alteracion de olageno en fascia transversalis

7/25/2019 Alteracion de Olageno en Fascia Transversalis

1/7

Hernia (1999) 4:181-1,87

ernia

9 Springer-Verlag 1999

l t e r e d c o l la g e n s y n t h e s i s i n f a s c i a t r a n s v e r s a l i s o f p a t i e n t s w i t h i n g u i n a l h e r n i a

U . K l in g e I H . Z h e n g I Z . Y . S i R . B h a r d w a j 2 B . K l o s t e r h a l f e n 2 a n d V . S c h u m p e l i c k I

1The Surgica l De partment, 2The Inst i tute of Pathology, The Technica l U nivers i ty of Aachen (RWT H), Pauwelsstr . 30, D-52o57 Aachen, G ermany

S u m m a r y . T h e a i m o f th i s s t u d y w a s t o s u b s t a n t i a t e t h e h y p o t h e s i s a s t o w h e -

t h e r a n a l t e re d m e t a b o l i s m o f t y p e I a n d t y p e I I I c o ll a g e n s h o u l d b e i n c l u d e d

a s p a t h o p h y s i o l o g i c a l c o n s i d e r a t io n s o f i n g u i n a l h e r n i a d e v e l o p m e n t o r n o t .

T h e r e f o r e , f a s c i a t r a n s v e r s a l i s d e r i v e d f r o m p a t i e n t s w i t h i n d i r e c t h e r n i a s

( n = 9 ) , d i r e c t h e r n i a s ( n = 7 ) a n d f r o m c o n t r o l s ( n = 7 ) w e r e i n v e s t ig a t e d b o t h

b y i m m u n o h i s t o c h e m i s t r y a n d p r o t e i n a n a l y si s ( W e s t e rn B l ot ). B o t h i m m u -

n o h i s t o c h e m i c a l a n a ly s i s a n d W e s t e r n B l o t a n a l y s i s s h o w e d t h a t t h e r a t i o o f

t h e r e l a t iv e a m o u n t s o f t y p e I t o t y p e I I I c o l l a g e n w a s s i g n i f i c a n tl y d e c r e a s e d

i n t h e f a s c i a tr a n s v e r s a l is o f p a ti e n t s w i t h i n d i r e c t a n d d i r e c t i n g u i n a l h e r n i a s

c o m p a r e d w i t h c o n t r o l s ( p < o . o o l ) . T h e r e l a ti v e r e d u c t i o n o f t h e c o l l a g e n I /I I I

r a t io m a y b e e x p l a i n e d b y a c o n c o m i t a n t i n c r e a s e i n c o l l ag e n t y p e I II s y n t h e -

s i s i n b o t h h e r n i a - f a m i l i e s . I n c o n t r a s t t o t h e c o n t r o l g r o u p t h e r e w a s n o

s i g n i f i c a n t d i f f e r e n c e b e t w e e n p a t i e n t s w i t h d i r e c t a n d i n d i r e c t h e r n i a . I t i s

c o n c l u d e d t h a t t h e c h a n g e i n c o l la g e n t y p e I / I I I r a t io , w i t h t h e r e s u l t i n g a l te -

r e d p h y s i c a l p r o p e r t i e s , m i g h t e s s e n t i a l l y p r e d i s p o s e i n d i v i d u a l s to t h e d e v e -

l o p m e n t o f i n g u i n a l h e r n i a . T h u s , a n a l t e r e d c o l la g e n m e t a b o l i s m w o u l d p r o -

v i d e a n a d d i t i o n a l t h e o r e t i c a l b a s is f o r t h e u s e o f a l lo p l a s ti c m a t e r i a ls , s u c h a s

s u r g ic a l m e s h e s , a n d a n e x p l a n a t i o n f o r t h e d i s a p p o i n t i n g h i g h r e c u r r e n c e

r a t es a f t e r a p p r o p r i a t e p r i m a r y h e r n i a r e p a i r, p a r t i c u l a r l y i f m e s h - f r e e t e c h -

n i q u e s h a v e b e e n u s e d .

Key words : Co ll agen I - - Co l l agen I I I - - He rn i a - - Fa sc i a t r ansve r sa li s - - Surg i-

ca l me sh

Correspondance to: U. Klinge

Received February 12 1999

Accepted in fin al for m July 12 I999

W e l l k n o w n r is k f a c t o r s a s s o c i a t e d

w i t h h e r n i a t i o n i n t h e i n g u i n a l a r e a a r e

p r i m a r i l y a n o p e n p r o c e s s u s v a g i n a l i s

a n d r e p e a t e d e l e v a t i o n o f i n t r a -a b d o -

m i n a l p r e s s u r e . H o w e v e r , t h e s e c l a s si -

c a l d e s c r i p t io n s a n d p a t h o p h y s i o l o g i -

c a l c o n c e p t s d o n o t a c c o u n t f o r t h e i n i -

t i a l a p p e a r a n c e o f a n i n d i r e c t i n g u i n a l

h e r n i a a f t e r t h e a g e o f f o r t y [ C o n n o r

1 97 3] , o r f o r t h e t e n d e n c y o f e l d e r l y

p a t i e n t s t o h a v e a t t e n u a t e d f a s c i a l

s t r u c t u r e s [ P e a c o c k 1974 S t o p p a 1998]

a n d a n i n c r e a s e d i n c i d e n c e o f d i r e c t

i n g u i n a l h e r n i a s . M o r e o v e r , t h e y c a n -

n o t a d e q u a t e l y e x p l a i n t h e u n s a t i s f a c -

t o r y h i g h r e c u r r e n c e r a t e s o f i n g u i n a l

h e r n i a s a f t e r p h y s i c a l s t r e n g t h h a s

b e e n r e s t o r e d b y s u r g ic a l m e s h - f r e e


2/7

182 U. Klinge,et ah Collagensynthesisand hernia

procedures [Lichtenstein 1993, Arlt

1997]. An essential condition for the

development of inguinal hernia is a

defect of the fascia transversalis. The-

refore its incision and repair is of spe-

cial importance for hernia repair with

regard to recurrence rate [Schumpelick

1994]. Pathological and biochemical

studies have demonstrated that

patients with inguinal hernia present

with a variable diameter and periodici-

ty of collagen fibrils [Nikolov

199o,

Read

1998],

a reduced collagen synthe-

sis, a diminished amount of polymeric

collagen, a lower rate of fibroblast pro-

liferation and a longer fibroblast gene-

ration time [Wagh

1971 ,

Ajabnoor

1992]. These factors correspond to an

increased elasticity of the transversalis

fascia [Pans

1997].

