pathophysiology and prevention of adhesion formation in a laparoscopic mouse model

192 Pages·2008·3.41 MB·English

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A LEUVENUNIVERSITYPRESS
ACTABIOMEDICALOVANIENSIA417
Katholieke Universiteit te Leuven
Faculteit Geneeskunde
Departement Vrouw en Kind,Afdeling Vrouw
Experimenteel Labo Gynaecologie
MariaMercedesBINDA
PATHOPHYSIOLOGY AND PREVENTION OF
ADHESION FORMATION IN A
LAPAROSCOPIC MOUSE MODEL
LEUVENUNIVERSITYPRESS
Thesissubmittedinpartialfulfillmentoftherequirementsforthedegree
* +
of DoctorindeMedischeWetenschappen
8
2008byLeuvenUniversityPress/PressesUniversitairesdeLouvain/UniversitairePers
Leuven.
Minderbroedersstraat4-bus5602,B-3000Leuven(Belgium)
Allrightsreserved.Exceptinthosecasesexpresslydeterminedbylaw,nopartofthis
publicationmaybemultiplied,savedinanautomateddatafileormadepublicinanyway
whatsoeverwithouttheexpresspriorwrittenconsentofthepublishers.
ISBN9789058676672
D/2008/1869/4
NUR:876
“Science moves with the spirit of an adventure characterized both by
youthful arrogance and by the belief that the truth, once found, would be
simple as well as pretty.”
James D. Watson

To Nicolò and Leo

TABLE OF CONTENTS

Chapter 1: Introduction 1
1.1 Definition, aetiology and incidence of intraperitoneal adhesions 1
1.2 Clinical significant of intraperitoneal adhesions 2
1.3 Pathophysiology of intraperitoneal adhesions 2
1.4 Postoperative adhesions: laparoscopy vs. laparotomy 4
1.5 Laparoscopy and pneumoperitoneum 5
1.6 Pneumoperitoneum as a cofactor in adhesion formation 5
1.7 Adhesion prevention 6
1.7.1 Limitation or prevention of initial peritoneal injury 7
1.7.2 Prevention of coagulation and fibrin deposition 7
1.7.3 Removal or dissolution of deposited fibrin 7
1.7.4 Prevention of the adherence of surfaces of adjacent structures
by keeping them apart 8
1.7.4.1 Mechanical barriers 9
1.7.4.2 Semisolid barriers 10
1.7.4.3 Liquid barriers or hydroflotation 11
1.7.4.4 Tissue precoating 12
1.7.4.5 Surfactant-like substances 12
1.7.5 Prevention of the organization of the persisting fibrin by
means of inhibiting the fibroblastic proliferation. 13
1.7.6 Prevention of the angiogenesis 13
1.7.7 Prevention of the oxidative stress 13
1.7.8 Prevention of the hypoxia 14
1.7.9 Summary: adhesion prevention today 14
1.8 General aims of this thesis 15
Chapter 2: Results 17
2.1 Results of aim#1: Final standardization of the laparoscopic mouse model 17
2.1.1. Effect of mouse strain upon adhesion formation 17
2.1.2. Effect of environmental temperature, dry ventilation, desiccation
and oversaturated insufflation gas upon mouse body temperature 18
2.1.3. Effect of temperature upon adhesion formation 23
2.1.4. Effect of desiccation upon adhesion formation 28
2.2. Results of aim#2: Screening of anti-adhesion products in our models 31
2.2.1. Screening of all the products which have been described to affect
adhesions in a model with 60 min pure CO pneumoperitoneum,
2
i.e., the hypoxia model 31
2.2.2. Screening of selected products which have been described to affect
adhesions in a model with 60 min CO pneumoperitoneum
2
+12% oxygen, i.e., the hyperoxia model 35
2.2.2.1. To confirm the hypothesis that hypothermia prevents
adhesions by making cells more resistant
to the toxic effects of the hyperoxia 35
2.2.2.2. To screen some of the products used in 2.2.1 in order to
know their relative effectiveness also in the hyperoxia model 35
2.3. Results of aims #3 and #4: Screening of combination of treatments 37
2.3.1. To confirm the hypothesis that hypothermia prevents adhesions
by making cells more resistant to hypoxia. 37
2.3.2. To screen some of the products used in the Section 2.2.1 in order
to know their relative effectiveness also in the normoxia model
and to combine with the low-temperature treatment. 37
2.3.3. To confirm that the addition of an extra trauma like
bleeding increases adhesion formation 37
2.3.4. Establishment of which combination of treatments will give
a maximum reduction of adhesions 39

Chapter 3: Discussion 41
3.1 Animal models to study adhesion formation 41
3.1.1 Existing models 41
3.1.2 The mouse model 42
3.1.3 Experimental factors which should be controlled and/or standardised
to investigate adhesion formation 43
3.1.4 New conceps of pathophysiology that have been derived from the
mouse model 45
3.1.4.1 Peritoneal hypoxia, normoxia and hyperoxia 45
3.1.4.2 Hypothemia decreases adhesions 47
3.1.4.3 Desiccation increases adhesion formation 50
3.1.4.4 Adhesion formation depends on the genetic background 52
3.2 Adhesion prevention 54
3.2.1 Prevention in the hypoxic model 54
3.2.2 Prevention in the hyperoxia model 59
3.2.3 Combination of treatments 62

