Mechanisms and therapeutic interventions of postoperative gastric ileus

术后胃肠梗阻的机制和治疗干预

基本信息

批准号：
10383642
负责人：
YVETTE FRANCE TACHE
金额：
--
依托单位：
VA GREATER LOS ANGELES HEALTHCARE SYSTEM
依托单位国家：
美国
项目类别：
财政年份：
2017
资助国家：
美国
起止时间：
2017-07-01 至 2022-06-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10383642
关键词：
3-Dimensional Abdomen Abdominal Pain Abdominal Surgical Procedures Acute Agonist Anti-Cholinergics Anti-Inflammatory Agents Appetite Stimulants Axon Brain Brain Stem Cephalic Characteristics Chemical Stimulation Chemicals Clinical Colon Complication Data Distant Efferent Pathways Enteral Enteric Nervous System Equilibrium Etiology Fiber Functional disorder Gastric Emptying Gastric Submucosa Gastrointestinal Surgical Procedures Gastrointestinal tract structure Gastroparesis Gene Expression Grant Half-Life Health Hormones Hospitalization Ileus Immune response Incidence Inflammation Inflammatory Inflammatory Response Injections Injury Interleukin-1 Intervention Intestines Intravenous Investigation Knowledge Label Laparotomy Lasers Mediator of activation protein Medical MicroRNAs Microdissection Modeling Molecular Biology Morphology Motor Motor Neurons Muscle Myenteric Plexus Nausea and Vomiting Neuroanatomy Neurons Neutrophil Infiltration Operative Surgical Procedures Oral Oral Administration Outcome Pathogenesis Pathway interactions Patients Pharmacology Phase Phenotype Physiological Plasma Play Postoperative Period Procedures Production Quality of life Rattus Reporting Resolution Reverse Transcriptase Polymerase Chain Reaction Role Small Intestines Stomach Suspensions Symptoms System TNF gene Techniques Technology Testing Therapeutic Intervention Three-Dimensional Imaging Thyrotropin-Releasing Hormone Tissues Vagus nerve structure Veterans War alpha-bungarotoxin receptor base cell motility chemokine cholinergic cholinergic neuron clinically relevant cost cytokine dorsal motor nucleus effective therapy experimental study gastrointestinal ghrelin improved inflammatory disease of the intestine innovation insight macrophage multimodality multiplex assay novel novel therapeutic intervention novel therapeutics placebo group pre-clinical prevent recruit response small molecule socioeconomics success synthetic polymer Bioplex therapeutically effective

项目摘要

Postoperative ileus (POI) is one of the main complication associated with abdominal surgery (AS) procedures. A number of Veterans deployed in the war zones undergo injuries requiring AS. After AS, patients usually develop nausea, vomiting, bloating, and abdominal pain which are major contributing factors to postoperative discomfort. The incidence of ileus is highest in gastrointestinal (GI) surgery with 24% of patients developing ileus and can be as high as 40% in laparotomy patients. The health burden and the cost of prolonged hospitalization due to POI have been estimated to be as much as $1.47 billion annually in the USA, illustrating its large socioeconomic impact. The lack of effective treatments has prompted novel experimental studies to elucidate the underlying mechanisms. Recent insight in the pathophysiology of POI induced by AS have identified intestinal inflammation triggered by handling of the intestine as a contributing mechanism which is clinically a relevant target for treatment. In other inflammatory conditions, there is evidence that resident macrophages within the GI muscularis contribute to both the initiation and the resolution of inflammation through activations of M1 and M2 phenotypes secreting pro- and anti-inflammatory cytokines respectively. Recent studies point to the vagus nerve controlling a cholinergic anti-inflammatory pathway. We previously established that thyrotropin-releasing hormone (TRH) in the brainstem plays a physiological role (including in the cephalic phase) to stimulate the vagus innervating the GI tract. In the last granting period, we reported that intracisternal (ic) injection of TRH prevents the neurogenic (early phase) of POI occurring within 2-h of AS. Our preliminary data obtained at 6-h post-surgery indicate that 1) AS increases M1 but not M2 macrophages and the infiltration of neutrophils in the gastric muscularis externa along with delay gastric emptying (GE); 2) central vagal activation by ic injection of the stable TRH agonist, RX77368 prevents the above increases and reduces the delayed GE induced by AS without modifying basal GE in sham group. In the last granting period, we also established that AS induces a sharp reduction of plasma levels of the prokinetic hormone, ghrelin known to influence vagal activity and the response is prevented by ic TRH before AS. In addition, we obtained preliminary data showing that the novel long acting and brain penetrant ghrelin agonist, HM01 administered orally activates vagal preganglionic motor neurons in the brainstem and prevents AS-induced delayed GE. Based on these reports and exciting supportive preliminary data, we will test 3 HYPOTHESES: Aim 1. AS induces inflammation in the rat gastric muscularis externa through changes in the activation status of M1 or M2 macrophages in the rat gastric muscularis externa. 2. Central vagal stimulation prevents AS-induced delayed GE by activating cholinergic anti-inflammatory pathway with the deactivation of M1 and or the activation of M2 macrophage leading to inhibiting the inflammation in the gastric muscularis externa. 3. The ghrelin agonist, HM01 is a promising candidate via oral administration to reverse POI by its dual potent prokinetic and anti- inflammatory actions through activation of vagal cholinergic pathway. These aims will be achieved in the rat model of AS-induced POI combined with state-of-the art technologies in neuroanatomy (CLARITY technique combined with targeted double or triple labeling, including anterograde tracing and 3D imaging of vagal fibers, enteric neurons and macrophages), molecular biology (Laser microdissection combined with RT-PCR, RNAscope, RT-qPCR, microRNA targeting, MILLIPLEX® Multiplex Assays using Bio-RAD Bio-Plex 3D suspension system powered by Luminex xMAP Technology) and functional study (gut motility and chemical stimulation of vagal activity). The completion of these specific aims will make a conceptual advance to target muscularis macrophages by deactivation of M1 and/or activation of M2 as a potential anti-inflammatory strategy and provide the first preclinical data to validate HM01 as a candidate for new therapy for POI.