The tensile strength

of the tissue depends largely upon the

proportions of type I and III collagen

[Henke11982]. Type I essentially repre-

sents a mature, cross-linked collagen

with thick fibres predominantly seen

in tendons and ligaments, whereas

type III consists of thin, immature and

isolated collagen fibres, mainly found

in embryonic tissue and smooth

muscle [Dale 1996, Fleischmajer 1 9 8 1

Fleischmajer 199o]. In the present

s tudy immunohis tochemist ry and

Western Blot analysis of the type I and

III collagens were undertaken to deter-

mine whether an al teration of collagen

synthesis and a change of the type I /

type III ratio in fascia transversalis was

associated with the development of

inguinal hernias.

aterial and method s

Between November 1997 and July 1998,

a total of 23 patients participated in the

study following informed consent in

the Depar tment o f Surgery at the Rhe-

nish-Westphalian Technical Universi-

ty, Aachen, Germany. The patients

who underwent primary hernia repair

had either indirect inguinal hernias

(male=8, female=l) or direct inguinal

hernias (male=6, female=l). Patients

undergoing other abdominal opera-

tions where a fascial sample could be

taken in the lower abdomen acted as

controls (male=5, female=2). There

was no significant difference in age

between the three groups (indirect her-

nias: 64 years (54-72); direct hernias 68

years

5 5 - 7 7 ) ;

controls: 63 years

(42-79)).

Patients undergoing steroid thera-

py, with previous history of any abdo-

minal surgery, diabetes, abdominal

aortic aneurysm and connective tissue

diseases were excluded from the study.

The tissue samples obtained of fascia

transversalis were transferred to the

laboratory on ice immediately after

surgery. They were defatted and frozen

in liquid nitrogen and then kept at -7o~

until used.

Immunoh is tochemica lstud ies

For detecting type I and type III colla-

gen in fascia transversalis, 5 pm cryo-

stat sections were cut at -2o~ and pla-

ced on cleaned slides coated with Poly-

L-lysine (Sigma, USA), and fixed at 4~

in acetone for lo min. Endogenous

peroxidase activity in the tissue sec-

tions was blocked with 0.3 H202 in

methanol for 30 min. Mouse anti-

human type I collagen (Sigma, USA)

and Goat anti-human type III collagen

(Southern Biotechnology, USA) were

used as primary antibodies in a dilu-

tion of 1:5oo and 1:2oo, respectively.

These primary antibodies were incuba-

ted at room temperature for 1 h. Hor-

seradish peroxidase conjugated rabbit

anti-mouse antibody (Dako, Germany)

and rabbit anti-goat antibody (Dako,

Germany) were used as secondary

antibodies each at a dilution of 1:5o.

Sections were incubated with the

secondary antibodies at room tempe-

rature for 30 min. As a chromogen

0.06 3.3-diaminobenzidine tetrachlo-

ride was used. Finally, the sections

were dehydrated, cleared in xyline, and

mounted in Vitro-clud| (R. Langen-

brinck, Germany).

Half of the sections were additio-

nally counterstained with haematoxy-

lin. The intensity of the antigen-anti-

body reaction was quantified by an

image analyser system (Quantimet

6oo, Leica, Germany) using lO rando-

mised fields for each specimen.

Control sections were not incubed with

primary antibodies. In all cases the

control sections showed no evidence of

staining and colour reaction under

microscopic examination. The back-

ground control value was substracted

from the value obtained for each non-

control section. This protocol was

repeated three times for each tissue

sample.

Col lagenex t rac t i on

Tissue specimens for collagen extrac-

tion were cut into 1-2 mm 3 blocks.

After briefly washing in double distil-

led water, the tissues were suspended

for 30 min in double distilled water

containing proteinase inhibitors:

20 pM PMSF (Sigma, USA), 5 mM

EDTA, 1 pg/ml Leupeptin (Boehringer,

Germany), 5 pg/ml Aprotinin (Fluka

Schweiz). After pulverising, the colla-

gens were solubilized for 24 hs at 4~

using limited pepsin digestion

(1 mg/ml) in 0.5 M acetic acid, (pH 2.5),

with continuous vigorous stirring [Mil-

ler 1 9 8 2 ] . The mixtures were centrifu-

ged at 35,000 g, at 4~ for 45 min and

the supernatants collected and kept at

-2o~ The precip itates were then

resuspended in fresh o.5 M acetic acid

containing pepsin and again re-extrac-

ted. This procedure was repeated for

three t imes for each sample.

Crystalline sodium chloride (NaC1)

was slowly added to the combined

supernatants until the final concentra-

tion of NaC1 was 0.7 M. The samples

were then centrifuged at 4~ for 45 min

at 35,ooog. The supernatants contai-

ning the solubilized type I and type III

collagen were dialysed overnight

against o.1 M acetic acid at 4~ and

then lyophilized.

