Treatment Of Non-healing Wounds Research Articles

Optimizing a five-factor cocktail to prepare reparative macrophages for wound healing.

The treatment of non-healing wounds, such as diabetic ulcers, remains a critical clinical challenge. Recent breakthroughs in cell therapy have shown great promise, with one primary focus on preparing cells with comprehensive reparative functions and foreseeable safety. In our previous study, we recapitulated the pro-regenerative and immunosuppressive functions of tumor-associated macrophages (TAMs) in non-tumor-derived macrophages, endowing the latter with characteristics for promoting diabetic wound healing - termed TAMs-educated macrophages (TAMEMs). To eliminate the use of tumor-derived sources and devise a more controllable method to prepare TAMEM-like cells, in this study, we identify a cocktail comprising five recombinant proteins as an essential condition to induce non-polarized macrophages (termed TAMEMs5) into therapeutic cells with pro-healing functions. The screened five factors are osteopontin (OPN), macrophage inflammatory protein (MIP)-2, chemokine (C-C motif) ligand 8 (CCL8), vascular endothelial growth factor (VEGF)-B, and macrophage colony-stimulating factor (M-CSF). We demonstrate the rationale for screening these factors and the phenotype of TAMEMs5 prepared from murine bone marrow-derived macrophages, which exhibit angiogenic and immunomodulatory effects in vitro. Then, we induce primary human monocytes from periphery blood into TAMEMs5, which show pro-healing effects in a human primary cell-based ex vivo model (T-SkinTM). Our study demonstrates a simple, effective, and controllable approach to induce primary macrophages to possess repairing activities, which may provide insights for developing cell-based therapeutics for non-healing wounds clinically.

Treatment of a non-healing oral wound in diabetic-induced rats

Aim: Non-healing wounds are one of the most substantial and difficult problems to treat. Wound healing involves a sequence of complex biological processes, but often the oral cavity microbiota adversely affects healing and forms a chronic non-healing wound. Methods: In this study, a biologically active membrane (BAM) is present, consisting of decellularized human amniotic membrane and bone marrow stem cells (BMSCs). The efficacy of BAM was evaluated in a model of non-healing oral wounds in rats with streptozotocin (STZ)-induced diabetes mellitus. Results: Studies have shown that BAM enhanced the healing of chronic oral wounds in animals with induced diabetes mellitus, reduced scarring, and reduced risk of infection. Paracrine freeze-dried BMSCs stimulated angiogenesis and improved wound conditions. Conclusions: BMSCs may lower glucose levels in rats with STZ-induced diabetes mellitus and improve the healing process of chronic diseases. However, more studies are needed to study the paracrine factors of BMSCs and their role in the treatment of non-healing wounds.

Mannose-Decorated Co-Polymer Facilitates Controlled Release of Butyrate to Accelerate Chronic Wound Healing.

Butyrate is a key bacterial metabolite that plays an important and complex role in modulation of immunity and maintenance of epithelial barriers. Its translation to clinic is limited by poor bioavailability, pungent smell, and the need for high doses, and effective delivery strategies have yet to realize clinical potential. Here, a novel polymeric delivery platform for tunable and sustainable release of butyrate consisting of a methacrylamide backbone with butyryl ester or phenyl ester side chains as well as mannosyl side chains, which is also applicable to other therapeutically relevant metabolites is reported. This platform's utility in the treatment of non-healing diabetic wounds is explored. This butyrate-containing material modulated immune cell activation in vitro and induced striking changes in the milieu of soluble cytokine and chemokine signals present within the diabetic wound microenvironment in vivo. This novel therapy shows efficacy in the treatment of non-healing wounds through the modulation of the soluble signals present within the wound, and importantly accommodates the critical temporal regulation associated with the wound healing process. Currently, the few therapies to address non-healing wounds demonstrate limited efficacy. This novel platform is positioned to address this large unmet clinical need and improve the closure of otherwise non-healing wounds.