术后肠梗阻 (POI) 是腹部手术 (AS) 相关的主要并发症之一。许多部署在战区的退伍军人都因受伤而需要进行 AS 治疗后，患者通常会接受 AS 治疗。出现恶心、呕吐、腹胀和腹痛，这是术后的主要原因胃肠道 (GI) 手术中肠梗阻的发生率最高，发生率为 24%。肠梗阻，剖腹手术患者的健康负担和延长费用可能高达 40%。据估计，美国每年因 POI 导致的住院费用高达 14.7 亿美元，这说明其巨大的社会经济影响促使缺乏有效的治疗方法进行新的实验研究。阐明了 AS 引起的 POI 病理生理学的最新见解。确定了由处理肠道引发的肠道炎症是一个促成机制临床上，有证据表明，在其他炎症性疾病中，这是治疗的相关目标。胃肠道肌层内的巨噬细胞有助于炎症的引发和消退通过激活分别分泌促炎细胞因子和抗炎细胞因子的 M1 和 M2 表型。最近的研究表明迷走神经控制着胆碱能抗炎通路。确定脑干中的促甲状腺素释放激素（TRH）发挥着生理作用（包括在头期）刺激支配胃肠道的迷走神经在最后的授权期间，我们报告了这一点。脑池内 (ic) 注射 TRH 可预防 AS 2 小时内发生的 POI 的神经源性（早期）。术后 6 小时获得的初步数据表明：1) AS 增加了 M1 巨噬细胞，但不增加 M2 巨噬细胞，并且胃外肌层中性粒细胞浸润并伴有胃排空延迟 (GE) 2) 中枢；通过注射稳定的 TRH 激动剂来激活迷走神经，RX77368 可防止上述增加和减少在不修改假手术组中由 AS 引起的延迟 GE 的情况下，我们还在最后的授予期间。确定 AS 会导致血浆中促动力激素 ghrelin 的水平急剧下降。影响迷走神经活动，并且该反应在 AS 之前被 IC TRH 阻止。初步数据显示，给予新型长效、脑渗透性胃饥饿素激动剂 HM01 口服可激活脑干中的迷走神经节前运动神经元并预防 AS 引起的延迟性 GE。根据这些报告和令人兴奋的支持性初步数据，我们将测试 3 个假设：目标 1. AS 通过改变M1或M2的激活状态诱导大鼠胃外肌层炎症大鼠胃外肌层的巨噬细胞2.中枢迷走神经刺激可预防AS引起的延迟。通过 M1 失活和/或 M2 激活来激活胆碱能抗炎途径的 GE 巨噬细胞导致抑制胃外肌层的炎症3.胃饥饿素激动剂， HM01 是一种通过口服给药逆转 POI 的有前途的候选药物，其具有双重有效的促动力和抗通过激活迷走神经胆碱能途径的炎症作用将在大鼠中实现。 AS 诱导的 POI 模型与最先进的神经解剖学技术相结合（CLARITY 技术结合有针对性的双重或三重标记，包括迷走神经纤维的顺行追踪和 3D 成像，肠神经元和巨噬细胞）、分子生物学（激光显微切割结合 RT-PCR、 RNAscope、RT-qPCR、microRNA 靶向、使用 Bio-RAD Bio-Plex 3D 的 MILLIPLEX® 多重检测由 Luminex xMAP 技术提供支持的悬浮系统）和功能研究（肠道动力和化学刺激迷走神经活动）。这些具体目标的完成将使目标在概念上取得进展。通过 M1 失活和/或 M2 激活作为潜在的抗炎剂来抑制肌层巨噬细胞策略并提供第一个临床前数据来验证 HM01 作为 POI 新疗法的候选者。