Electrophoresis and Weste rn l o t

Electrophoresis reagents and buffers

were prepared as described by Laemm-

li [197o]. 6.25 btg of protein (protein

essay (Bio-Rad, USA)) was loaded into

each well of a 6 polyacrylamide gel,

which was run in the stacking gel at

30 V and in the separating gel at loo

V. lO pl of biotinylated protein stan-

dards (Tropix USA) per lane was


3/7

U. Klinge, et aI: Collagen synthesis and hern ia 183

Fig. la f

Imrnun ostain ing for collagen ty pe [ and type III in fascia transversalis, a collagen type I in groups with indirect h ernia; b collagen type I in patients wit h dire ct hernia; c coliagen ty pe I in

controls; d collagen t ype ll ~ n patients w ith indirec t hernia; e collagen typ e III in patients w ith direct hern ia; f collagen t ype III in controls; a f: 200 x

u s e d as s t a n d a r d . P r o t e i n s f r o m

s o d i u m d o d e c y l s u l p h a t e - p o ly a c r y l a -

mide ge l ele trophoresis SDS-PAGE)

were e lec t ropho re t ica l ly t r ansfe r red to

a p o l y v i n y l i d e n - d i f l u o r i d e P V D F )

me mb ran e Biorad , USA) by appl ica -

t ion of a cur ren t o f 0 .8 m A/cm ~ for 1 h

a t r o o m t e m p e r a t u r e . T h e W e s t e r n -

L i g h t P l u s C h e m i l u m i n e s c e n t d e t e c -

t ion sys tem Tropix | USA) was used

for the imm unologica l de tec t ion . Br ie -

f l y, n o n s p e c i f i c b i n d i n g s i t e s w e r e

b loc ke d w i th b loc k ing bu f f e r f o r 1 h .

T he m e m br a ne s w e r e i nc uba t e d w i th

m onoc tona l a n t i - hum a n c o ll a ge n type


4/7

184 U. Klinge et al: Collage n synthesis and hern ia

I (Sigma, USA) and monoclonal anti-

human collagen type III (ICN Biomedi-

cals, Germany) at a dilution of 1:1.ooo

for 30 min, respectively. The mem-

branes were then incubated with a bio-

tinylated goat anti-mouse secondary

antibody at a di lution of 1:1o.ooo for 30

min, and subsequently incubated with

Avdix-AP conjugated at a dilution of

1:2o,ooo for 30 min. After 2x2 washing

in Assay buffer, a thin layer of CSPD

substrate solution was added to the

membranes, which membranes were

then exposed to x-ray film for 15-3o

min and visualised.

The relative amounts of type I and

type III collagen were determined by

Bio-Rad's Multi-Analyst| (Bio-Rad,

USA). A band of standard protein was

initially designated as a specific stan-

dard, following which the relative

values of protein bands corresponding

to collagen type I and type III within

the entire gel could be calculated inde-

pendently and automatically by the

software. Subsequently, the ratios of

the relative amounts of type I and type

III collagen were calculated and com-

pared with those of the control sub-

jects.

Statistical methods

Statistical analysis was c onducted

using Statistical Package for Social

Sciences (SPSS) software. Student's

two-tail t-test was used to determine

whether there were statistically signifi-

cant differences between either indi-

rect or direct inguinal hernia and

control and between indirect and

direct inguinal hernia. All data are pre-

sented as mean + SD (standard devia-

tion). Values of p


5/7

u. K linge,et al: Collagensynthesisand hernia 185

p a t i e n t s w i t h i n d i r e c t a n d d i r e c t h e r -

n i a s c o m p a r e d w i t h t h e c o n t r o l s . A s a

r e su l t , t h e r a t i o s o f t y p e I t o t y p e I I I

c o l l a g e n w a s L o 9 + o . 2 7 i n t h e g r o u p

w i t h i n d i r e c t h e r n i a s a n d 1 .2 _+ o.3 3 i n

t h e g r o u p w i t h d i r e c t h e r n ia s , w h e r e a s

t h e t y p e I / I I I c o l l a g e n r a t i o w a s

1 .5 4 _+ o .3 2 i n c o n t r o l s ( F i g . 2 ) T h e r e

w e r e n o d i f f e r e n c e s b e t w e e n t h e i n d i -

r e c t a n d d i r e c t h e r n i a g r o u p s ( p > o . o 5 ).

T h e d e c r e a se i n t h e r a t i o o f t y p e I t o

t y p e I I I c o l l a g e n b o t h i n p a t i e n t s w i t h

e i t h e r i n d i r e c t oz" d i r e c t h e r n i a s , w a s

h i g h l y s i g n if i c a n t c o m p a r e d w i t h t h a t

i n th e c o n t r o l s ( p < o . o m ) .

W e s t e r n l o t a n a l y s i s a f c o l la g e n t y p e I

a n d t y p e I I I

T w o p r o t e i n b a n d s o f c o ll a g e n t y p e I,

( cu{I} ) an d (ot2{I} ) were de t ec t ed u s ing

6 % S D S - P A G E a n d W e s t e r n B l o t .

O t h e r p r o t e i n s b a n d s o f h i g h e r m o l e -

c u l a r m a s s c o r r e s p o n d i n g t o t h e b l ,

a n d g l , 1 c o m p o n e n t s o f c o l l a g e n w e r e

a l so d e t e c t e d ( F i g u r e 3 ) - T h e r e l a t i v e

c o n t e n t o f c o ll a g e n t y p e I w a s

1 1 9 . 3 6 + 2 4 . 3 8 % f o r t h e p a t i e n t s w i t h

ind i rec t he rn ia , 125 .o8+23.19% for t he

p a t i e n t s w i t h d i r e c t h e r n i a , a n d

121.73+31.o1% for the con trols .

I n c o n t r a s t c o l l a g e n t y p e I I I

cons i s t s o f t h ree c , l ( I I I ) cha ins . Unde r

r e d u c i n g c o n d i t i o n s , t h e i n t e r - c h a i n

d i su l p h i d e b o n d s o f c tl ( II I ) c h a i n s a r e

o p e n e d a n d r e s u l t i n t h e p r e s e n c e o f

c o n s t i t u e n t c h a i n s o f m o l e c u l a r w e i g h t

9 5 - 1 1 o k D a i n m o l e c u l e s r e s i d e n t s

wi th in the f ib r i l l a r aggrega tes (F ig . 4 ) .

T h e r e l a t i v e c o n t e n t o f c o l la g e n t y p e

I I I r e a c h e d 1 7 2 . 1 4 + 2 3 .6 2 % f o r t h e

p a t i e n t s w i t h in d i r e c t h e r n i a ,

2 2 1 . o 9 + 4 5 . 2 8 % f o r t h e p a t i e n t s w i t h

direc t her nia an d n3.51-+21.31% for th e

cont ro l s .