29-OR: Diabetic Wound Keratinocytes Induce Macrophage JMJD3–Mediated Nlrp3 Expression

Macrophage (Mφ) plasticity is critical for normal wound repair; however, type 2 diabetic (T2D) wound Mφs display a delayed chronic inflammatory state that prevents the resolution of wound inflammation. Increased NLRP3 inflammasome gene expression and activation in Mφs contributes to impaired wound healing in T2D and is induced by diabetic wound environment factors, yet the molecular mechanisms regulating this are unclear. Our lab has shown that keratinocytes, structural cells in the skin, regulate skin inflammation and Mφ phenotype during wound healing by preferentially producing proinflammatory cytokines. Thus, this project explores the molecular mechanisms by which keratinocytes drive increased Nlrp3 expression in diabetic wound Mφs. Here, we found that Nlrp3 expression is increased in diabetic wound Mφs late post-injury, and this can be induced by stimulation of normal wound Mφs with diabetic wound keratinocyte supernatant. Further, we found that stimulation of Mφs with diabetic wound keratinocyte supernatant resulted in decreased H3K27me3 deposition at the Nlrp3 promoter. Using genetically engineered mice (Jmjd3 fl/fl lyz2cre), we demonstrate that JMJD3, a demethylase specific for H3K27, controls Mφ-mediated Nlrp3 expression and inflammasome activation during wound healing. Importantly, we show that diabetic wound keratinocytes induce Jmjd3 expression in Mφs via IL1 receptor and MyD88 upstream signaling. Interestingly, we found that IL1α is increased in human and murine wound diabetic keratinocytes compared to nondiabetic controls and stimulation of Mφs with IL1α increases Nlrp3 expression via a H3K27me3/JMJD3-mediated mechanism. Thus, our data suggest a role for keratinocyte IL1α in driving increased Nlrp3 expression in chronic diabetic wound Mφs via JMJD3. Continued investigation into the dysregulation of the keratinocyte-Mφ axis in diabetic wounds is key to developing novel treatments for non-healing wounds in T2D patients. Disclosure S. Wolf-Fortune: None. J. Moon: None. A. Joshi: None. P. Mazumder: None. E. Barrett: None. K.D. Mangum: None. K. Gallagher: None. Funding National Institutes of Health (1K99DK133828-01, P30DK089503, R01HL137919, R01DK124290, R01HL15627401, R01DK127531)

Modulation of the Wound Healing through Noncoding RNA Interplay and GSK-3β/NF-κB Signaling Interaction

Diabetic foot ulcers are seriously endangering the physical and mental health of patients. Due to the long duration of inflammation, the treatment of nonhealing wounds in diabetes is one of the most prominent healthcare problems in the world. The nuclear factor kappa B (NF-κB) signaling pathway, a classical pathway that triggers inflammatory response, is regulated by many regulators, such as glycogen synthase kinase 3 beta (GSK-3β). Noncoding RNAs, a large class of molecules that regulate gene expression at the posttranscriptional or posttranslational level, play an important role in various stages of wound healing, especially in the stage of inflammation. Herein, we summarized the roles of noncoding RNAs in the NF-κB/GSK-3β signaling, which might provide new ideas for the treatment of diabetic wound healing.

TRPV1: Role in Skin and Skin Diseases and Potential Target for Improving Wound Healing.

Skin is innervated by a multitude of sensory nerves that are important to the function of this barrier tissue in homeostasis and injury. The role of innervation and neuromediators has been previously reviewed so here we focus on the role of the transient receptor potential cation channel, subfamily V member 1 (TRPV1) in wound healing, with the intent of targeting it in treatment of non-healing wounds. TRPV1 structure and function as well as the outcomes of TRPV1-targeted therapies utilized in several diseases and tissues are summarized. In skin, keratinocytes, sebocytes, nociceptors, and several immune cells express TRPV1, making it an attractive focus area for treating wounds. Many intrinsic and extrinsic factors confound the function and targeting of TRPV1 and may lead to adverse or off-target effects. Therefore, a better understanding of what is known about the role of TRPV1 in skin and wound healing will inform future therapies to treat impaired and chronic wounds to improve healing.

