Download systemic response to polypropylene mesh used for the repair of

LUCRĂRI ŞTIINłIFICE MEDICINĂ VETERINARĂ VOL. XLI, 2008, TIMIŞOARA
SYSTEMIC RESPONSE TO POLYPROPYLENE MESH USED FOR
THE REPAIR OF ABDOMINAL WALL DEFECTS IN HORSES
C. OBER, A. MUSTE, L. OANĂ, N. MATEŞ, F. BETEG
University of Agricultural Sciences and Veterinary Medicine, 400372 Cluj-Napoca,
Calea Manastur no. 3-5, Cluj, Romania,
[email protected]
Summary
Tissue damage following defects of abdominal wall repair might be accompanied by
triggering of the systemic response. The purpose of this study was to assess the
modifications in the systemic response (leukocytes, C-reactive protein (CRP), albumin,
fibrinogen and C3 complement fraction) after subcutaneous premuscular-aponevrosis and
retromuscular implantation of polypropylene mesh in 5 horses.
Key words: horses, polypropylene mesh, eventration, inflammation
Polypropylene (PP) mesh is one of the most frequent materials used in
hernia repair in humans. The good results achieved with the different implants
available and the low incidence of recurrence after the repair of these defects has
placed prosthetic materials at the forefront with respect to the conventional suture
repair techniques (Burger et al. 2004, Kingsnorth et al. 2003). Also, mesh
hernioplasty is one option for repair of large abdominal wall defects in horses and
other large animal species. Operations using either knitted polypropylene or woven
plastic mesh are reportedly successful in over 80% of large animal patients
(Tulleners and Fretz 1983; van der Velden and Klein 1994).
Materials and methods
Five patients with defects of abdominal wall were included in this study
(Table 1).
The two methods performed for the repair of these defects were the
subcutaneous premuscular-aponevrosis method for three patients (no. 1,3 and 4)
and retromuscular method for two of its (no. 2 and 5). Peripheral venous blood
samples were collected preoperatively (24 h before surgery) and then 1, 2, 3 and 7
days postoperatively. The animals were supposed for a diet of 24 hours, was
effectuated body hygiene and a completely clinical examinations. It was placed an
intravenous catheter (jugular vein) for the administration of perfusions.
General anaesthesia was induced with a combination of Xylazine 0,3 mg/
kg bwt and Ketamine 2,2 mg/kg bwt, i.v. via jugular vein catheter. The animals was
intubated orotracheally and mantained on inhalant anaesthesia using Isoflurane.
The animals were positioned in lateral recumbency opposite of the
abdominal wall defect. The surgery place was aseptically prepared and draped for
surgery.
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LUCRĂRI ŞTIINłIFICE MEDICINĂ VETERINARĂ VOL. XLI, 2008, TIMIŞOARA
Table 1
Clinical cases used in this study
No. clinical cases (n=5)
Nr.
crt
1.
Species
Race
Horse
Metis
2.
Horse
3.
Age
Sex
Service
Abdominal wall defect
9 years
M
Traction
Metis
7 years
M
Traction
Horse
Metis
14 years
F
Traction
Eventration in cord of right
flank region
4.
Horse
Metis
16 years
M
Traction
Irreducible inguinal hernia
5.
Horse
Metis
12 years
F
Traction
Eventration in cord of left flank
region
Eventration in flank bevel
region
Eventration in left
underabdominal region
Instrumentary used was the proper surgery instrumentary for this kind of
interventions. The prosthetic meshes used contain polypropylene filament and
have dimensions of 30 X 30 cm.
Results and discussions
Hernioplasty determined an increase of leukocytes, maximum values being
recorded in first 2 days postoperative (Fig. 1). These increased values are induced
by tissue aggression of prosthetic biomaterial, a maxim aggression in first days
postoperative which decrease after beggining of the reparatory activity.
Like a member of a class which contains inflammatory markers for an
acute phase, was monitorised C-reactive protein (CRP). Semnificative elevated
blood levels of C-reactive protein (CRP) observed in first days after operation have
been suggested that the polypropylene mesh generate an intense inflammatory
response, especially in patients operated by retromuscular method (Fig. 2).
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LUCRĂRI ŞTIINłIFICE MEDICINĂ VETERINARĂ VOL. XLI, 2008, TIMIŞOARA
Leukocyte dynamics
pacient nr. 2
pacient nr. 5
pacient nr. 3
ziua 7
ziua 3
ziua 2
ziua 1
100000
90000
80000
70000
60000
50000
40000
30000
20000
10000
0
preoperator
leucocite (WBC)
pacient nr. 1
pacient nr. 4
Fig.1. Comparison of leukocytes count (103/µl) preoperative and over time after
operation.