T h e r e s u l t s s h o w t h a t d u e t o a

p a r a l l e l i n c r e a s e i n t y p e I I I c o l l a g e n

sy n t h e s i s t h e r a t io s o f r e l a ti v e a m o u n t

o f t y p e I t o t y p e I I I c o l l a g e n f e l l t o

0 . 6- + 0. 0 7 i n i n d i r e c t h e r n i a s a n d

0 . 6 9 _ + o . o 9 i n d i r e c t h e r n i a s , w h e r e a s

t h e r a t i o w a s 1 . o 9 _ + o . a 8 i n c o n t r o l s

(F ig . 5 ). The re w ere no d i f fe rences be t -

w e e n i n d i r e c t :a nd d i r e c t h e r n i a s

( p > o . o s ) . H o w e v e r , t h e r a t i o o f t y p e I

a n d t y p e I I I c o l l a g e n i n p a t i e n t s w i t h

e i t h e r i n d i r e c t o r d i r e c t h e r n i a s w e r e

s i g n if i c a n tl y d i ff e r e n t w h e n c o m p a r e d

w i t h t h a t o f c o n t r o l s ( p < o . o m ) .

iscussion

I n y o u n g p a t i e n t s a n i n d i r e c t i n g u i n a l

h e r n i a u s u a l l y o c c u rs t h r o u g h a n u n o -

b l i t e ra t ed processus vag ina l i s , whereas

a d i r e c t i n g u i n a l h e r n i a a p p e a r s

t h r o u g h a w e a k a r e a ( t h e H e s s e l b a c h

t r i a n g l e ) b e t w e e n t h e p u b i c r a m u s a n d

t h e m u s c u l o f a s c i al c o m p o n e n t s o f th e

l o w e r a b d o m i n a l w a l l . I n t e r e s t i n g l y ,

o l d e r p a t i e n t s w i t h i n g u i n a l h e r n i a a r e

u su a l l y r e p o r t e d t o h a v e a d e f e c t in t h e

f a s c ia t r a n s v e r s a l i s [ P e a c o c k 1974

S c h u m p e l i c k 1 9 9 4 ] , r e g a r d le s s o f w h e -

the r i t i s media l o r l a t e ra l t o t he ep igas-

t r i c vessel s . Obvious ly , t he de fec t i n the

fasc i a t r ansve rsa l i s p l ays a p ivo ta l ro l e

i n t h e d e v e l o p m e n t o f h e r n i a s . T h u s , i n

h e r n i a l s u r g e r y i t s i n c i s i o n a n d a d e -

q u a t e m e c h a n i c a l r e p a i r i s o f p a r t i c u -

l a r i m p o r t a n c e i n r e g a r d t o l o w r e c u r -

rence ra t e s .

U n f o r t u n a t e l y , f e w p r e v i o u s s t u d i e s

h a v e f o c u se d m a i n l y o n t h e p a t h o l o g i -

ca l changes o f t he fa sc i a t r ansve rsa l i s .

A d j a c e n t t o t h e h e r n i a d e f e c t th e t r a n s -

v e r sa l i s f a s c i a i s k n o w n t o b e t h i n n e r

a n d a t t e n u a t e d [ P e a c o c k 1 9 7 4 ] . U l t r a -

s t r u c t u r a l s t u d i e s h a v e r e v e a l e d a p p a -

r e n t s t r u c t u r a l c h a n g e s i n t h e c o l l a g e n

a n d f i b r o b l a s t s [ N i k o l o v 1 9 9 o ] . F u r -

t h e r m o r e , a m a r k e d a t t e n u a t io n o f t h e

f a s c i a t r a n s v e r s a l i s a n d a s i g n i f i c a n t

r e d u c t i o n i n t h e t h i c k n e s s o f c o n n e c t i -

v e ti s su e h a s b e e n d e m o n s t r a t e d i n t h e

a r e a o f t h e i n g u i n a l r i n g o n t h e c l i n ic a l

n o r m a l s i d e o f p a t ie n t s w i t h i n g u i n a l

h e r n i a [ P e a c o c k 19741. I n o n l y o n e

s tudy , Be l ldn e t a l [1997] a n a l y se d t h e

t y p e I / I I I c o l la g e n r a t io i n t r a n sv e r sa -

l is f a s c i a o f p a t i e n t s w i t h i n d i r e c t a n d

d i r e c t h e r n i a a n d f o u n d n o s i g n i f i c a n t

d i f f e re n c e b e t w e e n t h e s e t w o g r o u p s .

T h e se d a t a a r e i n a c c o r d a n c e w i t h o u r

f i n d i n g s . F u r t h e r m o r e , i n t h e p r e s e n t

s t u d y , w e f o u n d t h a t t h e r a t i o o f th e

r e l at i v e a m o u n t o f t y p e I / I I I c o l l ag e n

i n t r a n s v e r s a l i s f a s c i a f r o m p a t i e n t s

w i t h e i t h e r i n d i r e c t o r d i r e c t i n g u i n a l

h e r n i a w a s s i g n i f i c a n t l y l o w e r t h a n

t h a t in c o n t r o l s ( p < o . o o l ) , b o t h b y

i m m u n o h i s t o c h e m i s t r y a n d W e s t e r n

Blo t ana lys i s . As Be l l6n obse rved the re

w a s n o d i f f e re n c e s b e t w e e n p a t i e n t s

w i t h i n d i r e c t a n d d i r e c t i n g u i n a l h e r -

n i a (p>o .o5) .

A l t h o u g h i m m u n o h i s t o c h e m i s t r y is

k n o w n t o b e l e s s e x a c t t h a n t h e W e s -

t e r n b l o t an a l y s i s , w h e n a l a n a l y s e d

c o l l a g e n r a t i o s w e r e c o n s i d e r e d t h e

t w o m e t h o d s s h o w e d a h i g h c o r r e l a -

t i o n w i t h a P e a r so n ' s c o r r e l a t i o n c o ef -

f i c ie n t o f r = o .7 9 ( p = o . o o 3 ) , i n d i c a t i n g

t h e p r o b a b l e su i t a b i l i ty o f i m m u n o h i s -

t o c h e m i s t r y f o r s c r e e n i n g i n v e st ig a -

t ions .