Strategies for improving the therapeutic efficacy of mesenchymal stem cells in the treatment of nonhealing wounds

Strategies for improving the therapeutic efficacy of mesenchymal stem cells in the treatment of nonhealing wounds

Generation of Pigmented Skin Grafts from Human Hair Follicles and Dermal Fibroblasts.

Skin equivalents are able to mimic key features of human skin and they can be used for a very broad range of applications, such as fundamental studies of skin biology, disease, and toxicological models, as well as an alternative for animal testing. The high end of their use is in therapy of wound healing and repigmentation and disorders that massively affect individual health as well as quality of life and pose considerable burden to health care systems worldwide. Tissue-engineered skin grafts often originate from invasively obtained cell material (i.e., biopsy). Hereby, an unmet need for noninvasively gained autologous biological starting material has been created. The hair follicle, entirely noninvasively available by plucking, harbors a heterogeneous cell pool, including stem cells with an immense differentiation capacity, hereby representing an attractive source of cells, especially for purposes of regenerative medicine. In this study, we engineered three-dimensional pigmented epidermal and dermoepidermal grafts using human keratinocytes and melanocytes from the outer root sheath of hair follicles combined with dermal fibroblasts. The grafts were generally anatomically correct and functional regarding stratification and formation of epidermal melanin units, as well as extracellular matrix deposition, exhibiting moderate differences to the skin anatomy and function, typical for the in vitro culture. Impact statement The study focuses on generation of tissue-engineered skin equivalents, in particular, as a possible treatment for nonhealing wounds and depigmentation disorders. We developed an in vitro-generated three-dimensional pigmented epidermal and dermoepidermal graft using keratinocytes and melanocytes from the outer root sheath of human hair follicle combined with dermal fibroblasts. The anatomically and functionally correct grafts showed stratification, epidermal melanin units, and extracellular matrix deposition. They present an in vitro base for an autologous, pigmented graft as well as for further personalized in vitro experimental models generated from a noninvasively obtained cell source, addressing the unmet needs of the currently available clinical treatments.

Lucifensin, Chymotrypsin Proteins and Molecular Characterization of Lucilia sericata

Lucilia sericata, one of the most common species of the Calliphoridae family, is found in large numbers around droppings, garbage and carcasses. This fly species is important in medicine, forensics and veterinary medicine. The larvae of the parasite are important both in veterinary medicine and in combating of the animal diseases, as they cause significant losses in animal production. Since they are one of the first fly colonies to settle on corpses, they can also be used in determining the time of death in the field of forensic medicine. L.sericata larvae used in Maggot debridement treatment (MDT) which is a treatment method with fly larvae, help wound healing by destroying necrotic tissues and infectious agents in wounds. While the larvae protect themselves from polymicrobial flora with the proteins they secrete; at the same time, they make an interesting contribution to wound healing with these molecules secreted. One of the most important molecules discovered in recent years is lucimycin which has an antifungal effect. In addition, lucifensin and chymotrypsin secretions have gained importance in recent years due to their antibacterial effects and especially their effects on resistant gram-negative and positive bacteria. There is a need for the discovery of the molecules that can be alternative in the treatment of non-healing wounds or that can be applied together with existing antibiotics. It is necessary to investigate the antimicrobial characterization of the compounds involved in maggot therapy and their mechanisms. The aim of this study was to clone, molecular characterization and analysis of the antigenic structures of lucifensin and chymotrypsin genes, which are important defensin molecules secreted by L.sericata larvae used in MDT. Primarily, the cultivation of L.sericata colonies to be used in molecular studies were performed. Later, RNA isolation and cDNA synthesis from larvae were carried out. Lucifensin and chymotrypsin genes were individually inserted into the pJet1.2 plasmid by cloning reactions. The presence of the recombinant plasmid was confirmed by PCR screening and DNA sequence analysis methods in all steps. Nucleotide and amino acid based molecular characterizations of these two genes, which are important larval components in wound treatment, have been made. Antigenic regions and three-dimensional structures of the proteins were obtained. The isolate numbered MT495795 of the L.sericata lucifensin gene and the isolate numbered MT495794 of the chymotrypsin gene were registered to GenBank. This data reported for the first time in the Republic of Turkey will contribute to the literature. From the beginning of the 20th century until the discovery of the antibiotics, MDT was applied especially on soldiers but did not find much application area after the discovery of the antibiotics. Drug resistance, which is the most important problem encountered in the treatment of the wounds today, has led to the recall of MDT and its mechanism of action. In this study the data, obtained will constitute a source for the multidisciplinary studies of the scientists from different fields on the discovery and applicability of the important moleculesin the treatment of the wounds.

