Untersuchung von bovinem Perikard (Tutomesh®) und beschichtetem Polypropylen (Proceed®) in paraösophagealer Position im Schweinemodell

 

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Zusammenfassung

Hintergrund: Hiatushernien werden heute zunehmend netzgestützt versorgt, wobei hierzu immer häufiger auch biologische Implantate eingesetzt werden. Im Zusammenhang mit synthetischen Netzen am Hiatus oesophageus sind Ösophagusperforationen als seltene, aber schwerwiegende Komplikation beschrieben. Der Stellenwert der verschiedenen Netzarten ist in der experimentellen Forschung bislang nur unvollständig herausgearbeitet. Im vorliegenden Großtiermodell wurden 2 Implantattypen (Tutomesh® und Proceed®) hinsichtlich ihrer Biokompatibilität und mechanischen Stabilität untersucht. Material und Methoden: Als Versuchstiere kamen 12 drei Monate alte Hausschweine zum Einsatz. Bei jeweils 6 Tieren wurde Tutomesh® bzw. Proceed® am Hiatus oesophageus im Sinne eines Bridging implantiert. Nach einer Beobachtungszeit von 3 Monaten wurde der Versuch beendet. Es erfolgte eine Endoskopie und die intraoperative makroskopische Befundbeurteilung. Anhand repräsentativer histologischer Schnitte wurden histopathologische und immunhistochemische Parameter der Biokompatibilität untersucht sowie an standardisierten Gewebeproben eine Zugfestigkeitsprüfung durchgeführt. Ergebnisse: Bei 1 Tier der Proceed®-Gruppe bestand endoskopisch eine Ösophagitis Grad II. Eine Ösophagusarrosion bestand bei keinem Tier. Die Adhäsionsanalyse zeigte diskret weniger Adhäsionen in der Tutomesh®-Gruppe. Es bestand kein signifikanter Unterschied im Hinblick auf die untersuchte Entzündungs- und Immunantwort zwischen beiden Netzen. Der wesentlichste Befund der mechanischen Analyse ist ein Reißkraftverlust des Tutomesh®-Gewebe-Komplexes von 30 % gegenüber nativem Gewebe bzw. mehr als 50 % gegenüber Tutomesh® vor Implantation. Schlussfolgerungen: Nach 3 Monaten zeigt sich beim Vergleich der Entzündungsantwort kein signifikanter Unterschied zwischen beiden Implantaten. Der Reißkraftverlust des Tutomesh®-Gewebe-Komplexes ist unter klinischen Gesichtspunkten am Hiatus oesophageus vermutlich nicht relevant und wird durch das sog. Remodeling biologischer Materialien erklärt. Das Remodeling wiederum hängt vom Ausmaß des Cross-linkings des jeweiligen Materials ab. Biologischen Hernienimplantaten wie Tutomesh® wird am Hiatus oesophageus im langfristigen Verlauf ein deutliches Potenzial zur Komplikationsvermeidung zugetraut. Dieses Potenzial ist nach 3 Monaten anhand unserer Daten nicht eindeutig belegbar. Zur Klärung dieser Fragestellung sind daher weitere experimentelle Untersuchungen v. a. zum Langfristverlauf wünschenswert.

Abstract

Background: Hiatal hernias are nowadays increasingly treated with meshes. Often, biological implants are being used for this application. Oesophageal perforations have been reported as rare but serious complications from the application of synthetic meshes at the oesophageal hiatus. The role of the different mesh types has not been clearly established by experimental research so far. In the present large animal model, we investigated two implant types (Tutomesh® and Proceed®) with respect to their biocompatibility and mechanical stability. Material and Methods: We used 12 domestic pigs aged three months. Tutomesh® and Proceed® were implanted in 6 animals each for bridging at the oesophageal hiatus. After a follow-up of 3 months, the experiment was terminated. We performed endoscopy and intraoperative macroscopic evaluation of the situs. In representative histological sections, established histopathological and immunohistochemical parameters of biocompatibility were investigated and tensile strength testing was performed on standardised tissue samples. Results: One animal of the Proceed® group had grade 2 oesophagitis. None of the animals had an oesophagus arrosion. The analysis of adhesions revealed slightly less adhesions in the Tutomesh® group. There was no significant difference with respect to the investigated inflammation response and immune response between both meshes. The most substantial finding of the mechanical analysis was a loss of tear strength of the Tutomesh®-tissue-complex of 30 % as compared to native tissue and more than 50 % compared to Tutomesh® prior to implantation, respectively. Conclusions: After 3 months, there was no significant difference between the two implant types with respect to the inflammatory response. The loss of tear strength of the Tutomesh®-tissue-complex at the oesophageal hiatus is probably clinically not relevant and may be explained by the so-called biological remodeling of biological materials. The remodeling depends on the extent of the cross-linking of the respective material. It is expected that biological hernia implants, such as Tutomesh®, may have a marked potential for avoiding complications at the oesophageal hiatus in the long run. This potential cannot be proven after 3 months from our data. Further experimental investigations are necessary to clarify this issue, in particular with respect to the long-term results.

