Clinical Problems: Results of Closure of Loop Transverse Colostomies

The postoperative course of 139 patients who underwent closure of a loop transverse colostomy at St. Mark''s Hospital between 1961 and 1970 after distal resection and anastomosis of the large intestine for neoplastic or diverticular disease has been reviewed in detail. There were no deaths and the incidence of breakdown at the site of the colostomy closure was 2·9%. The procedure can be straightforward and safe.     

Effects of corticosteroid-induced apoptosis on airway epithelial wound closure in vitro

Damage to the airway epithelium is common in asthma. Corticosteroids induce apoptosis in and suppress proliferation of airway epithelial cells in culture. Whether apoptosis contributes to impaired epithelial cell repair after injury is not known. We examined whether corticosteroids would impair epithelial cell migration in an in vitro model of wound closure. Wounds (approximately 0.5-1.3 mm2) were created in cultured 1HAEo- human airway epithelial cell monolayers, after which cells were treated with up to 10 microM dexamethasone or budesonide for 24 h. Cultured cells were pretreated for 24 or 48 h with dexamethasone to observe the effect of long-term exposure on wound closure. After 12 h, the remaining wound area in monolayers pretreated for 48 h with 10 microM dexamethasone was 43+/-18% vs. 10+/-8% for untreated control monolayers. The addition of either corticosteroid immediately after injury did not slow closure significantly. After 12 h the remaining wound area in monolayers treated with 10 microM budesonide was 39+/-4% vs. 43+/-3% for untreated control monolayers. The proportion of apoptotic epithelial cells as measured by terminal deoxynucleotidyltransferase-mediated dUTP biotin nick end labeling both at and away from the wound edge was higher in monolayers treated with budesonide compared with controls. However, wound closure in the apoptosis-resistant 1HAEo-.Bcl-2+ cell line was not different after dexamethasone treatment. We demonstrate that corticosteroid treatment before mechanical wounding impairs airway epithelial cell migration. The addition of corticosteroids after injury does not slow migration, despite their ability to induce apoptosis in these cells.     

Prostaglandin E(2) regulates wound closure in airway epithelium

Repair of the airway epithelium after injury is critical for the maintenance of barrier function and the limitation of airway hyperreactivity. Airway epithelial cells (AECs) metabolize arachidonic acid to biologically active eicosanoids via the enzyme cyclooxygenase (COX). We investigated whether stimulating or inhibiting COX metabolites would affect wound closure in monolayers of cultured AECs. Inhibiting COX with indomethacin resulted in a dose-dependent inhibition of wound closure in human and feline AECs. Specific inhibitors for both COX-1 and COX-2 isoforms impaired wound healing. Inhibitors of 5-lipoxygenase did not affect wound closure in these cells. The addition of prostaglandin E(2) (PGE(2)) eliminated the inhibition due to indomethacin treatment, and the exogenous application of PGE(2) stimulated wound closure in a dose-dependent manner. Inhibition of COX with indomethacin only at initial time points resulted in a sustained inhibition of wound closure, indicating that prostanoids are involved in early wound repair processes such as spreading and migration. These differences in wound closure may be important if arachidonic acid metabolism and eicosanoid concentrations are altered in disease states such as asthma.     

Flap surgery to cover olecranon pressure ulcers in spinal cord injury patients

In the quadriplegic patient, the periolecranon region is subjected to continuous and permanent mechanical shearing and pressure forces. As the sensation of this region is partially impaired secondary to the level of the spinal cord injury, this anatomical area is prone to develop bursitis and then a chronic open draining wound. This type of wound is refractory to conservative measures. Surgical closure of this functional area can represent a challenge to the plastic and reconstructive surgeon because not all of the surgical options available are suitable for spinal cord injury patients. Therefore, we describe our clinical experience, which consists of seven patients with traumatic complete quadriplegia treated between 1989 and 1998 (all patients were male) who presented with an open olecranon ulcer, septic bursitis, or aseptic bursitis, and who underwent surgical closure by direct closure, local arm fasciocutaneous flap, or cross-chest flap to cover the periolecranon soft-tissue defects. The follow-up period ranged from 3 months to 8 years (mean, 44 months). All types of flaps achieved wound closure without losing range of motion at the elbow; however, at 10 to 12 months after surgery, an olecranon pressure ulcer or septic bursitis recurred in three of seven patients. These three patients required surgical revision. The local fasciocutaneous rotational flap was found to be effective for closing periolecranon soft-tissue defects and can be reused in instances of recurrence. Patient education is essential to prevent re-ulceration in that functional area in the spinal cord injury patient.     