Molecular Characterization of Lucimycin Gene of Lucilia sericata

Lucilia sericata, a member of the Calliphoridae family, is one of the most common species in the genus Lucilia. Medical importance of L.sericata stems from its use in maggot debridement therapy (MDT). MDT is the name of L.sericata larvae being sterilized and used in the treatment of non-healing wounds. L.sericata maggots used in the treatment of chronic and non-healing wounds (decubitus ulcer, venous leg ulcer, diabetic foot ulcer, etc.) clean the wounds with the help of secreted proteolytic trypsin and lucimycin -like enzymes. The aim of the study was to determine the molecular characterization of lucimycin gene obtained from L.sericata larvae in MDT by using molecular methods and to contribute to the literature. In this study, continuous production of adult colonies of L.sericata species was carried out in insectarium unit where conditions such as light, humidity and temperature were formed. The life cycle of L.sericata was followed and the production of eggs, larvae, pupae, adult flies and fly colonies of the species were formed. In the third stage larvae obtained from adult flies in the insectarium unit, RNA was isolated and subsequently cDNA synthesis was performed by reverse transcription. Polymerase chain reaction (PCR) analysis of the synthesized cDNAs with the specific primers designed for the lucimycin gene of L.sericata was performed and the obtained amplicons were cloned into pJET1.2/blunt vector and the plasmid was purified. The recombinant plasmids were sequenced with vector-specific primers and target gene region sequences were obtained. After the molecular characterization of the isolate with nucleotide sequences was determined, it was registered to GenBank database with the accession number MF964229. The PCR product of 288 bp was obtained from the cDNA obtained from the larvae of L.sericata produced in the insectarium unit by PCR using lucimycin specific primers. The PCR product imaged on the gel was purified by transformation and subsequent colonies were screened to see whether they contained recombinant plasmids. Three of the colonies were identified as recombinant plasmids containing L.sericata lucimycin gene by PCR screening. From three colonies confirmed by PCR screening, recombinant plasmids containing L.sericata lucimycin gene were purified by miniprep. The recombinant plasmid product was confirmed to contain the L.sericata lucimycin gene by PCR from a total of 20 μl of the recombinant plasmid miniprep product. DNA sequencing analysis was performed to confirm the plasmid after cloning. The 288 bp L.sericata lucimycin sequence was confirmed by DNA sequence analysis. The lucimycin gene isolated was confirmed by specific and pJET1.2 forward and reverse primers using Blastn algorithm as a result of species and/or subspecies using the Blastn algorithm and the related isolate was recorded in GenBank database with the MF964229 accessory number. The DNA sequence of the isolated sample was compared with other isolates found in GenBank by Pubmed/Blast program. KJ413251.1 was found to be 99% similar to the GenBank isolate. The 113th nucleotide was C (cytosine) in the sequence of our isolate, while the existence of G (guanine) in the sequence numbered KJ413251.1 GenBank revealed the difference between the two sequences. In this study the molecular characterization of lucimycin gene derived from L.sericata larvae were determined for the first time in Turkey, it is assumed that this molecule which has an antifungal property, can be used in the studies that will be carried out in the future, especially in microorganisms causing cutaneous infections. The study is important since the isolate is registered as a biological asset of Turkey in GenBank and also being the second study in the world.