I n r e l a t i o n to t h e c o n t r o l g r o u p t h e

dec reased type I / I I I co l l agen ra t io in

h e r n i a p a t i e n t s w a s p a r a l l e l e d b y a

r e m a r k a b l e i n c r e a se i n t y p e I I I c o l l a -

g e n s y n t h e s i s . T h e s e r e s u l t s s u p p o r t

t h e f i n d i n g s o f F r i e d m a n e t a l [ 19 93 ],

w h o r e p o r t e d a m a r k e d i n c r e a s e i n

t y p e I I I c o l l a g e n m R N A e x p r e s s i o n

w i t h a p a r a l l e l d e c r e a s e i n c o l l a g e n

type I / I I I r a t io in f ib rob las t cu l tu res

o b t a i n e d f r o m t h e s k i n o f p a t i e n t s

u n d e r g o i n g h e r n i a ti o n .

I t is w e ll k n o w n t h a t t y p e I a n d t y p e

I I I c o l l a g e n c o e x i s t w i t h i n i n d i v i d u a l

f i b r i l s [ I i m o t o 1 9 8 8 ] , a n d t h a t t h e i r

r a t i o i s r e la t e d t o t h e d i a m e t e r o f t h e

co l l agen f ib r i l s [Da le 1996 , F l e i schma-

j e r 199o] . Type I co l l agen i s found as

d e n se b u n d l e s i n t i s su e s , su c h a s t e n -

d o n , l ig a m e n t s a n d d e r m i s . T h e s e

b u n d l e s c o n t a i n l a r g e - d i a m e t e r c o l la -

g e n f i b r i l s p r o v i d i n g su p e r i o r m e c h a -

n i c a l i n te g r i t y w h i c h t h u s d e t e r m i n e s

t h e s t r e n g t h o f t h e s e t i s s u e s . I n

c o n t r a s t t y p e I I I c o l l a g e n f o r m s t h i n

i so la t ed f ib r il s t ha t a re fo un d l a rge ly in

t i s s u e s t h a t r e q u i r e s o m e d e g r e e o f

f l e x i b il i ty a n d p l a s t i c i ty ( e . g. e m b r y o -

n i c s k i n , b l o o d v e s s e l s , a n d s m o o t h

musc le ) , and has a spec i f i c ro l e in the

d e t e r m i n a t i o n o f f ib r i l s tr u c t u r e , t i s su e

a r c h i t e c t u r e a n d f u n c t i o n [ D a l e 1 9 9 6 ,

Fleis chm ajer 1981, 199o].

I n g e n e r a l c o l l a g e n s t r e n g t h

d e c r e a se s w i t h i n c r e a s i n g f i b r e d i a m e -

t e r. T h e l a r g e d i a m e t e r f i b re s a r e m a d e

u p o f s m a l l e r f i b r i l s w i t h a g r e a t e r

c h a n c e o f f a i l u re b e c a u s e o f s l ip p a g e

b e t w e e n f i b r il s , r a t h e r t h a n b e c a u se o f

t h e b r e a k a g e o f c o l l a g e n m o l e c u l e s

[ A r m s t r o n g 1 9 9 2 ] . T h u s , t h e i n c r e a se

i n t y p e H I c o l l a g e n sy n t h e s i s d e t e c t e d


6/7

186 U. Klinge, et ah Collagen synthesis and hern ia

i n p a t i e n t s w i t h i n d i r e c t a n d d i r e c t

i n g u i n a l h e r n i a c a n r e s u l t i n a n i n c r e a -

s e i n s m a l l e r c o l l a g e n f i b r i l s w i t h a

c o n c o m i t a n t d e c r e a s e o f la r g e d i a m e -

t e r f i b r e s . T h i s m i g h t b e r e s p o n s i b l e

f o r t h e r e d u c t i o n i n m e c h a n i c a l s t r e n g -

t h a n d c h a n g e i n t h e p h y s i c a l p r o p e r -

t i e s o f t h e c o l l a g e n m a t r i x i n t h e a b d o -

m i n a l w a l l, a n d t h u s m a y p r e d i s p o s e

i n d i v i d u a l s t o t h e d e v e l o p m e n t o f

i n g u i n a l h e r n i a . T h i s h y p o t h e s i s i s

s u p p o r t e d b y th e f i n d in g s o f H u r m e

[ 9 9 ]

a n d L e h t o [ 1 9 85 ] f o r w o u n d h e a -

l i n g p r o c e ss e s . T h e y o b s e r v e d t h a t t h e

e a r l y sc a r t i ss u e f o r m a t i o n w i t h a p r e -

d o m i n a n t p r o p o r t i o n o f t y p e I II c ol la -

g e n i s q u i t e e l a s ti c a n d d o e s n o t c o n t r i -

b u t e s i g n i f i c a n t l y t o w o u n d t e n s i l e

s t r e n g t h . A c c o r d i n g l y , t h e g r e a t e s t

i n c r e a s e i n t e n s i l e s t r e n g t h i s o b s e r v e d

d u r i n g t h e l a t t e r s t a g e s o f h e a l i n g a n d

t i s s u e r e p a i r . T h i s c o r r e s p o n d s t o a n

i n c r e a s e o f ty p e I c o l l ag e n p r o d u c t i o n

a n d t h e f o r m a t i o n o f m o r e s t a b l e in t e r -

m o l e c u l a r c r o s s - l i n k s .

