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Ernst L, Kümmecke AM, Zieglowski L, Liu W, Schulz M, Czigany Z, Tolba RH. Implementation of the Surgical Apgar Score in Laboratory Animal Science: A Showcase Pilot Study in a Porcine Model and a Review of the Literature. Eur Surg Res 2023; 64:54-64. [PMID: 34903685 PMCID: PMC9808704 DOI: 10.1159/000520423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/21/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION In an attempt to further improve surgical outcomes, a variety of outcome prediction and risk-assessment tools have been developed for the clinical setting. Risk scores such as the surgical Apgar score (SAS) hold promise to facilitate the objective assessment of perioperative risk related to comorbidities of the patients or the individual characteristics of the surgical procedure itself. Despite the large number of scoring models in clinical surgery, only very few of these models have ever been utilized in the setting of laboratory animal science. The SAS has been validated in various clinical surgical procedures and shown to be strongly associated with postoperative morbidity. In the present study, we aimed to review the clinical evidence supporting the use of the SAS system and performed a showcase pilot trial in a large animal model as the first implementation of a porcine-adapted SAS (pSAS) in an in vivo laboratory animal science setting. METHODS A literature review was performed in the PubMed and Embase databases. Study characteristics and results using the SAS were reported. For the in vivo study, 21 female German landrace pigs have been used either to study bleeding analogy (n = 9) or to apply pSAS after abdominal surgery in a kidney transplant model (n = 12). The SAS was calculated using 3 criteria: (1) estimated blood loss during surgery; (2) lowest mean arterial blood pressure; and (3) lowest heart rate. RESULTS The SAS has been verified to be an effective tool in numerous clinical studies of abdominal surgery, regardless of specialization confirming independence on the type of surgical field or the choice of surgery. Thresholds for blood loss assessment were species specifically adjusted to >700 mL = score 0; 700-400 mL = score 1; 400-55 mL score 2; and <55 mL = score 3 resulting in a species-specific pSAS for a more precise classification. CONCLUSION Our literature review demonstrates the feasibility and excellent performance of the SAS in various clinical settings. Within this pilot study, we could demonstrate the usefulness of the modified SAS (pSAS) in a porcine kidney transplantation model. The SAS has a potential to facilitate early veterinary intervention and drive the perioperative care in large animal models exemplified in a case study using pigs. Further larger studies are warranted to validate our findings.
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Affiliation(s)
- Lisa Ernst
- Institute for Laboratory Animal Science & Experimental Surgery, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
- *Lisa Ernst,
| | - Anna Maria Kümmecke
- Institute for Laboratory Animal Science & Experimental Surgery, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Leonie Zieglowski
- Institute for Laboratory Animal Science & Experimental Surgery, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Wenjia Liu
- Department of Surgery and Transplantation, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Mareike Schulz
- Institute for Laboratory Animal Science & Experimental Surgery, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - René H. Tolba
- Institute for Laboratory Animal Science & Experimental Surgery, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
- **René H. Tolba,
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A Proof-of-Concept Preclinical Study Using a Novel Thermal Insulation Device in a Porcine Kidney Auto-Transplantation Model. Int J Mol Sci 2022; 23:ijms232213806. [PMID: 36430283 PMCID: PMC9697795 DOI: 10.3390/ijms232213806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
Ischemia-reperfusion injury remains a fundamental problem during organ transplantation logistics. One key technical factor is the rapid allograft rewarming during the time of vascular reconstruction in the recipient. In this pilot study, a new thermal insulation bag (TIB) for organ transplantation was used. Insulation capacity, tissue compatibility, and usability were tested initially ex vivo on porcine kidneys (n = 24) followed by the first in vivo usage. Fourteen female German landrace pigs underwent kidney auto-transplantation after 24 h cold storage (4 °C). During the implantation process the kidney was either insulated with the new TIB, or it was not thermo-protected at all, which represents the clinical standard. In this proof-of-concept study, the usability (knife-to-skin-time) and the general thermal capacity (30 min warm storage at 38 °C ex vivo p < 0.001) was shown. The clinical outcome showed significant differences in the determination of CRP and pi-GST levels. Syndecan-1 Antibody staining showed clear significant higher counts in the control group (p < 0.01) indicating epithelial damage. However, the effect on renal outcomes in not severely pre-damaged kidneys does not appear to be conclusively significant. A close follow-up study is warranted, especially in the context of marginal organs or in cases where anastomosis-times are prolonged due to surgical complexity (e.g., multiple vessels and complex reconstructions).