Traditional and advanced therapeutic modalities for wounds in the paediatric population: an evidence-based review.

Children can have non-healing wounds due to a wide range of pathologies, including epidermolysis bullosa (EB), pilonidal disease and Stevens-Johnson syndrome, with some causes being iatrogenic, including extravasation injuries and medical device-related hospital-acquired pressure ulcers. Furthermore, paediatric wounds are vastly different from adult wounds and therefore require a different treatment approach. While there are numerous types of dressings, topical remedies, and matrices with high-tier evidence to support their use in adults, evidence is scarce in the neonatal and paediatric age groups. The purpose of this review is to discuss the basic principles in paediatric wound management, as well as to present new treatment findings published in the literature to date. The benefits and risks of using different types of debridement are discussed in this review. Various topical formulations are also described, including the need to use antibiotics judiciously. Databases were searched for relevant sources including Pubmed, Embase, Web of Science and DynaMed. Search terms used included 'wound care', 'wound management', 'paediatrics', 'children', 'skin substitutes', and 'grafts'. Additionally, each treatment and disease entity was searched for relevant sources, including, for example: 'Apligraf', 'dermagraft', 'Manuka honey', 'antibiotic', 'timolol', and 'negative pressure wound therapy' (NPWT). Amniotic membrane living skin equivalent is a cellular matrix that has been reportedly successful in treating paediatrics wounds and is currently under investigation in randomised clinical trials. Helicoll is an acellular matrix, which shows promise in children with recessive dystrophic EB. NPWT may be used as a tool to accelerate wound closure in children; however, caution must be taken due to limited evidence to support its safety and efficacy in the paediatric patient population. Integra has been reported as a useful adjunctive treatment to NPWT as both may act synergistically. Hospitalised children and neonates frequently have pressure ulcers, which is why prevention in this type of wound is paramount. Advancements in wound care are rapidly expanding. Various treatments for non-healing wounds in paediatric and neonatal patients have been reported, but high tier evidence in these populations is scarce. We hope to shed light on existing evidence regarding the different therapeutic modalities, from debridement techniques and dressing types to tissue substitutes and topical remedies. There have been promising results in many studies to date, but RCTs involving larger sample sizes are necessary, in order to determine the specific role these innovative agents play in paediatric wounds and to identify true safety and efficacy.

Bacteriophages for Chronic Wound Treatment: from Traditional to Novel Delivery Systems.

The treatment and management of chronic wounds presents a massive financial burden for global health care systems, with significant and disturbing consequences for the patients affected. These wounds remain challenging to treat, reduce the patients’ life quality, and are responsible for a high percentage of limb amputations and many premature deaths. The presence of bacterial biofilms hampers chronic wound therapy due to the high tolerance of biofilm cells to many first- and second-line antibiotics. Due to the appearance of antibiotic-resistant and multidrug-resistant pathogens in these types of wounds, the research for alternative and complementary therapeutic approaches has increased. Bacteriophage (phage) therapy, discovered in the early 1900s, has been revived in the last few decades due to its antibacterial efficacy against antibiotic-resistant clinical isolates. Its use in the treatment of non-healing wounds has shown promising outcomes. In this review, we focus on the societal problems of chronic wounds, describe both the history and ongoing clinical trials of chronic wound-related treatments, and also outline experiments carried out for efficacy evaluation with different phage-host systems using in vitro, ex vivo, and in vivo animal models. We also describe the modern and most recent delivery systems developed for the incorporation of phages for species-targeted antibacterial control while protecting them upon exposure to harsh conditions, increasing the shelf life and facilitating storage of phage-based products. In this review, we also highlight the advances in phage therapy regulation.

