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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. 237 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). 238 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 239 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. 240 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. 241 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. References 1. Burger A.M.D., R.W.P. Luijendijk, W.C.J.P. Hop, J. A.M.D. Halm, E.G.G.M.D. Verdaasdonk, J.P. Jeekel, Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia, 2004, Ann Surg 240, 578–585. 2. DI Vita G., S. Milano, R. Patti et al., Cytokine modifications after tensionfree hernioplasty or open conventional inguinal hernia repair, 2001, Am J Surg 181, 487–491. 3. Gaughan E.M., Inguinal hernias in horses, 1998, Compend Contin Educ Pract Vet 20:1057–1059. 4. Hunt T.K., D.R. Knighton, K.K. Thakral et al., Studies on inflammation and wound healing angiogenesis and collagen synthesis stimulated in vivo by resident and activated wound macrophages, 1984, Surgery 96, 48–54. 5. Kingsnorth A.,K. Leblanc, Hernias: inguinal and incisional, 2003, Lancet 362, pp. 1561–1571. 6. Marien T., Standing laparoscopic herniorrhaphy in stallions using cylindrical polypropylene mesh prosthesis, 2001, Equine Vet J 33:91–96. 7. Muste A., Patologia şi clinica bolilor chirurgicale, 2008, Ed. Risoprint, ClujNapoca. 8. Polverini, P.J., P.S. Cotran, M.A. Gimbrone JR et al., Activated macrophages induce vascular proliferation, 1977, Nature 269, 804–806. 9. Rosch R., Junge K., A. Schachtrupp, U. Klinge, B. Klosterhalfen, V. Schumpelick, Mesh implants in hernia repair. Inflammatory cell response in a rat model, 2003, Eur. Surg. Res. 35 (2003), 161–166. 10. Tulleners E.P., Fretz P.B., Prosthetic repair of large abdominal wall defects in horses and food animals, 1983, J. Am. vet. med. Ass, 258-262. 11. 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