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Becker F, Kebschull L, Rieger C, Mohr A, Heitplatz B, Van Marck V, Hansen U, Ansari J, Reuter S, Strücker B, Pascher A, Brockmann JG, Castor T, Alexander JS, Gavins FNE. Bryostatin-1 Attenuates Ischemia-Elicited Neutrophil Transmigration and Ameliorates Graft Injury after Kidney Transplantation. Cells 2022; 11:cells11060948. [PMID: 35326400 PMCID: PMC8946580 DOI: 10.3390/cells11060948] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 12/19/2022] Open
Abstract
Ischemia reperfusion injury (IRI) is a form of sterile inflammation whose severity determines short- and long-term graft fates in kidney transplantation. Neutrophils are now recognized as a key cell type mediating early graft injury, which activates further innate immune responses and intensifies acquired immunity and alloimmunity. Since the macrolide Bryostatin-1 has been shown to block neutrophil transmigration, we aimed to determine whether these findings could be translated to the field of kidney transplantation. To study the effects of Bryostatin-1 on ischemia-elicited neutrophil transmigration, an in vitro model of hypoxia and normoxia was equipped with human endothelial cells and neutrophils. To translate these findings, a porcine renal autotransplantation model with eight hours of reperfusion was used to study neutrophil infiltration in vivo. Graft-specific treatment using Bryostatin-1 (100 nM) was applied during static cold storage. Bryostatin-1 dose-dependently blocked neutrophil activation and transmigration over ischemically challenged endothelial cell monolayers. When applied to porcine renal autografts, Bryostatin-1 reduced neutrophil graft infiltration, attenuated histological and ultrastructural damage, and improved renal function. Our novel findings demonstrate that Bryostatin-1 is a promising pharmacological candidate for graft-specific treatment in kidney transplantation, as it provides protection by blocking neutrophil infiltration and attenuating functional graft injury.
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Affiliation(s)
- Felix Becker
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (F.B.); (L.K.); (C.R.); (A.M.); (B.S.); (A.P.); (J.G.B.)
| | - Linus Kebschull
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (F.B.); (L.K.); (C.R.); (A.M.); (B.S.); (A.P.); (J.G.B.)
| | - Constantin Rieger
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (F.B.); (L.K.); (C.R.); (A.M.); (B.S.); (A.P.); (J.G.B.)
| | - Annika Mohr
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (F.B.); (L.K.); (C.R.); (A.M.); (B.S.); (A.P.); (J.G.B.)
| | - Barbara Heitplatz
- Gerhard Domagk Institute of Pathology, University Hospital Münster, 48149 Münster, Germany; (B.H.); (V.V.M.)
| | - Veerle Van Marck
- Gerhard Domagk Institute of Pathology, University Hospital Münster, 48149 Münster, Germany; (B.H.); (V.V.M.)
| | - Uwe Hansen
- Department of Molecular Medicine, Institute for Musculoskeletal Medicine, University Hospital Münster, 48149 Münster, Germany;
| | - Junaid Ansari
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA;
| | - Stefan Reuter
- Division of General Internal Medicine, Nephrology and Rheumatology, Department of Medicine D, University Hospital of Münster, 48149 Münster, Germany;
| | - Benjamin Strücker
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (F.B.); (L.K.); (C.R.); (A.M.); (B.S.); (A.P.); (J.G.B.)
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (F.B.); (L.K.); (C.R.); (A.M.); (B.S.); (A.P.); (J.G.B.)
| | - Jens G. Brockmann
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (F.B.); (L.K.); (C.R.); (A.M.); (B.S.); (A.P.); (J.G.B.)
| | | | - J. Steve Alexander
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA;
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA
- Correspondence: (J.S.A.); (F.N.E.G.)
| | - Felicity N. E. Gavins
- Department of Life Sciences, Centre for Inflammation Research and Translational Medicine (CIRTM), Brunel University London, Uxbridge UB8 3PH, UK
- Correspondence: (J.S.A.); (F.N.E.G.)
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Abstract
Large animal studies of long-term ischemia reperfusion are hampered by the use of immunosuppressive drugs to inhibit the influence of the allogeneic response. In small animals, this can be controlled by using inbred strains of the animal. For obvious reasons, this is not possible in large animals such as pigs. Since studies in pigs usually are the last step before first-in-man studies, this remains a problem trying to resemble a clinical situation. In the following short paper, we describe a novel auto kidney transplantation model that can be used for long term ischemia reperfusion studies. We also suggest a control setting to balance out the possible influence of an increased surgical trauma.
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