Development and Characterisation of a Decellularised Porcine Dermis for Chronic Non-Healing Wounds

Introduction - Decellularisation is a process used to remove cells and cellular remnants, whilst preserving the structure of the non-immunogenic extracellular matrix. A decellularised human dermis, produced using a method of decellularisation that uses low concentration detergent and proteinase inhibitors, has been shown to be of utility in the treatment of non-healing wounds, following just a single application1-2.

Local Administration of Interleukin-1 Receptor Antagonist Improves Diabetic Wound Healing.

Impaired healing of the skin is a notable cause of patient morbidity and mortality. In diabetic individuals, dysregulated inflammation contributes to delayed wound healing. Specific immunomodulatory agents may have a role in the treatment of diabetic wounds. One of these molecules is interleukin-1 receptor antagonist (Anakinra; Amgen Corp.). Although interleukin-1 receptor antagonist (Anakinra; Amgen Corp.) is approved by the Food and Drug Administration (FDA) for the treatment of rheumatoid arthritis and neonatal-onset multisystem inflammatory disease, little is known about the local use this drug in cutaneous wound healing. Therefore, the aim of this study is to determine the effect of locally administered interleukin-1 receptor antagonist on delayed wound healing, specifically, in a diabetic mouse model. Two 6-mm full-thickness wounds were created on the dorsa of diabetic (db/db) mice and stented. One-hour postwounding, wound margins were subcutaneously injected with either (1) low-dose interleukin-1 receptor antagonist in a gelatin-transglutaminase gel vehicle or (2) the gel vehicle only. Wounds were imaged on days 0, 7, 14, and 21 postwounding, and wound area was determined. Wound biopsies were collected on day 21 and immunohistochemically stained for neutrophil and macrophage infiltration. Wounds treated with interleukin-1 receptor antagonist had significantly smaller wound area than nontreated wounds on day 7 and day 14 postwounding. Treated wounds also showed significantly less neutrophil and macrophage infiltration. These findings support the hypothesis that interleukin-1 receptor antagonist may have an important role in cutaneous wound healing, possibly by promoting successful resolution of acute inflammation and hence accelerating wound closure. Thereby, administration of IL-1Ra may be useful in the treatment of nonhealing wounds.

Amount and distribution of selected biologically active factors in amniotic membrane depends on the part of amnion and mode of childbirth. Can we predict properties of amnion dressing? Aproof-of-concept study.

Aim of the studyThe amniotic membrane is used as a dressing material, e.g. in ocular surgery or treatment of non-healing wounds. Of note, results of previous studies differ significantly, presumably due to the biological properties of amnion. Some authors suggest that these properties may depend on inter-donor variations, as well as the method of delivery. The aim of our study was to analyse the content of selected factors important for tissue regeneration in various areas of amnion samples originating from elective caesarean sections and on-term natural deliveries.Material and methodsCervical and placental samples of amniotic membranes originating from physiological deliveries and caesarean sections have been collected with subsequent preparation of amniotic membrane extracts. The screening of amnion samples was performed using a proteome microarray system.ResultsIn all of the amnion samples high amounts of angiogenin, IGF-binding proteins-1, -2, and -3, serine protease inhibitor E1, and TIMP-1 were detected. Important variations in the content of these factors were observed between physiological delivery and caesarean section-derived membranes, as well as between placental and cervical portions of the same membrane.ConclusionsOur study has shown that the content of selected growth factors and regulators of ECM turnover in amniotic membrane samples vary between various donations, and that they depend on the region of the membrane or delivery method. This may determine its potential applications in wound treatment and ophthalmologic surgery. However, our observations require further verification in clinical settings.