I n d i v i d u a l c o l l a g e n m o l e c u l e s a r e

h i g h l y o r g a n i s e d , w i t h t h e m e c h a n i c a l

p r o p e r t i e s o f c o l la g e n b e i n g d e p e n d e n t

u p o n c r o s s - l i n k s b e t w e e n c ~ - c h a i n s

w i t h i n a s i n g l e m o n o m e r a s w e l l a s

b e t w e e n c ~ - c h a i n s i n a d j a c e n t m o n o -

m e r s [ H e n k e l 1 9 8 2 ] . A s m o l e c u l e s o f

t y p e I a n d t y p e I I I c o l l a g e n h a v e t h e

s a m e l e n g t h a n d d i a m e t e r a n d b o t h

m o l e c u l e s c a n s u b s t i t u t e f o r o n e a n o -

t h e r i n c r o s s - l i n k e d p e p t i d e s , i t i s

c o n c e i v a b l e t h a t b o t h t y p e s o f m o l e -

c u l e s c a n f o r m m i x e d f i b r i l s w i t h i n f i -

n i t e ly v a r y in g p r o p o r t i o n s o f th e t w o

c o n s t it u e n t s. T h e p r o p o r t i o n o f ty p e

I I I c o l l a g e n i n m i x e d f i b r i l s m a y

d e p e n d d i r e c t ly u p o n t h e r a t i o o f t h e

s y n t h e s i s e d t y p e I a n d t y p e I I I c o l la g e n

m o l e c u l e s [ F l e i s c h m a j e r 1 98 1 ]. W i t h o u t

c r o s s - l i n k i n g t h e r e i s lo s s o f m e c h a n i -

c a l s t r e n g t h . I t h a s b e e n r e p o r t e d t h a t

i n c h r o n i c a l l y v o l u m e - o v e r l o a d e d a n d

c o n s e q u e n t l y h y p e r t r o p h i e d h e a rt s

t h e r e i s a n i n c r e a s e o f c r o s s - l i n k i n g

l o c a l i s e d o n t y p e I a n d t y p e I I I c o l la g e n

[ I i m o t o 1 9 8 8 ] . C o n s e q u e n t l y , a l t e r a -

t i o n s i n c o l l a g e n c r o s s - l i n k i n g is

t h o u g h t t o i m p a i r m y o c a r d i a l c o n t r a c -

t i l i ty [Capas so 1989] . Thus , an inc rease

o f ty p e I I I c o l la g e n m a y b e p r e d o m i -

n a n t l y r e s p o n s i b l e f o r t h e c h a n g e s o f

t h e g e o m e t r i c a l a r r a n g e m e n t o f c o l la -

g e n f i b r il s a n d o f c r o s s -l i n k s b e t w e e n

t y p e I a n d I I I c o ll a g e n . M o r e o v e r , t h e

o v e r a b u n d a n c e o f t y p e I I I c o ll a g en

r e l a t i v e to t y p e I c o l l a g e n c o u l d l e a d t o

a n i n c r e a s i n g i n so l u b l e, n o n - p o l y m e r i c

c o l l a g e n i n h i b i t i n g t h e a s s o c i a t e d p r o -

p e r t i e s o f t y p e I c o l l a g e n [ F r i e d m a n

1993].

A s a r e s u l t , t h e s e c h a n g e s c a n

c a u s e w e a k e n i n g o f t h e a b d o m i n a l w a l l

a n d p r o m o t e t h e d e v e l o p m e n t o f

i n g u i n a l h e r n i a .

I t is t h o u g h t t h a t e a r l y r e c u r r e n c e s

a f t e r a n t e r i o r m e s h - f r e e r e p a i r r e s u l t

f r o m t e c h n i c a l e r r o r s o r e x c e s s i v e t e n -

s i o n o n t h e s u t u r e l i n e c a u s e d b y t h e

a p p r o x i m a t i o n o f ti s su e . T h i s m i g h t b e

t r u e f o r e a r l y f a i l u r e s b u t c a n n o t

e x p l a in t h e a p p e a r a n c e o f r e c u r r e n c e s

s e v e r a l y e a r s a f t e r o p e r a t i o n . O u r f i n -

d i n g s i n d i c a t e t h a t t h e s e l a t e r e c u r -

r e n c e s m i g h t b e i n f l u e n c e d b y a d e f e c t

i n c o l l a g e n s y n t h e s i s w i t h t h i n n i n g o f

s c ar t is s u e a n d c o n t i n u e d i n h e r e n t

w e a k n e s s o f th e i n g u i n a l f l o o r [ L i c h -

t e n s t e i n 1993 A r l t 1997 F r i e d m a n

1993].

E v e n if n o n a b s o r b a b l e s u t u r e

m a t e r i a l i s u s e d i t h a s t o b e a s s u m e d

t h a t a f t e r a c e r t a i n t i m e t h e s e l o s e t h e i r

m e c h a n i c a l f u n c t i o n , w h i c h t h e n

d e p e n d s p u r e l y o n t h e t e n s i l e s t r e n g th

o f t h e i n d u c e d s c a r ti s s u e. A c c o r d i n g

t o o u r f i n d i n g s a n d t h e s e r e p o r t e d b y

o t h e r s , i t m a y b e i n f e r r e d t h a t t h e a l t e-

r e d c o l l a g e n m e t a b o l i s m s e e n i n f a s c i a

t r a n s v e r s a l i s m a y b e a g e n e r a l i s e d p h e -

n o m e n o n i n t h e s e p a t i e n t s , p e r h a p s

p r e d o m i n a n t l y i n t h e i n g u i n a l r e g i o n .

I f a s i m p l e m e s h - f r e e c l o s u r e i s p e r f o r -

m e d o r a n a u t o g e n o u s t i s s u e is a p p l i e d

i n t h e t r e a t m e n t o f p r i m a r y o r i n c i s io -

n a l h e r n i a i n t h e s e p a t i e n ts , a b n o r m a l

c o l l a g en m e t a b o l i s m m a y s t il l b e

d e t e c t e d i n t h e s k i n [ F r i e d m a n

19931

t h e r ec t u s s h e a t h [ W a g h

1971]

