). MSCs participating in wound healing were found not only to suppress inflammation of the wound but also to increase the skin regeneration-related growth factors that enable the recovery of the skin. An optimal number of about 3 × 10(5) MSCs injected into the site was found to adapt themselves to the skin wound-healing process effectively.

A multi-step method for preparation of porcine small intestinal submucosa (SIS)

Porcine small intestinal submucosa (SIS) has been widely used in repairing various tissues and organs. Despite this, some SIS products have the capacity to cause variable inflammatory responses after implantation resulting in severe adverse effects due to porcine cell existence. In this study, we described a multi-step method including mechanical disassociation, degrease, enzyme digestion, detergent treatment, freeze-drying and sterilization by irradiation for preparation of SIS. The efficacy of acellularization was evaluated by histological observation and the content of porcine immunoreceptor DAP12 gene. The change of growth factors contents within SIS accompanying with decellularization was quantitatively assessed by ELISA. Inflammatory reaction of SIS implanted subcutaneously in a rat was investigated. The histological examination revealed no remaining cells after enzyme digestion. Moreover, qPCR analysis demonstrated that the content of a porcine immunoreceptor gene DAP12 DNA in final SIS product (SISv) was only 1.05% of that in SIS samples (SISi) prepared by mechanical disassociation. Degrease with methanol/chloroform dramatically reduced the contents of VEGF, b-FGF, TGF-β, and TNF-α within SISii, but further treatment could not significantly reduced the contents of growth factors. SIS implanted into rats showed that inflammatory cells was more accumulated surrounded to SISi at 1, and 2 weeks, but reduced in SISv samples. The degree of inflammatory reaction for SISv was significantly less than that of SISi.

Enhanced angiogenesis of modified porcine small intestinal submucosa with hyaluronic acid-poly(lactide-co-glycolide) nanoparticles: from fabrication to preclinical validation

Hyaluronic acid-poly(de-co-glycolide) nanoparticles (HA-PLGA NPs) were synthesized to stabilize the porous structure of porcine small intestinal submucosa (SIS), to improve surface biocompatibility and to enhance performance in tissue regeneration. HA-PLGA NPs were characterized for size, zeta potential, surface morphology, and HA loading. Human microvascular endothelial cells responded to HA-PLGA NPs and HA-PLGA modified SIS (HA-PLGA-SIS) with elevated cell proliferation. HA-PLGA-SIS significantly enhanced neo-vascularization in an in ovo chorioallantoic membrane angiogenesis model. The angiogenic capability of the newly fabricated HA-PLGA-SIS was tested in a canine bladder augmentation model. Urinary bladder augmentation was performed in beagle dogs following hemi-cystectomy using HA-PLGA-SIS. The regenerated bladder was harvested at 10 weeks post augmentation and vascularization was evaluated using CD31 immunohistochemical staining. Bladder regenerated with HA-PLGA-SIS had significantly higher vascular ingrowth compared to unmodified SIS. This study shows that HA-PLGA NPs may represent a new approach for modifying naturally derived SIS biomaterials in regenerative medicine.

Extracellular matrices for gastrointestinal surgery: Ex vivo testing and current applications

AIM: To assess the effects of bile and pancreatic juice on structural and mechanical resistance of extracellular matrices (ECMs) in vitro.

METHODS: Small-intestinal submucosa (SIS), porcine dermal matrix (PDM), porcine pericardial matrix (PPM) and bovine pericardial matrix (BPM) were incubated in human bile and pancreatic juice in vitro. ECMs were examined by macroscopic observation, scanning electron microscopy (SEM) and testing of mechanical resistance.

RESULTS: PDM dissolved within 4 d after exposure to bile or pancreatic juice. SIS, PPM and PDM retained their integrity for > 60 d when incubated in either digestive juice. The effect of bile was found to be far more detrimental to mechanical stability than pancreatic juice in all tested materials. In SIS, the loss of mechanical stability after incubation in either of the digestive secretions was less distinct than in PPM and BPM [mFmax 4.01/14.27 N (SIS) vs 2.08/5.23 N (PPM) vs 1.48/7.89 N (BPM)]. In SIS, the extent of structural damage revealed by SEM was more evident in bile than in pancreatic juice. In PPM and BPM, structural damage was comparable in both media.

CONCLUSION: PDM is less suitable for support of gastrointestinal healing. Besides SIS, PPM and BPM should also be evaluated experimentally for gastrointestinal indications.