Raman spectroscopy combined with SHG gives a new perspective for rapid assessment of the collagen status in the healing of cutaneous wounds

Accurate and rapid assessment of the healing status of a wound in a simple manner would enable clinicians to diagnose wounds in time and promptly adopt appropriate treatments for nonhealing wounds.

Общая и местная криотерапия в комплексном лечении ран

In recent decades, cryotherapy has gained recognition and dissemination in various fields of medicine, the influence of cold on different systems of the body is studied, the mechanism of human adaptation to the action is revealed. There are new technical possibilities of cold generation and modern crynoidal. Cryotherapy is divided into general and local, with the use of moderately low and low temperatures. Local cryotherapy is divided into hardware and software functional tests. Healthy human body to acute cooling meets a number of standard reactions. Depending on the intensity, duration, dynamics, impact, scientists divide the destructive and regenerative cryotherapy, cryosurgery. Modern cryosurgery is a gentle and economical method of eliminating pathological tissues. The main mechanism of action of low temperatures on biological tissue is the formation of intracellular ice, damaging organelles, membranes. The rate of cooling and thawing are important. At the time of cryotherapy, the boundary of the zone of freezing increases in all directions from the edge of the cryo applicator, and the subsequent reaction of cryodestruction are identical at any location of the hearth. For the treatment of venous ulcers, the authors gave a description of the ways of use the snow of carbonic acid, spraying liquid nitrogen on necrotic tissue. Cryotherapy is well defined in treatment of non-healing wounds.

A superabsorbent polymer-containing wound dressing efficiently sequesters MMPs and inhibits collagenase activity in vitro

Superabsorbent polymer (SAP)-containing wound dressings present a valuable and unique category of wound management products. An in vitro approach was used to assess the effects of a new SAP dressing in treatment of non-healing wounds. It was shown that the SAP dressing possesses a significant binding capacity for MMP-2 and MMP-9 in vitro (P < 0.001). The inclusion of the bound proteases was so strong that no MMP-2 and only marginal amounts of MMP-9 were released from the dressing samples in a subsequent elution step. In addition, the SAP dressing was able to take up collagenase and reduce its activity in vitro. However, collagenase was not completely inactivated upon binding and enzyme-mediated substrate turnover could be observed at the dressings. In conclusion, in vitro data confirm the positive effect of the SAP wound dressing observed in vivo. The findings suggest that it should be specifically useful for highly exuding wounds with an elevated proteolytic activity that needs to be reduced to support healing.

Autologous growth factors used for the treatment of recurrent fistula-in-ano preliminary results