The Diagnosis and Treatment of Arterial Injuries

Repair of arterial injuries has decreased the amputation rate to 15% from 50%, which was prevalent when ligation was practised. Methods of treatment include lateral repair, resection of damaged area with end-to-end anastomosis, and resection and graft, with or without the assistance of partial or complete cardiopulmonary bypass. Lacerations of large arteries (aorta, iliac) may be treated by lateral repair. Lacerations of smaller arteries are best treated by resection and anastomosis, or by resection and graft. True and false aneurysms and arteriovenous fistulas are best treated by resection and restoration of blood flow. “Spasm” in an artery is frequently due to intimal rupture or subintimal hemorrhage, and likewise requires resection and anastomosis in many instances. Clinical examples of each type of injury are presented. Angiography is of great value in establishing the precise abnormality present, its location, the degree of collateral circulation, and the result achieved by surgery.     

Exposure to external environment of low ion concentrations is the trigger for rapid wound closure in Xenopus laevis embryos

Wounds in Xenopus laevis embryos close rapidly, as previously described. In this study, we examined the dependence on extracellular Na(+) and/or Cl(-) ion concentrations of the closure of wounds in Xenopus embryos inflicted by thermal injury. Wound closure did not occur in normal amphibian medium (100% NAM), while wound areas remarkably decreased either in 10-50% NAM or in 100% NAM lacking Na(+) or Cl(-). Similarly, wound areas did not change in a set of Na(+) and Cl(-) ion concentrations equivalent to those of the humoral fluids of intact Xenopus embryos, but rapid wound closure was induced by decreasing the concentration of either of the two ions. A tangential accumulation of actin cytoskeleton along the wound edge was associated with wound closure. However, a similar actin alignment formed even under the 100% NAM condition, in which wounds did not close, as stated above. The epidermis around the wound edge exhibited ellipse-shaped hypertrophy, and the marginal cells centripetally elongated during wound closure. On the other hand, no distinct morphological changes occurred in 100% NAM, although the epidermis was somewhat thickened. Thus, the morphological changes in the epidermis specific to the low ionic environment most likely play active roles in the wound closure of Xenopus laevis embryos, whereas the tangential actin alignment alone may be insufficient. Taken together, we propose that the wound closure in Xenopus embryos is triggered by a decline in either the extracellular Na(+) or Cl(-) ion concentration, and that this process is required for the abovementioned changes in the shape of the marginal cells.     

Mesenchymal stem cells: Paracrine signaling and differentiation during cutaneous wound repair

Cutaneous wounds persist as a health care crisis in spite of increased understanding of the cellular and molecular responses to injury. Contributing significantly to this crisis is the lack of reliable therapies for treatment of wounds that are slow to heal including chronic wounds and deep dermal wounds that develop hypertrophic scars. This article will review the growing evidence demonstrating the promise of multipotent mesenchymal stem/stromal (MSCs) for the treatment of impaired wound healing. MSCs are often referred to as mesenchymal stem cells despite concerns that these cells are not truly stem cells given the lack of evidence demonstrating self-renewal in vivo. Regardless, abundant evidence demonstrates the therapeutic potential of MSCs for repair and regeneration of damaged tissue due to injury or disease. To date, MSC treatment of acute and chronic wounds results in accelerated wound closure with increased epithelialization, granulation tissue formation and angiogenesis. Although there is evidence for MSC differentiation in the wound, most of the therapeutic effects are likely due to MSCs releasing soluble factors that regulate local cellular responses to cutaneous injury. Important challenges need to be overcome before MSCs can be used effectively to treat wounds that are slow to heal.     