• Literatur

• 1 Feußner H, Friess H, Wilhelm D. Netzversorgung am Hiatus: Pro und Contra. Passion Chirurgie Q 2011; 1: 10-13
  PubMedGoogle Scholar
• 2 Stadlhuber RJ, Sherif AE, Mittal SK et al. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc 2009; 23: 1219-1226
  CrossrefPubMedGoogle Scholar
• 3 Zügel N, Lang RA, Kox M et al. Severe complication of laparoscopic mesh hiatoplasty for paraesophageal hernia. Surg Endosc 2009; 23: 2563-2567
  CrossrefPubMedGoogle Scholar
• 4 Antoniou SA, Pointner R, Granderath FA. Hiatal hernia repair with the use of biologic meshes: a literature review. Surg Laparosc Endosc Percutan Tech 2011; 21: 1-9
  CrossrefPubMedGoogle Scholar
• 5 Hiles M, Record Ritchie RD, Altizer AM. Are biologic grafts effective for hernia repair?: a systematic review of the literature. Surg Innov 2009; 16: 26-37
  PubMedGoogle Scholar
• 6 El-Hayek KM, Chand B. Biologic prosthetic materials for hernia repairs. J Long Term Eff Med Implants 2010; 20: 159-169
  CrossrefPubMedGoogle Scholar
• 7 Scheuerlein H, Rauchfuss F, Dittmar Y et al. Modifizierte Netzimplantation bei großer paraösophagealer Typ-III-Hernie. Zentralbl Chir 2011; 136: 625-628
  Article in Thieme ConnectPubMedGoogle Scholar
• 8 James NL, Poole-Warren LA, Schindhelm K et al. Comparative evaluation of treated bovine pericardium as a xenograft for hernia repair. Biomaterials 1991; 12: 801-809
  CrossrefPubMedGoogle Scholar
• 9 Sandor M, Xu H, Connor J et al. Host response to implanted porcine-derived biologic materials in a primate model of abdominal wall repair. Tissue Eng Part A 2008; 14: 2021-2031
  CrossrefPubMedGoogle Scholar
• 10 Zheng F, Lin Y, Verbeken E et al. Host response after reconstruction of abdominal wall defects with porcine dermal collagen in a rat model. Am J Obstet Gynecol 2004; 191: 1961-1970
  CrossrefPubMedGoogle Scholar
• 11 Butler CE, Burns NK, Campbell KT et al. Comparison of cross-linked and non-cross-linked porcine acellular dermal matrices for ventral hernia repair. J Am Coll Surg 2010; 211: 368-376
  CrossrefPubMedGoogle Scholar
• 12 Deeken CR, Melman L, Jenkins ED et al. Histologic and biomechanical evaluation of crosslinked and non-crosslinked biologic meshes in a porcine model of ventral incisional hernia repair. J Am Coll Surg 2011; 212: 880-888
  CrossrefPubMedGoogle Scholar
• 13 Shah BC, Tiwari MM, Goede MR et al. Not all biologics are equal!. Hernia 2011; 15: 165-171
  CrossrefPubMedGoogle Scholar
• 14 Harth KC, Rosen MJ. Major complications associated with xenograft biologic mesh implantation in abdominal wall reconstruction. Surg Innov 2009; 16: 324-329
  CrossrefPubMedGoogle Scholar
• 15 Altizer AM, Davidson JM, Hiles M. Chemical cross-linking and biologic grafts. General Surg News 2010; 10: 8-9
  PubMedGoogle Scholar
• 16 Shankaran V, Weber DJ, Reed RL et al. A review of available prosthetics for ventral hernia repair. Ann Surg 2011; 253: 16-26
  CrossrefPubMedGoogle Scholar
• 17 Berrevoet F, Fierens K, De Gols J et al. Multicentric observational cohort study evaluating a composite mesh with incorporated oxidized regenerated cellulose in laparoscopic ventral hernia repair. Hernia 2009; 13: 23-27
  CrossrefPubMedGoogle Scholar
• 18 Böhm G, Binnebösel M, Krähling E et al. Influence of the elasticity module of synthetic and natural polymeric tissue substitutes on the mobility of the diaphragm and healing process in a rabbit model. J Biomater Appl 2011; 25: 771-793
  CrossrefPubMedGoogle Scholar
• 19 Adhesion Scoring Group. Improvement of interobserver reproducibility of adhesion scoring systems. Fertil Steril 1994; 62: 984-988
  PubMedGoogle Scholar
• 20 Scheidbach H. Die total endoskopische präperitoneale Patchplastik (TEP) und der prothetische Einsatz von Polypropylen. Experimentelle und klinische Ergebnisse [Habilitation]. Magdeburg: Otto-von-Guericke-Universität; 2004
  Google Scholar
• 21 Petter-Puchner AH, Walder N, Redl H et al. Fibrin sealant (Tissucol) enhances tissue integration of condensed polytetrafluoroethylene meshes and reduces early adhesion formation in experimental intraabdominal peritoneal onlay mesh repair. J Surg Res 2008; 150: 190-195