Dear Sir, The risk of postoperative complications such as fistula recurrence or incontinence increases in patients with recurrent fistulas and high transsphincteric and suprasphincteric fistulas [1, 2]. Due to the large number of postoperative complications, in recent years, there have been some attempts to treat this disease conservatively. Methods of treatment include tissue adhesives and plugs that close the internal orifice as well as autologous growth factors that are present in the platelet-rich plasma and used as “natural glue” to close the lumen of the fistula. Autologous platelet-rich plasma (APRP) is platelet concentration derived from centrifuged full blood collected from a patient right before surgery. The platelet-rich plasma (PRP) obtained using the Gravitational Platelet Separation III System (GPS® III, Biomet Merck, UK) constitutes 10 % of the original volume of the collected blood and more than 90 % of its mass is made of platelets. Platelet-rich plasma preparation is administered to the fistula tract following curettage (Fig. 1). We report our experience with the GPS® System in 2 patients with anal fistula. Fig. 1 Autologous platelet-rich plasm administration to fistula tract A 50-year-old male underwent surgery for recurrent suprasphincteric posterior horseshoe fistula at our unit. At a time of surgery curettage of the fistula tract was performed, and then a GPS® III preparation was administered to the fistula tract. The patient was discharged home 2 days after surgery. Fourteen days after surgery, the patient presented at the ward due to an inflammatory infiltration. Two months after surgery, a follow-up examination revealed fistula recurrence. A 37-year-old male with recurrent intersphincteric anterior fistula-in-ano, and with a narrow, transsphincteric branch running towards the puborectalis loop also underwent surgical treatment at our unit. At a time of surgery, the main tract of the fistula was removed and APRP (GPS® III) was administered to the narrow lateral tract following curettage. The patient was discharged home on postoperative day 3. No recurrence of the fistula was reported within the 6-month follow-up period. The first experiences with using growth factors were related to the treatment of patients with chronic skin ulcers [3]. At present, indications for using APRP therapy are being expanded. APRP is used in burn units and for the treatment of non-healing wounds. There are also reports of using APRP for the treatment of tendon injuries, muscle injuries, degenerative lesions of tendons and joints and bone voids, mainly in maxillofacial surgery. APRP therapy is also offered by aesthetic surgery centres, where it is used to fill deep wrinkles. In the healing process, thrombin stimulates platelet alpha-granules to release growth factors which, through appropriate stem cell receptors, stimulate stem cell differentiation. Reports of using autologous growth factors for the treatment of fistula-in-ano date back to the late 1990s. In 1999, a paper on the treatment of patients with recurrent fistula-in-ano was published [2]. It described a group of 30 patients with complex fistulas, rectovaginal fistulas and vesicorectal fistulas. The cure rate was 60 %. A similar cure rate was reported by Cintron et al. [1]. In the literature, there are reports of using APRP as an element of multi-stage treatment of fistula-in-ano. The first stage involves inserting a loose seton through the fistula tract in order to drain and heal any local inflammatory lesions. The second stage involves APRP administration, which resulted in fistula healing in as many as 75 % of patients [4]. Hagen et al. [5] used the two-stage method, and in 2009 they published the results of administering APRP to 10 patients with high transsphincteric fistulas. The first stage of treatment involved draining the fistula tract and then closing the internal opening with a patch of mucous membrane and filling the tract with APRP. After almost 2 years of follow-up, fistula recurrence was observed in 10 % of the patients. Available publications include papers that present small groups of patients, different types of fistulas qualified for APRP treatment and different methods of surgery. However, the results are encouraging since this method has no negative effect on anal sphincter function.

Acellular Fetal Bovine Dermal Matrix in the Treatment of Nonhealing Wounds in Patients with Complex Comorbidities

In contrast to the narrow indications for living skin equivalents, extracellular matrix biomaterials are clinically used in a wide range of wound-healing applications. Given the breadth of possible uses, the goal of this study was to retrospectively compile and analyze the clinical application and effectiveness of an extracellular matrix biomaterial derived from fetal bovine dermis (PriMatrix; TEI Biosciences, Boston, Massachusetts) in patients treated by a single physician and monitored postsurgically in an outpatient wound care center. A retrospective medical record review was conducted of consecutive patients treated from January 2007 through January 2009 with meshed PriMatrix after sharp/surgical debridement and coverage with standard moist wound therapy dressings. Twenty-nine patients and 34 wounds were compiled. All of the wounds were unresponsive to conservative treatment owing to complications, including infection, exposed bone or tendon, and other comorbidities known to delay healing. Wounds included 11 diabetic ulcers, 8 venous stasis ulcers, 10 nonhealing traumatic wounds, and 5 other chronic wounds. Thirty of 34 wounds healed, with four patients lost to follow-up. Mean time to healing for diabetic foot ulcers was 105 days with an average of 2.6 PriMatrix applications. Mean time to healing for venous, traumatic, and other chronic wounds was 74 to 82 days with an average of 1.2 to 1.4 PriMatrix applications. In patients with comorbidities known to delay healing, the implantation of PriMatrix promoted the healing and, ultimately, full reepithelialization of otherwise unresponsive wounds of varied etiology, including those with complications of infection or exposed bone or tendon.