Matrix metalloproteinases (MMPs) are required for wound closure and healing during larval leg regeneration in the flour beetle,Tribolium castaneum

Regenerative abilities are found ubiquitously among many metazoan taxa. To compare mechanisms underlying the initial stages of limb regeneration between insects and vertebrates, the roles of matrix metalloproteinases (MMPs) and fibroblast growth factor (FGF) signaling were investigated in the red flour beetle, Tribolium castaneum. RNA interference-mediated knockdown of MMP2 expression delayed wound healing and subsequent leg regeneration. Additionally, pairwise knockdown of MMP1/2 and MMP2/3, but not MMP1/3, resulted in inhibition of wound closure. Wound healing on the dorsal epidermis after injury was also delayed when MMPs were silenced. Our findings show that functionally redundant MMPs play key roles during limb regeneration and wound healing in Tribolium. This MMP-mediated wound healing is necessary for the subsequent formation of a blastema. In contrast, silencing of FGF receptor did not interfere with the initial stages of leg regeneration despite the alterations in tanning of the cuticle. Thus, insects and vertebrates appear to employ similar developmental processes for the initial stages of wound closure during limb regeneration, while the role of FGF in limb regeneration appears to be unique to vertebrates.     

Mechanism of repair of lenticular wounds in Rana pipiens. I. Role of cell migration

The earliest visible changes that occur in the normal organization of the lens epithelium after a penetrating wound in the lens suggest that passage of an injury stimulus outward from the wound occurs within the first half day after injury: changes in normal tissue architecture appear near the wound at six hours and move outward to involve the proliferative zone by 12 hours. This is followed by migration of cells toward the wound. There is a slight increase in cell number in the proliferative zone within the first day, followed at later intervals by a decrease there and a concomitant increase in cell number adjacent to the wound. After a pre-injury injection of H³-TdR (or I¹²⁵-UdR), labeled cells that had incorporated the precursor in the normal proliferative zone were found progressively closer to the wound with increasing time. Only the cells which incorporated the radioactive tracer could be followed, but it is likely that cells in the central areas also migrated toward the wound since they showed spindling and superimposition. Migration of cells into the wound margins is an important phase of wound closure which begins long before the major productions of new cells by mitosis.     

Knockdown of heme oxygenase-2 impairs corneal epithelial cell wound healing

Heme oxygenase (HO) represents an intrinsic cytoprotective system based on its anti‐oxidative and anti‐inflammatory properties mediated via its products biliverdin/bilirubin and carbon monoxide (CO). We showed that deletion of HO‐2 results in impaired corneal wound healing with associated chronic inflammatory complications. This study was undertaken to examine the role of HO activity and the contribution of HO‐1 and HO‐2 to corneal wound healing in an in vitro epithelial scratch injury model. A scratch wound model was established using human corneal epithelial (HCE) cells. These cells expressed both HO‐1 and HO‐2 proteins. Injury elicited a rapid and transient increase in HO‐1 and HO activity; HO‐2 expression was unchanged. Treatment with biliverdin or CORM‐A1, a CO donor, accelerated wound closure by 10% at 24 h. Inhibition of HO activity impaired wound closure by more than 50%. However, addition of biliverdin or CORM‐A1 reversed the effect of HO inhibition on wound healing. Moreover, knockdown of HO‐2 expression, but not HO‐1, significantly impaired wound healing. These results indicate that HO activity is required for corneal epithelial cell migration. Inhibition of HO activity impairs wound healing while amplification of its activity restores and accelerates healing. Importantly, HO‐2, which is highly expressed in the corneal epithelium, appears to be critical for the wound healing process in the cornea. The mechanisms by which it contributes to cell migration in response to injury may reside in the cytoprotective properties of CO and biliverdin. J. Cell. Physiol. 226: 1732–1740, 2011. © 2010 Wiley‐Liss, Inc.     