  CrossrefPubMedGoogle Scholar
• 22 Schreinemacher MH, Emans PJ, Gijbels MJ et al. Degradation of mesh coatings and intraperitoneal adhesion formation in an experimental model. Br J Surg 2009; 96: 305-313
  CrossrefPubMedGoogle Scholar
• 23 Urbach V, Lindemann M, Paolucci V. Bovines Perikard – Anwendungstechniken bei der operativen Versorgung von Hernien. Abstract, 125. Kongress der Deutschen Gesellschaft für Chirurgie, 16.04.2008. Im Internet: http://www.egms.de/en/meetings/dgch2008/08dgch578.shtml Stand: 01.08.2014
  PubMedGoogle Scholar
• 24 Gaertner WB, Bonsack ME, Delaney JP. Experimental evaluation of four biologic prostheses for ventral hernia repair. J Gastrointest Surg 2007; 11: 1275-1285
  CrossrefPubMedGoogle Scholar
• 25 Kapan S, Kapan M, Goksoy E et al. Comparison of PTFE, pericardium bovine and fascia lata for repair of incisional hernia in rat model, experimental study. Hernia 2003; 7: 39-43
  CrossrefPubMedGoogle Scholar
• 26 Petter-Puchner AH, Fortelny RH, Silic K et al. Biologic hernia implants in experimental intraperitoneal onlay mesh plasty repair: the impact of proprietary collagen processing methods and fibrin sealant application on tissue integration. Surg Endosc 2011; 25: 3245-3252
  CrossrefPubMedGoogle Scholar
• 27 Desai KM, Diaz S, Dorward IG et al. Histologic results 1 year after bioprosthetic repair of paraesophageal hernia in a canine model. Surg Endosc 2006; 20: 1693-1697
  CrossrefPubMedGoogle Scholar
• 28 Wassenaar EB, Mier F, Sinan H et al. The safety of biologic mesh for laparoscopic repair of large, complicated hiatal hernia. Surg Endosc 2012; 26: 1390-1396
  CrossrefPubMedGoogle Scholar
• 29 Ansaloni L, Cambrini P, Catena F et al. Immune response to small intestinal submucosa (surgisis) implant in humans: preliminary observations. J Invest Surg 2007; 20: 237-241
  CrossrefPubMedGoogle Scholar
• 30 Gilbert TW, Freund JM, Badylak SF. Quantification of DNA in biologic scaffold materials. J Surg Res 2009; 152: 135-139
  CrossrefPubMedGoogle Scholar
• 31 Oelschlager BK, Petersen RP, Brunt LM et al. Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes. J Gastrointest Surg 2012; 16: 453-459
  CrossrefPubMedGoogle Scholar
• 32 Gaertner WB, Bonsack ME, Delaney JP. Visceral adhesions to hernia prostheses. Hernia 2010; 14: 375-381
  CrossrefPubMedGoogle Scholar
• 33 Senft J, Gehrig T, Lasitschka F et al. Influence of weight and structure on biological behavior of polypropylene mesh prostheses placed at the esophageal hiatus. J Laparoendosc Surg 2014; 24: 383-390
  PubMedGoogle Scholar
• 34 Jansen M, Otto J, Jansen PL et al. Mesh migration into the esophageal wall after mesh hiatoplasty: comparison of two alloplastic materials. Surg Endosc 2007; 21: 2298-2303
  CrossrefPubMedGoogle Scholar
• 35 Otto J, Kämmer D, Jansen PL et al. Different tissue reaction of oesophagus and diaphragm after mesh hiatoplasty. Results of an animal study. BMC Surg 2008; 12: 8
  PubMedGoogle Scholar
• 36 Greenawalt KE, Butler TJ, Rowe EA et al. Evaluation of sepramesh biosurgical composite in a rabbit hernia repair model. J Surg Res 2000; 94: 92-98
  CrossrefPubMedGoogle Scholar
• 37 Burger JW, Halm JA, Wijsmuller AR et al. Evaluation of new prosthetic meshes for ventral hernia repair. Surg Endosc 2006; 20: 1320-1325
  CrossrefPubMedGoogle Scholar
• 38 Schug-Pass C, Sommerer F, Tannapfel A et al. The use of composite meshes in laparoscopic repair of abdominal wall hernias: are there differences in biocompatibily?: experimental results obtained in a laparoscopic porcine model. Surg Endosc 2009; 23: 487-495
  CrossrefPubMedGoogle Scholar
• 39 Deeken CR, Faucher KM, Matthews BD. A review of the composition, characteristics, and effectiveness of barrier mesh prostheses utilized for laparoscopic ventral hernia repair. Surg Endosc 2012; 26: 566-575
  CrossrefPubMedGoogle Scholar
• 40 Müller-Stich BP, Mehrabi A, Kenngott HG et al. Is a circular polypropylene mesh appropriate for application at the esophageal hiatus? Results from an experimental study in a porcine model. Surg Endosc 2009; 23: 1372-1378
  CrossrefPubMedGoogle Scholar