t h e

t r a n s v e r s a l i s f a s c i a [ N i k o l o v 1 9 9 o] a n d

t h e p e r i t o n e u m [ A j a b n o o r 1 9 9 2 ] o f t h e

i n g u i n a l r e g i o n . T h e r e f o r e , i t i s r e a s o -

n a b l e t h a t th e c o m p l e x m e t a b o l i c

a b n o r m a l i t i e s o f c o l l ag e n o f t h e s e t is -

s u e s w i ll d e c r e a s e t h e r e s i s t a n c e o f th e

a b d o m i n a l w a l l t o m e c h a n i c a l s t r e s s

a n d c o r r e s p o n d i n g h ig h r e c u r r e n c e

r a t e s s h o u l d t h e r e f o r e b e t h e p r e d e s t i -

n e d c l in i c a l r e s u l t o f p r i m a r y h e r n i a

r e p a i r . T h u s , o u r r e s u l t s s u p p o r t t h e

i d e a t h a t i m p l a n t a t i o n o f s u r g i c a l

m e s h e s s h o u l d l e a d t o a d e c r e a s e i n

r e c u r r e n c e r a t e s i n c o n d i t i o n s o f a n

a l t e r e d c o l l a g e n m e t a b o l i s m . T h e

n o n a b s o r b a b l e p o l y m e r ) m e s h e s

u s u a l l y s u p p o r t t h e t e n s il e s t r e n g t h o f

t h e a b d o m i n a l w a l l a f t e r c o r r e c t

i m p l a n t a t i o n . I n t h i s c o n t e x t i t a p p e a r s

r e a s o n a b l e t h a t t h e u s e o f a b s o r b a b l e

m e s h e s c a n n o t u s u a l l y p r e v e n t t h e

r e c u r r e n c e , b e c a u s e t h e i n d u c t i o n o f a

s c a r p l a t e a s a m e c h a n i c a l s t a b l e a n a t o -

m i c a l s t r u c t u r e a f t e r m e s h i m p l a n t a -

t i o n s e e m s t o b e d o u b t f u l i n p a t i e n t s

w i t h a l t e r e d c o l l a g e n d e p o s i t i o n a n d

c r o s s - l i n k i n g . P a r t i c u l a r l y i n t h e s e , a n d

i n o l d e r p a t i e n t s w i t h l a r g e d e f e c t s i n

t h e f a s ci a t r a n s v e r s a l i s o r r e c u r r e n t

h e r n i a s , t h e u se o f n o n a b s o r b a b l e

m e s h e s s e e m t o b e f a v o u r e d . N e v e r t h e -

l e ss , w i t h r e g a r d t o t h e p e r s i s t e n t f o r e i -

g n b o d y r e a c t i o n [ K l in g e 1999] a n d

s o m e o c c a s i o n a l l y s e v e r e c o m p l i c a -

t i o n s, s u c h a s m e s h m i g r a t i o n a n d f is -

t u l a f o r m a t i o n w i t h i t s u p t o n o w i n d e -

f i n i t e c u m u l a t i v e r a t e , t h e i r u s e s h o u l d

b e r e s t r i c t e d i n y o u n g p a t i e n ts .

I n c o n c l u s i o n , a s a r e s u l t o f i n c r e a -

s e d t y p e I I I c o l l a g e n s y n t h e s i s , t h e

r a t i o o f t y p e I / I I I c o l l a g e n i n t h e t r a n s -

v e r s a l i s f a s c i a f r o m p a t i e n t s b o t h w i t h

i n d i r e c t a n d d i r e c t h e r n i a s w a s s i g n i f i -

c a n t l y d e c r e a s e d i n c o m p a r i s o n t o

c o n t r o l s . T h e r a t i o i n p a t i e n t s w i t h

i n d i r e c t h e r n i a s w a s n o t s i g n i f i c a n t l y

d i f f e r e n t f r o m t h a t i n p a t i e n t s w i t h

d i r e c t h e r n i a s . T h e a l t e r a t i o n i n c o l l a -

g e n m e t a b o l i s m m a y f a v o u r t h e d e v e -

l o p m e n t o f h e r n ia s r e g a r d l e s s o f w h e -

t h e r t h e y a r e i n d i r e c t o r d i r e c t .

Acknowledgements.This work was supported by

a BMBF grant p roject no.

olKS95o3/9

for IZKF-

BIOMAT, RW TH-A achen.Moreover, he authors

gratefullyappreciate he personalgrants of Dr. H.

Zheng and Dr. Z.Y. Si suppo rted by E thicon

Ham burg, Germany.


7/7

U. Kl inge , e t a l : Col lagen synthe sis and her n ia 187

eferences

A j a b n o o r M A , M o k M a r A M , R a fe e A A , T a h a

AM . (1 99 2 ) De fe ct i v e c o ll a g e n me t a b o l i sm i n

S a u d i p a t i e n t s w i t h h e r n i a . A n n C l i n B i o -

them 29:43o-436

A r l t G , S c h u m p e l i c k V ( 1 9 9 7 ) T r a n s i n g u i n a l e

p r g p e r i t o n e a l e N e t z p l a s t i k ( T I P P ) i n d e r

V e r s o r g u n g d e r R e z i d i v l e i s t e n h e r n i e . C h i -

rurg 68:1235-1238

A r m s t r o n g C G , O C o n n o r P , G a r d n e r D L ( 19 92 )

M e c h a n i c a l b a s i s o f c o n n e c t i v e t i s s u e

d i s e as e s . I n : G a r d n e r

DL,

e d . Pa t h o l o g i c a l

b a s i s o f t h e c o n n e c t i v e t i s su e d i se a se s , e d l .

Ed wa rd Arn o l d , L o n d o n , p p 2 61 -2 81

B e l l d n JM , B u j f i n J , Ho n d u v i l l a NG, Jn ra d o F ,

Gi me n o M ] , Tu rn a y J , Ol mo N (1 99 7 ) S t u d y

o f b i o c h e mi c a l su b s t ra t e a n d ro l e o f me t a l l o -

p ro t e a se s i n fa sc i a t r a n sv e rsa l is f ro m h e rn i a l

processes . Eur I Cl in Inves t 27:51o-516

C a p a s s o J M , R o b i n s o n T F , A n v e r s a P ( 1 9 8 9 )

Al t e ra t i o n i n c o l]Lag e n c ro ss - l i n k i n g i m p a i r

my o c a rd i a l c o n t ra c t i l i t y i n t h e mo u se h e a r t .