Annexins II and V Inhibit Cell Migration

Cell motility is a crucial component involved in wound healing, development, and tumor metastasis. This study investigated whether extracellular annexins, members of a calcium- and phospholipid-binding family of proteins, play a role in the migration of Lewis lung carcinoma cells. Using assays for wound closure and migration through 8-μm pores, it was found that annexins II and V significantly (>40%) inhibited migration of these highly metastatic cells. Additionally, anti-annexin II antibodies enhanced migration of these same cells in the wound closure assay, while an irrelevant antibody (anti-calmodulin) showed no effect. These effects may be due to annexin–membrane binding and inhibition of phospholipid movement that is necessary for the formation of membrane protrusions.     

Intrathoracic versus Cervical Anastomosis after Resection of Esophageal Cancer: A matched pair analysis of 72 patients in a single center study

ABSTRACT: BACKGROUND: The aim of this study was to analyze the early postoperative outcome of esophageal cancer treated by subtotal esophageal resection, gastric interposition and either intrathoracic or cervical anastomosis in a single center study. METHODS: 72 patients who received either a cervical or intrathoracic anastomosis after esophageal resection for esophageal cancer were matched by age and tumor stage. Collected data from these patients were analyzed retrospectively regarding morbidity and mortality rates. RESULTS: Anastomotic leakage rate was significantly lower in the intrathoracic anastomosis group than in the cervical anastomosis group (4 of 36 patients (11 %) vs. 11 of 36 patients (31 %); p = 0.040). The hospital stay was significantly shorter in the intrathoracic anastomosis group compared to the cervical anastomosis group (14 (range 10-110) vs. 26 days (range 12 - 105); p = 0.012). Wound infection and temporary paresis of the recurrent laryngeal nerve occurred significantly more often in the cervical anastomosis group compared to the intrathoracic anastomosis group (28 % vs. 0 %; p = 0.002 and 11 % vs. 0 %; p = 0.046). The overall Inhospital mortality rate was 6 % (4 of 72 patients) without any differences between the study groups. CONCLUSIONS: The present data support the assumption that the transthoracic approach with an intrathoracic anastomosis compared to a cervical esophagogastrostomy is the safer and more beneficial procedure in patients with carcinoma of the lower and middle third of the esophagus due to a significant reduction of anastomotic leakage, wound infection, paresis of the recurrent laryngeal nerve and shorter hospital stay.     

Microenvironment-induced myofibroblast-like conversion of engrafted keratinocytes

Myofibroblasts,recognized classically by-smooth muscle actin(-SMA)expression,play a key role in the wound-healing process,promoting wound closure and matrix deposition.Although a body of evidence shows that keratinocytes explanted onto a wound bed promote closure of a skin injury,the underlying mechanisms are not well understood.The basal layer of epidermis is rich in undifferentiated keratinocytes(UKs).We showed that UKs injected into granulation tissue could switch into-SMA positive cells,and accelerate the rate of skin wound healing.In addition,when the epidermis sheets isolated from foreskin cover up the wound bed or are induced in vitro,keratinocytes located at the basal layers or adjacent sites were observed to convert into myofibroblast-like cells.Thus,UKs have a potential for myofibroblastic transition,which provides a novel mechanism by which keratinocyte explants accelerate skin wound healing.     

RhoA and Rac1 are both required for efficient wound closure of airway epithelial cells

Repair of the airway epithelium after injury is critical for restoring normal lung. The reepithelialization process involves spreading and migration followed later by cell proliferation. Rho-GTPases are key components of the wound healing process in many different types of tissues, but the specific roles for RhoA and Rac1 vary and have not been identified in lung epithelial cells. We investigated whether RhoA and Rac1 regulate wound closure of bronchial epithelial cells. RhoA and Rac1 proteins were efficiently expressed in a cell line of human bronchial epithelial cells (16HBE) by adenovirus-based gene transfer. We found that both constitutively active RhoA and dominant negative RhoA inhibited wound healing, suggesting that both activation and inhibition of RhoA interfere with normal wound healing. Overexpression of wild-type Rac1 induced upregulation of RhoA, disrupted intercellular junctions, and inhibited wound closure. Dominant negative Rac1 also inhibited wound closure. Inhibition of the downstream effector of RhoA, Rho-kinase, with Y-27632 suppressed actin stress fibers and focal adhesion formation, increased Rac1 activity, and stimulated wound closure. The activity of both RhoA and Rac1 are influenced by the polymerization state of microtubules, and cell migration involves coordinated action of actin and microtubules. Microtubule depolymerization upon nocodazole treatment led to an increase in focal adhesions and decreased wound closure. We conclude that coordination of both RhoA and Rac1 activity contributes to bronchial epithelial wound repair mechanisms in vitro, that inhibition of Rho-kinase accelerates wound closure, and that efficient repair involves intact microtubules.     

