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The Effects of Methylene Blue on Adhesion Formation in a Rat Model of Experimental Peritonitis

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The Effects of Methylene Blue on Adhesion Formation in a Rat Model of Experimental Peritonitis Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2011;17 (3):205-209 Experimental Study Deneysel Çalışma doi: 10.5505/tjtes.2011.93609 The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis Deneysel peritonit modelinde metilen mavisinin adezyon formasyonu üzerine etkileri Mustafa Uygar KALAYCI,1 Hasan Erol EROĞLU,2 Dilek KUBİLAY,3 Aliye SOYLU,4 Banu SANCAK,5 Ceyhan UĞURLUOĞLU,6 Uğur ERÇİN,5 Yavuz Savaş KOCA2 BACKGROUND AMAÇ We investigated the effects of methylene blue (MB) on the Sıçanlarda oluşturulan kolon duvar hasarı ve fekal peri- early and late phases of adhesion and abscess formation in tonit modelinde metilen mavisinin (MM) erken ve geç a standard colonic wall injury and fecal peritonitis model dönemde adezyon ve apse oluşumu üzerine etkileri in- in rats. celendi. METHODS GEREÇ VE YÖNTEM There were four groups: Group I (only laparotomy, n=10), Çalışmada dört grup vardı; Grup I (yalnızca laparotomi, Group II (peritonitis + MB, n=15), Group III (peritonitis n=10), Grup II (peritonit ve MM, n=15), Grup III (kolon + saline, n=15), and Group IV (colon incision + saline, insizyonu ve salin, n=15) ve Grup IV (kolon insizyonu ve n=15). Mortality, morbidity, adhesion scores, histopatho- salin, n=15). Tüm deneklerde mortalite, morbidite, adez- logic analyses, serum tumor necrosis factor-alpha (TNF-α) yon skorları, histopatolojik analiz, serum tümör nekroz levels, and tissue hydroxyproline (5-HP) levels were evalu- faktörü-α (TNF-α) ve doku hidroksiprolin (5-HP) düzey- ated in all animals. Descriptive statistical methods were leri değerlendirildi. Tanımlayıcı istatistiksel analiz Krus- used with Kruskal-Wallis test. When a statistical difference kal Wallis testi ile, istatistiksel anlamlılık saptandığında was obtained between groups, Mann-Whitney U test was ise gruplar arasındaki fark Mann-Whitney U testi ile ana- used to confirm the difference between two groups. liz edildi. RESULTS BULGULAR Adhesion scores of Groups I, III and IV were significantly Grup I, Grup III ve Grup IV’ün adezyon skorları Grup II’ye higher than in Group II. TNF-α levels were significantly göre anlamlı yüksekti. TNF-α düzeyleri ise Grup I, Grup III higher in Groups I, III and IV. 5-HP levels were significant- ve Grup IV’de yüksek bulundu. 5-HP düzeyleri Grup I ve ly lower in Groups I and II compared to Groups III and IV. Grup II’de Grup III ve Grup IV’e göre düşüktü. CONCLUSION SONUÇ Based on these results, it appears that MB may prevent MM’nin peritonit modelinde peritoneal adezyonları önle- peritoneal adhesions in a peritonitis model, but wound diği, ancak yara iyileşmesini olumsuz etkilediği söylene- healing could be impaired. MB should be further evaluated bilir. Bu ikili karşıt etkinin daha fazla araştırılması gere- because of its dual effect. kir. Key Words: Adhesion; methylene blue; peritonitis. Anahtar Sözcükler: Adezyon; metilen mavisi; peritonit. 1Dept. of General Surgery, Okmeydani Training and Research Hospital, 1Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Istanbul; 2Dept. of General Surgery, Suleyman Demirel University, Faculty İstanbul; 2Süleyman Demirel Üniversitesi Tıp Fakültesi, Genel Cerrahi of Medicine, Isparta; 3Dept. of Medical Biochemistry, Dr. Abdurrahman Anabilim Dalı, Isparta; 3Dr. Abdurrahman Yurtaslan Eğitim ve Araştırma Yurtarslan Training and Research Hospital, Ankara; 4Dept. of Hastanesi, Biyokimya Bölümü, Ankara; 4Bakırköy Dr. Sadi Konuk Eğitim Gastroenterology, Bakirkoy Dr. Sadi Konuk Training and Research ve Araştırma Hastanesi, Gastroenteroloji Kliniği, İstanbul; Hospital, Istanbul; 5Dept. of Medical Biochemistry, Gazi University Faculty 5Gazi Üniversitesi Tıp Fakültesi, Klinik Biyokimya Anabilim Dalı, Ankara; of Medicine, Ankara; 6Dept. of Pathology, Dr. Faruk Sukan Children 6Dr. Faruk Sükan Çocuk Hastanesi, Patoloji Bölümü, Hospital, Konya, Turkey. Konya. Correspondence (İletişim): Hasan Erol Eroğlu, M.D. Muzaffer Türkeş Mah., Doktorlar-Mühendisler Sitesi No: 15/1, 32200 Isparta, Turkey. Tel: +90 - 246 - 211 55 87 e-mail (e-posta): [email protected] 205 Ulus Travma Acil Cerrahi Derg Adhesion formation is a major complication in sur- ceding the experiments. The experimental protocol gery.[1,2] It has been estimated that the annual health- was approved by the Suleyman Dermirel University care costs associated with adhesiolysis procedures Faculty of Medicine Animal Care and Use Committee. amount to more than 1 billion USD in the United Experimental Groups States.[3] After colon surgery, the readmission rate due to adhesions is about 5-15%.