Circ Res 65:1657-:L664

C o n n e r WT, Pe a c o c k EE (1 97 3 ) So me s t u d i e s o n

t h e e t i o l og y o f i n g u i n a l h e r n i a . A m I S u r g

126:732-735

Dale PD, Sherra t t IA, Main i PK 1996) A m a t h e -

m a t i c a l m o d e l f o r c o l la g e n f i b r e f o r m a t i o n

d u r i n g f o e t a l a n d a d u l t d e r m a l w o u l d h e a -

l ing . Proc R Soc Lo nd B 263:653-660

Fle ischm ajer R, Perli s[h JS, Burgeso n RE, Shaik h-

Bahai F, TimpI R (199o) Type I and type III

i n t e ra c t i o n s d u r i n g f i b r il l o g en e s i s . An n N.Y.

Acad Sci 58o: 161-175

Fl e i sc h ma i e r R , T i mp l R , Tu d e rm a n L , R a i sh e r L ,

W i e s t n e r M , P e r l i s h J S , G r a v e s P N ( 19 81 )

U l t r a s t r u c t n r a l i d e n t i f i c a t i o n o f e x t e n s i o n

a mi n o p ro p e p t i d e s o f t y p e I a n d I I I c o l la g e n s

i n h u m a n sk i n . P ro c Na i l Ac a d Sc i USA 7 8:

736o-7364

F r i e d m a n D W , B o y d C D , N o r t o n P , G r e c i R S ,

Boyars ky AH, Mac kenzie JW, Beak SB (1993)

In c re a se s i n t y p e I I I c o l l a g e n g e n e e x p re s -

s i o n a n d p r o t e i n s y n t h e s i s i n p a t i e n t s w i t h

i n g u i n a l h e rn i a s . A n n S u rg 2 1 8:754-76o

He n k e l W, G l a n v il l e R W (1 98 2 ) C o v a l e n t cro s s -

l i n k i n g b e t we e n mo l e c u l e s o f t y p e I a n d I I I

collagen. Eur J Biochem 122:2o5-213

Hu r me T , Ka l imo H, Sa n d b e rg M , Le h t o M , Vu o -

rio E

1991)

Local iza t ion of type and III co l -

l a g e n a n d f i b ro n e c t i n p ro d u c t i o n i n i n j u re d

g a s t ro c n e m i u s mu sc l e . La b In v e s t 6 4 :7 6 -8 4

Iimoto DS, Covel l JW, Harper E (1988) Increase

i n c ro ss - l i n k i n g o f t y p e I a n d t y p e I I I c o l la -

g e n s a s s o c i a te d w i t h v o l u m e - o v e r l o a d

hyp ert rop hy . Ci rc Res 63 :399-4o8

Kl i n g e U, Kl o s t e rh a l fe n B , M i i l le r M , S c h u mp e -

l i c k V 1999) F o r e i g n b o d y r e a c t i o n t o

m e s h e s u s e d f o r t h e r e p a i r o f a b d o m i n a l

wal l he rn ias . EJS, 165:665-673

La e m ml i UK (1 97 o ) C le a va g e o f s t ru c t u ra l p ro -

t e i n s d u r i n g t h e a s se mb l y o f t h e h e a d o f b e c -

terioph age T4. Natu re 227:68o-85

L e h t o M , S i m s T J , B a i l e y A J ( 19 8 5 ) S k e l e t a l

m u s c l e i n j u r y - - m o l e c u l a r c h a n g e s i n t h e

c o l l a g e n d u r i n g h e a l i n g . R e s Ex p M e d B e r l

185:95-106

Li c h t e n s t e i n IL , Sh u l ma n AG, Ami d PK (1 9 9 3 )

T h e c a u s e , p r e v e n t i o n , a n d t r e a t m e n t o f

re c u r re n t g ro i n h e rn i a . Su rg C l i n No r t h Am

73:529-544

M i l l e r E J , P h o d e s R K ( 1 9 8 2 ) P r e p a r a t i o n a n d

c h a ra c t e r i z a t i o n o f t h e d i f fe re n t t y p e s o f c o l -

lagen . Methods Enzymol 82 :33-64

N i k o l o v V S P , B e l t s c h e v B (1 9 9 o ) S o m e u l t r a -

s t ru c t u ra l f e a t u re s o f f a sc i a tr a n sv e rsa l i s i n

d i re c t i n g u i n a l h e rn i a s i n se n i l e me n . An a t

Anze iger 17o: 265-272

Pans A, Pi~rard GE, Albert A, Desaive C (1997)

B i o c h e mi c a l a s se s sme n t o f t h e t r a n sv e rsa l i s

fa sc i a a n d re c t u s a b d o mi n i s a p o n e u ro s i s i n

i n g u i n a l h e r n i a t i o n : p r e l i m i n a r y r e s u l t s .

He rn ia 1 :27-30

Pe a c o c k EE , M a d d e n IW (1 9 7 4 ) S t u d i e s o n t h e

b i o lo g y a n d t r e a t m e n t o f r e c u r r e n t i n g u i n a l

h e rn i a : I I . mo rp h o l o g i c a l c h a n g e s . An n Su rg

179:567-571

R e a d R C (1 99 8 ) M e t a b o l ic f a c t o r s c o n t r i b u t i n g t o

hern ia t ion . Hern ia 2 :51-55

S c h u m p e l i c k V , T r e u t n e r K H , A r l t G ( 1 9 9 4 )

In g u i n a l h e rn i a re p a i r i n a d u l t s . La n c e t 3 4 4:

375-379

St o p p a R (1 9 9 8 ) He rn i a i n t h e a b d o mi n a l wa l l .

I n : C h e v r e l l P , H e r n i a s a n d s u r g e r y o f t h e

a b d o mi n a l wa l l , 2 n d Ed n . Sp r i n g e r -Ve r l a g ,

Berl in , pp 174-179

W agh PV , Read RC (1971) Col lagen d efic iency in

re c t u s sh e a t h o f p a t i e n t s wi t h i n g u i n a l h e r -

n ia t ion . Proc Soc Exp Bio l Med 137:382-384

alteracion de olageno en fascia transversalis

Documents