Acute and definitive management of traumatic osteocutaneous defects of the lower extremity

Twenty-two lower extremity osteocutaneous defects resulting from high-energy trauma were managed from the onset of injury to rehabilitation by a collaborative effort between orthopedic and plastic surgeons. Emergency debridement of devitalized soft tissue and bone, external fracture stabilization, and serial debridements prepared the wound for closure with predominantly free-muscle transfers performed an average of 17 days (range 3 to 43 days) after injury. Cancellous or vascularized fibula grafting, depending on defect size, was performed an average of 9 weeks (range 6 to 16 weeks) after muscle flap closure. In this group of patients, whose average injury severity score was 18 (range 9 to 45) and whose average segmental bone defect was 8 cm (range 3 to 18 cm), the average time after injury to full weight bearing was 61 weeks (range 39 to 120 weeks). The early infection rate was 14 percent. Two extremities were amputated. There have been no chronic infections. Follow-up has ranged from 9 to 34 months.     

Possible roles of ENaC and Cl(-) channel in wound closure in Xenopus laevis embryos

Our previous report showed that rapid wound closure in Xenopus laevis embryos was associated with a decrease in the extracellular concentration of either Na(+) or Cl(-) ions. In this study, we examined the wound closure in Xenopus embryos when epithelial Na(+) channel (ENaC), Na(+)/K(+) ATPase (Na(+) pump) or CICs (members of Cl(-) channel) were blocked by each specific inhibitor. Blockage of ENaC and CIC restricted the rate of wound closure during the first 30 min PW and during the subsequent period, respectively. In contrast, inhibition of Na(+) pump had no effect on the rate of wound closure. Furthermore, simultaneous administration of both ENaC and CIC inhibitors resulted in the cumulative reduction of wound closure. Thus, it is plausible that these ion channels play active roles in wound closure in Xenopus embryos. NPPB is known to inhibit both CIC-2 and CIC-3. Immunohistochemical experiments showed that CIC-3, but not CIC-2, was expressed in Xenopus embryos, suggesting that the reduced wound closure by NPPB was due to blockage of CIC-3. A local enhancement of CIC-3 expression at the leading edge of the wounded epidermis was found to be specific to closing wounds that were kept in 10% NAM. An in vitro wounding assay also showed a pattern of CIC-3 expression at the margin of the scratch wound comparable to the results in vivo. These findings suggest that intracellular translocation of CIC-3 is involved in wound closure. We propose that the ion channels, including CIC-3, play a crucial role in wound closure in Xenopus embryos.     

Mesenchymal stromal cells of human umbilical cord Wharton's jelly accelerate wound healing by paracrine mechanisms

Background aimsMesenchymal stromal cells (MSC) can be isolated from the perivascular connective tissue of umbilical cords, called Wharton's jelly. These human umbilical cord perivascular cells (HUCPVC) might provide therapeutic benefits when treating skeletal or cutaneous malformations in neonatal patients.MethodsHUCPVC were isolated, and their proliferation rate, marker expression and multilineage differentiation potential determined. HUCPVC or their conditioned medium (HUCPVC-CM) was injected into the excisional wound of a mouse splinted-wound model. The effects of the treatment on wound closure were examined by morphohistochemical and gene expression analyses.ResultsHUCPVC expressed typical MSC markers and could differentiate into osteoblastic and adipogenic lineages. HUCPVC transplanted into the mouse wound accelerated wound closure. Immunohistologic analysis showed that the HUCPVC accelerated wound healing by enhancing collagen deposition and angiogenesis via paracrine mechanisms. Furthermore, treatment with HUCPVC-CM alone significantly enhanced wound closure. HUCPVC-CM increased the number of anti-inflammatory M2 macrophages expressing resistin-like molecule (RELM)-α/CD11b and promoted neovessel maturation. Quantitative polymerase chain reaction (PCR) analysis showed that HUCPVC-CM increased the expression of tissue-repairing cytokines interleukin (IL)-10, transforming growth factor (TGF)-β1, vascular endothelial growth factor (VEGF)-1 and angiopoietin-1 at the healing wound.ConclusionsOur results show that HUCPVC promotes wound healing via multifaceted paracrine mechanisms. Together with their ability to differentiate into the osteogenic linage, HUCPVC may provide significant therapeutic benefits for treating wounds in neonatal patients.     