C-reactive protein dynamics
proteina C
reactiva (mg/dl)
pacient nr. 1
pacient nr. 2
pacient nr. 3
pacient nr. 4
pacient nr. 5
6
4
2
0
preoperator
ziua 2
ziua 7
Fig.2. Preoperative and postoperative C-reactive protein values
Albumin was investigated as a negative acute-phase protein and used for
clinical outcomes prediction. After the implantation of the prosthetic material was a
slight but not significant decrease in albumin levels and after seven days the levels
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LUCRĂRI ŞTIINłIFICE MEDICINĂ VETERINARĂ VOL. XLI, 2008, TIMIŞOARA
were in physiological limits (Fig. 3). The inflammatory reaction is the main reason
for depressed serum albumin levels.
Albumin dynamics
albumina (g/dl)
pacient nr. 1
pacient nr. 2
pacient nr. 3
pacient nr. 4
pacient nr. 5
4
3
2
1
0
preoperator
ziua 2
ziua 7
Fig.3. Preoperative and postoperative albumin values
In that polypropylene mesh generate an acute inflammatory response,
especially in patients operated by retromuscular method is illustrated by a
significantly increasing of concentrations of fibrinogen immediately postoperatively
compared to baseline (Fig. 4).
Fibrinogen dynamics
fibrinogen
(mg/dl)
pacient nr. 1
pacient nr. 2
pacient nr. 3
pacient nr. 4
pacient nr. 5
600
400
200
0
preoperator
ziua 2
ziua 7
Fig.4. Preoperative and postoperative fibrinogen values
Because the polypropylene mesh has a hydrophobe surface, it has affinity
C3 complement fraction-fixing, as we can see in Fig. 5.
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LUCRĂRI ŞTIINłIFICE MEDICINĂ VETERINARĂ VOL. XLI, 2008, TIMIŞOARA
C3 complement fraction dynamics
Complement
C3 (mg/dl)
pacient nr. 1
pacient nr. 2
pacient nr. 3
pacient nr. 4
pacient nr. 5
100
50
0
preoperator
ziua 2
ziua 7
Fig. 5: Preoperative and postoperative C3 complement fraction values
It is widely accepted that, the introduction of a foreign body in the host
might elicit inflammatory response and subsequent complications (R. Rosch et al.
2003). Such prolonged changes represent the total physiological response to
surgical trauma (G. Di Vita et al. 2001). The process of wound healing is a
continuum that classically is separated into a series of overlapping phases:
coagulation, inflammation, proliferation, angiogenesis, and resolution. The
inflammatory phase of wound healing is characterized by the infiltration of
neutrophils, macrophages, and lymphocytes, which participate by releasing
proinflammatory cytokines and growth factors, ingesting foreign materials,
increasing vascular permeability, and promoting fibroblast activity (Polverini et al.
1977, Hunt et. al. 1984).
We present evidence that serum levels of CRP, leukocytes and fibrinogen
were significantly increased postoperatively in all patients compared with their
baseline values. We also observed the affinity of polypropylene mesh for C3
complement fraction-fixing and depressing of serum albumin levels. More
significantly increased postoperatively values were observed in patients operated
by retromuscular method.
Follow up all the patients revealed a lower incidence of complications, 50
days postoperatively. This approach is associated with early postoperative return to
usual activities and a very low recurrence rate.
Conclusions
1. The present study is attempting to compare the application of a
polypropylene mesh by two conventional methods for the repair of abdominal
wall defects in horses concerning their effect on triggering of the
inflammatory cascade.
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LUCRĂRI ŞTIINłIFICE MEDICINĂ VETERINARĂ VOL. XLI, 2008, TIMIŞOARA
2. We present evidence that serum levels of CRP, leukocytes and fibrinogen
were significantly increased postoperatively in all patients compared with
their baseline values.
3. Polypropylene mesh has affinity for C3 complement fraction-fixing and
depress serum albumin levels.
4. This analysis seems to confirm that different surgical procedures may
induce various levels of inflammation and that the implantation of prostheses
significantly stimulates the inflammatory response.
5. Based on these findings, it might be sugessted that application of a
polyprophylene mesh is a safer method of repair of abdominal wall defects in
horses.
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