[4] Adhesion-related mor- Rats were divided into four groups including lapa- tality reaches up to 15%, and inadvertent enterotomy rotomy (Group I; n=10), peritonitis+MB (Group II; at a desiotomy occurs in 19% in additional operations. n=15), peritonitis+saline (Group III; n=15), and colon [5] Indeed, the rate of residual infection after perito- incision+saline (Group IV; n=15) groups. Mortality, nitis can be as high as 50%, necessitating abdominal morbidity, adhesion scores, bacterial analysis, histo- re-exploration or percutaneous abscess drainage in ad- pathologic analysis, tissue hydroxyproline (5-HP), hesions.[5,6] Multiple factors have been associated with and plasma tumor necrosis factor-alpha (TNF-α) level this problem, such as poor surgical technique, damage were taken as control parameters. to the serosal surface of the intestinal wall, powder of Surgical Operations gloves, type of suture material, devitalized tissue, pel- vic inflammatory disease, cholecystitis, and appendi- The animals were weighed and anesthetized with citis.[7,8] intramuscular (im) ketamine (50 mg/kg) and xyla- zine (6 mg/kg). The abdominal skin was disinfected Although several materials have been used to avoid with 70% Betadine solution. Midline laparotomy per- adhesion formation in elective surgery, there are in- formed with a 3 cm incision was the sole intervention sufficient data on this issue in the case of peritonitis. in the laparotomy group. In the peritonitis+MB group, Experimental data show that the use of antiadhesive the colon was explored and incised with a scalpel. The agents in peritonitis reduces adhesions and abscesses abdomen was contaminated with the cecal content in and related mortality.[9,10] To avoid adhesion forma- order to induce fecal peritonitis. The defect was su- tion in peritonitis, tenoxicam, aminoguanidine, beta tured with 4-0 polypropylene. Before closing the ab- glucan, polysaccharide carboxy methyl cellulose and domen, MB (1%, 2 ml) was applied through the suture phlennium saprophyte have been used in different line and abdominal viscera. In the peritonitis+saline studies.[11-14] group, the colon was explored and incised with a scal- Adhesion formation is associated with significant pel. The abdomen was contaminated with the cecal oxidative stress, both from the activation of the me- content in order to induce fecal peritonitis. The defect sothelium and underlying endothelial cells and, more was sutured with 4-0 polypropylene. Before closing importantly, from the infiltration and subsequent acti- the abdomen, sterile saline solution (2 ml) was applied vation of neutrophils and macrophages and cytokines. through the suture line and abdominal viscera. In the [15-17] Methylene blue (MB) acts as an antioxidant and colon incision+saline group, the colon was explored may reduce intraabdominal nascent fibrinous adhe- and incised with a scalpel. The defect was sutured sions, and is rapidly degraded via intraabdominal with 4-0 polypropylene. Before closing the abdomen, proteases such as tissue plasminogen activator (tPA), sterile saline solution (2 ml) was applied through the which is a major component of the peritoneal fibrino- suture line and abdominal viscera. The abdomen was lytic system.[16] MB was defined as an effective agent closed in two layers with 3-0 silk. to avoid the permanent fibrous adhesion formation in Postoperative Evaluations peritoneal trauma due to antioxidant activity.[18] All animals were given water only on the first post- Based on the literature concerning the antiadhe- operative day; standard rat chow and water ad libitum sive properties of MB, the present study was designed were provided on the second postoperative day. There to investigate the effects of MB on the early and late was no difference in food intake between the groups. phases of adhesion and wound healing in an experi- Body weight and water and food intake were moni- mental colonic wall injury and fecal peritonitis model tored daily throughout the postoperative period, for up in rats. to 7 days. MATERIALS AND METHODS On the postoperative 3rd day, 5 animals from Group Animals I and 7 animals from Groups II, III and IV were taken for analyses. On the postoperative 7th day, 5 animals Female Wistar-Albino rats (225-280 g) were from Group I and 8 animals from Groups II, III and IV housed in an air-conditioned room at a constant tem- were taken for the rest of the examinations. perature of 22±2°C with 12:12 h light/dark cycle and fed a standard diet and water ad libitum. The animals Mortality, morbidity, adhesion scores, histopatho- were acclimatized for one week before the experi- logic analyses, serum TNF-α levels and tissue 5-HP ments. Only water was provided in the 12 hours pre- levels were evaluated in all animals. 206 May - Mayıs 2011 The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis Microbiologic Analysis chemical analyses. TNF-α levels of serum samples
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