Role of the cytoskeleton during injury-induced cell migration in corneal endothelium

The role of microfilaments and microtubules during injury-induced cell migration of corneal endothelial cells in situ along their natural basement membrane has been investigated using organ culture. In the noninjured tissue, actin is localized at or near the plasma membrane, whereas tubulin is observed as a delicate lattice pattern throughout the cytoplasm. Twenty-four hours after a circular freeze injury, cells surrounding the wound area extend processes into this region. Fluorescent microscopy using phallotoxins and anti-tubulin antibodies demonstrated the presence of stress fibers and microtubule reorganization within these cells. Between 24 and 48 h post-injury endothelial cells move into the wound region, and by 48 h, the injury zone is repopulated and the monolayer is becoming reestablished. When injured corneas are placed in media containing 5 x 10(-7) M cytochalasin B, endothelial cell migration occurs; but it is slow, and wound closure is not complete even by 72 h. In contrast, when tissues are cultured in the presence of 10(-8) M colchicine, cell movement is greatly reduced, complete wound closure does not occur, and endothelial cells at the wound edge fail to display extensions typical of migrating cells. Furthermore, when injured endothelia are exposed to 0.05 micrograms/ml of actinomycin D for 15 min within the first hour after injury and transferred back into culture media lacking the drug for the duration of the experiment, migration does not occur and the wound persists. These actinomycin D treated cells remain viable as shown by their ability to incorporate 3H-uridine and 3H-thymidine. Fluorescence microscopy of actinomycin D treated tissues revealed the presence of stress filaments but disorganized microtubule patterns. Interestingly, 24 h after injury, if the tissue is exposed to actinomycin D, even for periods of up to 1 h, migration is not inhibited. Our results indicate that injury-induced endothelial cell movement appears to be more dependent on microtubule than microfilament reorganization and may require a critical timing of macromolecular synthesis.     

Signaling pathways and cell mechanics involved in wound closure by epithelial cell sheets

BACKGROUND: Sheets of cells move together as a unit during wound healing and embryonic tissue movements, such as those occurring during gastrulation and neurulation. We have used epithelial wound closure as a model system for such movements and examined the mechanisms of closure and the importance of the Rho family of Ras-related small GTPases in this process. RESULTS: Wounds induced in Madin-Darby canine kidney (MDCK) epithelial cell monolayers close by Rac- and phosphoinositide-dependent cell crawling, with formation of lamellipodia at the wound margin, and not by contraction of a perimarginal actomyosin purse-string. Although Rho-dependent actin bundles usually form at the margin, neither Rho activity nor formation of these structures is required for wound closure to occur at a normal rate. Cdc42 activity is also not required for closure. Inhibition of Rho or Cdc42 results, however, in statistically significant decreases in the regularity of wound closure, as determined by the ratio of wound margin perimeter over the remaining denuded area at different times. The Rac-dependent force generation for closure is distributed over several rows of cells from the wound margin, as inhibition of motility in the first row of cells alone does not inhibit closure and can be compensated for by generation of motile force in cells behind the margin. Furthermore, we observed high levels of Rac-dependent actin assembly in the first few rows of cells from the wound margin. CONCLUSIONS: Wounds in MDCK cell sheets do not close by purse-string contraction but by a crawling behavior involving Rac, phosphoinositides and active movement of multiple rows of cells. This finding suggests a new distributed mode of signaling and movement that, nevertheless, resembles individual cell motility. Although Rho and Cdc42 activities are not required for closure, they have a role in determining the regularity of closure.