Elsevier

Surgery

Volume 166, Issue 5, November 2019, Pages 914-925
Surgery

Small Intestine
Protective effect of adipose tissue–derived mesenchymal stromal cells in an experimental model of high-risk colonic anastomosis

https://doi.org/10.1016/j.surg.2019.07.023Get rights and content

Abstract

Background

Dehiscence of intestinal anastomosis results in high morbidity and mortality. The aim of this study was to investigate the effects of locally administered adipose tissue-derived mesenchymal stromal cells in a model of high-risk colonic anastomosis in rats.

Methods

Seven days after induction of colitis with 2,4,6-trinitrobenzene sulfonic acid, Wistar rats were submitted to a transection of the descending colon followed by end-to-end anastomosis and were then treated with 2×106 adipose tissue-derived mesenchymal stromal cells (from the preperitoneal fat) or an acellular culture solution instilled onto the surface of the anastomosis. At day 14, after macroscopic survey of the abdominal cavity, the anastomotic area was submitted to histologic and immunohistochemical analysis, evaluation of myeloperoxidase activity, fibrosis, epithelial integrity, NF-κ B activation, expression of inflammatory cytokines, and extracellular matrix-related genes.

Results

Anastomotic leakage and mortality associated with high-risk anastomosis decreased with treatment with adipose tissue-derived mesenchymal stromal cells (P < .03). Application of adipose tissue-derived mesenchymal stromal cells resulted in lower histologic scores (P = .011), decreased deposition of collagen fibers (P = .003), preservation of goblet cells (P = .033), decreased myeloperoxidase activity (P = .012), decreased accumulation of CD4+ T-cells (P = .014) and macrophages (P = .011) in the lamina propria, a decrease in the number of apoptotic cells (P = .008), and the activation of NF-κ B (P = .036). Overexpression of IL-17, TNF-α , IFN-γ, and metalloproteinases in the acellular culture solution–treated, high-risk anastomosis group decreased (P < .05) to near normal values with adipose tissue-derived mesenchymal stromal cells treatment.

Conclusion

Improvements in outcomes of a high-risk colonic anastomosis with adipose tissue-derived mesenchymal stromal cells therapy reflect the immunomodulatory activity and healing effect of these cells, even after just topical administration and reinforces their use in future translational research.

Introduction

Among the postoperative complications in colorectal operations, anastomotic dehiscence represents a serious problem to the patient because of its potential consequences, such as fecal peritonitis and sepsis.1 It has been estimated that about one third of deaths related to anastomotic dehiscence can be attributed to the extravasation of colorectal contents after operative procedures.2 The morbidity associated with anastomotic dehiscence results in increased durations of hospital stay, costs, and mortality, and a greater risk of cancer recurrence.3, 4, 5

The incidence of anastomotic dehiscence with leakage has been related to several variables, such as the operative procedure (elective or emergency), the topography (right or left large bowel and upper or lower rectum), the presence of intestinal obstruction, and local factors such as intestinal microbiota, shear forces resulting from peristalsis, fecal transit, and underlying diseases.2 In particular, in the presence of inflammatory bowel disease (IBD), dehiscence of an intestinal anastomosis represents a severe, post-operative complication with greater morbidity and mortality. Moreover, it has been estimated that more than half of the patients with Crohn’s disease (CD) will require an operative procedure within 10 years after diagnosis.6, 7 Currently, notwithstanding all accumulated knowledge in the field of IBD, available therapies are still of limited efficacy and continue to impose important safety concerns. In view of the need for safer and more effective options, cell-based therapies have been investigated as potential novel alternatives.8, 9

Mesenchymal stromal cells (MSCs) constitute a subset of nonhematopoietic stem cells with multi-lineage potential that can be found in various tissues, including bone marrow, skin, muscle, and fat.10 In fat tissues, these cells are referred to as adipose tissue-derived mesenchymal stromal cells (AT-MSCs) and represent an abundant source of functional cells, potentially relevant to therapeutic applications using autologous or allogeneic MSCs.11 The interest in using MSCs for treating chronic inflammatory diseases is because they are home to inflammatory sites where they promote immunomodulatory effects and participate in tissue repair.12, 13 In human IBD, AT-MSCs have been used recently with relatively successful results. For example, complete healing of fistulas was observed in >80% of patients with CD in a modified, intention-to-treat analysis in which AT-MSCs were injected directly into fistula tracts, with no adverse events.14 In a phase 3, randomized, double-blind controlled trial in patients with CD with perianal fistula, a single intralesional injection of expanded allogeneic AT-MSCs resulted in more effective closure with less treatment-related adverse events than the placebo group.15 In experimental models of anastomosis, performed either on ischemic colon16 or after high-dose irradiation,17 treatment with MSCs promoted accelerated healing. In this study, our aim was to evaluate the potential beneficial effect of locally administered AT-MSCs in a rodent model of a high-risk colonic anastomosis.

Section snippets

Ethics statement

All procedures reported in this study were in compliance with Brazilian national regulations for animal experiments and were in accordance with the guidelines of the International Care and Use Committee of the National Institutes of Health, and Guide for the Care and Use of Laboratory Animals.18 The institutional animal care committee of the Federal University of Rio de Janeiro approved the care and use of animals and the procedures carried out in this study (approval number # 004/15).

Animals and experimental groups

The study

Treatment with AT-MSCs decreased postanastomotic morbidity and mortality

During the follow-up period after the operative procedure, no changes in weight were detected among the animals regardless of the treatment. Macroscopic analysis of the abdominal cavity, however, showed greater colonic distension, wall thickening, and more exuberant perianastomotic adhesions in groups 1 and 5 (submitted to TNBS-induced colitis). Local complications, including fistula, abscess, and peritonitis, were observed in 8 animals submitted to the high-risk anastomosis and treated with

Discussion

In this study, the beneficial effects of the topical application of AT-MSCs were demonstrated in a high-risk colonic anastomosis in a rat model of colitis. Regarding efficacy, AT-MSCs prevented the mortality and complications associated with this high-risk colonic anastomosis, and consistently stabilized the intestinal architecture after 1 week of treatment. In particular, we demonstrated that topical application of AT-MSCs contributed to the preservation of epithelial integrity, stabilizing

Funding/Support

This work was supported by grants from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) (302401/2016-4) and the Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ) (E26/202.781/2017).

Conflict of interest/Disclosure

The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

Acknowledgments

We thank Jose Nazioberto D. de Farias and Alyson do Rosario Jr. for their technical assistance with the tissue processing.

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