Anastomotic sealing by extracellular matrices (ECM) improves healing of colonic anastomoses in the critical early phase

BACKGROUND

Extracellular matrices have proven potential for in vivo tissue regeneration at gastrointestinal luminal organs. In this study, small intestinal submucosa (SIS) was tested as a sealant for colonic anastomoses in a rodent model.

METHODS

In the rodent model, standard colonic anastomoses in the control group (CG; n = 30) and anastomoses sealed by omentum (n = 30) were compared to SIS-sealed anastomoses in the study group (SG; n = 30). After 4-, 30-, and 90-day macroscopic and microscopic healing, bursting pressure and anastomotic stricture rate were evaluated.

RESULTS

The rate of anastomotic dehiscence was 1/10 after 4 days and 0/10 after 30 and 90 days in all groups. In the SG, the bursting pressure was significantly increased after 4 days compared to CG (148 +/- 9 vs. 108 +/- 8 mmHg; p > 0.05). Histologically, after 4 days of neovascularization, fibroblast ingrowth and collagen deposition were significantly increased in SG compared to CG. After 30 days, nonsignificant differences were noted in all three parameters. Adhesion rate and anastomotic stricture rate were not significantly affected by SIS sealing after 4, 30, and 90 days.

CONCLUSION

Especially in the critical phase of anastomotic healing up to day 4, anastomotic healing was improved by SIS sealing. SIS sealing did not cause long-term complications.

Distinctive degradation behaviors of electrospun polyglycolide, poly(DL-lactide-co-glycolide), and poly(L-lactide-co-epsilon-caprolactone) nanofibers cultured with/without porcine smooth muscle cells

Biodegradable nanofibers have become a popular candidate for tissue engineering scaffolds because of their biomimetic structure that physically resembles the extracellular matrix. For certain tissue regeneration applications, prolonged in vitro culture time for cellular reorganization and tissue remodeling may be required. Therefore, extensive understanding of cellular effects on scaffold degradation is needed. There are only few studies on the degradation of nanofibers, and also the studies on degradation throughout cell culture are rare. In this study, polyglycolide (PGA), poly(DL-lactide-co-glycolide) (PLGA) and poly(L-lactide-co-epsilon-caprolactone) [P(LLA-CL)] were electrospun into nanofibrous meshes. The nanofibers were cultured with porcine smooth muscle cells for up to 3 months to evaluate their degradation behavior and cellular response. The results showed that the degradation rates are in the order of PGA >> PLGA > P(LLA-CL). PGA nanofibers degraded in 3 weeks and supported cell growth only in the first few days. PLGA nanofiber scaffolds facilitated cell growth during the first 30 days after seeding, but cell growth was slow thereafter. P(LLA-CL) nanofibers facilitated long-term (1-3 months) cell growth. mRNA quantification using real-time polymerase chain reaction revealed that some smooth muscle cell markers (alpha-actinin and calponin) and extracellular matrix genes (collagen and integrin) seemed to be downregulated with increased cell culture time. Cell culture significantly increased the degradation rate of PGA nanofibers, whereas the effect on PLGA and P(LLA-CL) nanofibers was limited. We found that the molecular weight of P(LLA-CL) and PLGA nanofibers decreased linearly for up to 100 days. Half lives of PLGA and P(LLA-CL) nanofibers were shown to be 80 and 110 days, respectively. In summary, this is the first study to our knowledge to evaluate long-term polymeric nanofiber degradation in vitro with cell culture. Cell culture accelerated the nanofibrous scaffold degradation to a limited extent. P(LLA-CL) nanofibers could be a good choice as scaffolds for long-term smooth muscle cell culture.

The porcine small intestinal submucosa (SIS) patch in foot and ankle reconstruction

We undertook a retrospective cohort study of 54 patients who underwent foot and ankle soft tissue reconstructive surgery augmented with a porcine small intestinal submucosal (SIS) patch. The mean patient age was 44 (range 17 to 68) years, there were 21 (38.89%) males in the cohort, and the mean follow-up duration was 1080 (range 365 to 1943) days. Clinical outcomes were considered excellent in 46 (85.19%) patients, good/fair in 3 (5.56%) patients, and poor in 5 (9.26%) patients; and no adverse events attributable to the xenograft were observed. Direct SIS patch failure, resulting in stretching of the repair, re-tear, or tendon stenosis, occurred in 3 (5.56%) patients, and delayed incision healing occurred in 6 (11.11%) patients. Based on our observations, we concluded that the porcine SIS xenograft, when used to augment cellular and vascular in-growth, is a viable adjunct to musculoskeletal reconstructions of the foot and ankle.