3.3 Pathophysiology of adhesion formation 65
3.4 Future Aspects 67
3.5 Summary 68
3.6 Summary in Dutch 70
Chapter 4: Bibliografy 73
Addendum 87
Addendum 1: General methods and procedures 87
1.1 The laparoscopic mouse model 87
1.1.1 Animals 87
1.1.2 Anaesthesia and ventilation 87
1.1.3 Laparoscopic surgery 88
1.1.4 Induction of intraperitoneal adhesions 88
1.1.5 Scoring of adhesions 88
1.1.6 Our triple model 89
1.2 Set up and general design of the experiments 89
1.2.1 Environmental temperature 90
1.2.2 Body and pneumoperitoneum temperatures and
pneumoperitoneum relative humidity 90
1.2.3 Pneumoperitoneum gas conditions: desiccation and humidification 91
1.3 Statistics 91

Addendum 2: Binda MM, Molinas CR, Koninckx PR. Reactive oxygen species
and adhesion formation: Clinical implications in adhesion
prevention. Human Reproduction 18 (12): 2503-2507, 2003. 95

Addendum 3: Molinas CR, Binda MM, Campo R, Koninckx PR. Adhesion
formation and interanimal variability in a laparoscopic mouse
model varies with strains. Fertility & Sterility 83(6):1871-4, 2005. 101

Addendum 4: Binda MM, Molinas C.R., Mailova K. and Koninckx P.R.
Effect of temperature upon adhesion formation in a laparoscopic
mouse model. Human Reproduction 19(11):2626-32, 2004. 107

Addendum 5: Binda MM, Molinas CR, Hansen P. and Koninckx PR. Effect
of desiccation and temperature during laparoscopy on adhesion
formation in mice Fertility & Sterility 86(1):166-175, 2006. 115

Addendum 6: Molinas CR, Binda MM and Koninckx PR. Angiogenic factors
in peritoneal adhesion formation.
Gynecological Surgery 3: 157-167, 2006. 127

Addendum 7: Binda MM, Molinas CR, Bastidas A. and Koninckx PR. Effect
of reactive oxygen species scavengers and anti-inflammatory drugs
upon CO pneumoperitoneum-enhanced adhesions in a laparoscopic
2
mouse model. Surgical Endoscopy 21(10):1826-34, 2007. 139
Addendum 8: Binda MM, Molinas CR, Bastidas A, Jansen M and Koninckx PR.
Efficacy of barriers and hypoxia inducible factor inhibitors to prevent
CO pneumoperitoneum-enhanced adhesions in a laparoscopic
2
mouse model. Journal of Minimally Invasive Gynecology
14(5):591-9, 2007. 149

Addendum 9: Binda MM and Koninckx PR. The role of the pneumoperitoneum
in adhesion formation Adhesions News & Views 10: 11-13, 2007. 159

Addendum 10: Binda MM, Hellebrekers B, Declerck P, Koninckx PR. Effect of
Reteplase and PAI-1 antibodies upon postoperative adhesion
formation in a laparoscopic mouse model (submitted) 163

Addendum 11: Binda MM and Koninckx PR. Prevention of hyperoxia enhanced
adhesions in a laparoscopic mouse model. 177

Addendum 12: Binda MM and Koninckx PR. Combination of treatments
to prevent pneumoperitoneum enhanced adhesions in a
laparoscopic mouse model. 179
ACKNOWLEDGEMENTS

I would like to present this thesis to the Katholieke Universiteit Leuven through its
rector Prof. Marc Vervenne and to the Faculty of Medicine through its dean Prof. Bernard
Himpens.

I am grateful to the members of the jury, Prof. Ignace Vergote (Departement of
Obstetric and Gynecology, KUL), Prof. Raf Sciot (Departement of Medical Diagnostic
Sciences, KUL), Prof. Marc Miserez (Department of Abdominal Surgery, KUL), Prof. Michel
Canis (Polyclinique de l’Hôtel Dieu, Clermont-Ferrand, France), Prof. Hans Jeekel
(Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands),
for their useful comments and suggestions.

I would like to thank Prof. Philippe Koninckx for all his support and especially for his
enthusiasm during this thesis; especially for his patience in reading carefully the manuscripts
several times till they were ready to submit, something that helped me a lot to learn how to
write a scientific paper. He always encouraged me to think and to work independenly.

I would like also to thank my colleagues from the Laboratory for Experimental
Gynaecology. I am thankful to Roger Molinas for teaching me the laparoscopic mouse model
and everything related with the experimental work and most of all for his friendship. I thank
Silvia Caluwaerts, Salwan Al-Nasiry and Rieta Van Bree for being always smiling and
positive while supporting me. I thank Prof Robert Pijnenborg, Lisbeth Vercruysse, Catherine
Luyten, Lieve Verbist, Suzan Lambin and Adriana Bastidas for all their help. Thanks also to
the gynecology team Kristel Van Calsteren, Isabelle Cadron and Tim Van Mieghem for
answering all my questions during Leo's pregnancy. I thank Diane Wolput and Marleen
Craessaerts for all the logistic support.

I am grateful to Eugeen Steurs from Storz who helped me – always in a good mood -
to solve problems with the laparoscopic stuff.