J Plast Surg Hand Surg, 2013; Early Online: 1–4 © 2013 Informa Healthcare ISSN: 2000-656X print / 2000-6764 online DOI: 10.3109/2000656X.2013.863777
ORIGINAL ARTICLE
The effects of resveratrol on flap survival in diabetic rats N. Sinem Ciloglu1, Kayhan Zeytin1 & Fugen Aker2 Department of Plastic and Reconstructive Surgery, Istanbul, Turkey and 2Department of Pathology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by University of Utah on 06/17/14 For personal use only.
1
Abstract Resveratrol is an antioxidant agent with multiple positive impacts on the body. It is known to have anti-diabetic, anti-inflammatory, anti-carcinogenic, and neuroprotective effects. The goal of this study is to demonstrate the antioxidant and anti-diabetic effects of resveratrol on flap survival in diabetic rats. Streptozotocin-induced diabetic Sprague-Dawley albino rats were treated with 10 mg/kg resveratrol following a flap surgery. Histological findings regarding polymorphonuclear leukocyte (PMNL) density, vascular proliferation, fibroblast density, and tissue necrosis were compared between resveratrol-treated and control rats. Significantly higher PMNL density was found in the control group (p = 0.005); while vascular proliferation and the fibroblast density were higher in the resveratrol group (p = 0.004 and p = 0.021, respectively). Collagen density was also higher in the resveratrol group and the difference has statistical significance (p = 0.024). Lymphocyte density was not significantly different between groups (p = 0.061). When the necrosis in the distal areas was evaluated histologically, 20% of the resveratrol group had epidermal tissue necrosis, thus 90% of the control group had epidermal or full-layer necrosis. Resveratrol improved flap survival significantly in diabetic rats. Therefore, diabetic patients requiring complex reconstructive procedures may benefit from resveratrol; so, clinical trials are required to support this study. Key Words: Repair, necrosis
Introduction Diabetes is one of the leading diseases that negatively impact wound healing. It prepares the grounds for complications such as flap necrosis, wound dehiscence, and infection, following reconstructive interventions for extremity ulcers, in particular flap surgery. These negative outcomes of diabetes are based on the increase in blood viscosity due to deformation in the erythrocyte membrane [1,2]; while the main reasons of wound healing impairment in diabetic patients are microcirculatory dysfunction and decreased angiogenesis [3]. Resveratrol (3,5,4’-trihydroxy-trans-stilbene) is a stilbenoid, a type of natural phenol, and a phytoalexin produced naturally by several plants. The first discovery of Resveratrol was due to the low incidence of cardiovascular diseases in the Bordeaux region of France, despite an increased amount of saturated fat and cholesterol intake and heavy smoking, which was known as the French paradox. It is an antioxidant agent with multiple positive impacts on the body. It is known to have anti-diabetic, anti-inflammatory, anti-carcinogenic, and neuroprotective effects [4–7]. The goal of this study is to demonstrate the antioxidant and anti-diabetic effects of resveratrol on flap survival in diabetic rats. Materials and methods This study was conducted after obtaining approval from Marmara University Experimental Animals Ethics Committee. The facilities of Marmara University Experimental Animal Laboratory and Haydarpasa Numune Training and Research Hospital, Pathology Laboratory have been used.
Sprague-Dawley albino rats weighing 250–300 g, aged between 4–5 months, and having normal blood glucose level (80–300 mg/dL) were injected with streptozotocin to induce diabetes as described below. Rats with blood glucose levels 300 mg/dl. Furthermore, after the rats have been sacrified, hematoxylin and eosin stained skin biopsies of the rats showed hyaline arteriosclerosis, which is a finding of small vessel disease in diabetes. Resveratrol is an antioxidant which also has anti-diabetic effects [4-6]. The natural antioxidant role of resveratrol is explained through three different antioxidant mechanisms. The first one is competing with coenzyme Q and reducing the oxidative chain complex at the formation area of reactive oxygen radicals. The second and third mechanisms are capturing the superoxide radical and inhibiting the lipid peroxidation induced by fenton reaction products [12]. Another study has shown that resveratrol increases the amount of associated enzymes such as glutathione peroxidase, glutathione reductase, and glutathione-S-transferase in human lymphocytes [13]. The anti-diabetic effects of resveratrol occur through various mechanisms. It increases the number and the activity of the insulin-dependent glucose transporter membrane protein GLUT-4 which is located in the cell membrane [14]. It inhibits the insulin secretion mechanism in pancreatic b-cells, which makes these temporarily resting cells regain their insulin secretion abilities. Besides, resveratrol slows down and inhibits the cell-damage induced by a number of cytokines on b-cells [15]. There are studies examining the effects of materials known to have antioxidant properties on the survival of flaps removed from the dorsal area of rats [16,17]. However, the number of flap studies conducted with diabetic rats is limited. Isken et al. [9] have reported a study on diabetic rats that has shown that pentoxifylline has positive effects on the survival of the flap. In this study we examined the effects of resveratrol on the survival of the randomly patterned flaps removed from the
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by University of Utah on 06/17/14 For personal use only.
4 N. S. Ciloglu et al. dorsal area of rats with diabetes. At the end of day 7, the histological examination of the samples removed from the distal edges of the flaps showed that 20% of the resveratrol group had necrosis areas with epidermis only. On the other hand, 90% of the control group had necrotic areas of various thicknesses. Compared to the control group, the resveratrol group had significantly lower PMNL density, and significantly higher vascular proliferation and fibroblast density. The possible mechanisms of action of resveratrol that may alter flap survival are due to its pharmacological activities that modulate platelet aggregation and the anti-inflammatory response, including downregulation of pro-inflammatory mediators [18]. It reduces ischemia-reperfusion injury and improves microcirculation. Conclusion Resveratrol is an antioxidant with anti-diabetic properties. The present study suggests that resveratrol, due to its dual effect, decreases the flap necrosis associated with ischemia and oxidative stress, and may enhance flap survival in diabetic rats. Its routine use in the clinical setting cannot be recommended at the moment, but diabetic patients requiring complex reconstructive procedures may benefit from resveratrol. Therefore, clinical trials are required to support this study. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
[5]
[6]
[7] [8] [9] [10] [11] [12] [13] [14]
[15]
References [1] Colen BL. The diabetic foot. In Cohen M, editor. Mastery of plastic and reconstructive surgery. Bosto, MA: Little, Brown; 1994. p 1839–63. [2] Colen LB, Stevenson A, Sidorov V, et al. Microvascular anastomotic thrombosisin experimental diabetes mellitus. Plast Reconstr Surg 1997;99:156–62. [3] Cho CH, Sung HK, Kim KT, et al. COMP-angiopoietin-1promotes wound healing through enhanced angiogenesis, lymphangiogenesis, and blood flow in a diabetic mouse model. Proc Natl Acad Sci USA 2006;103:4946–51. [4] Minakawa M, Miura Y, Yagasaki K. Piceatannol, a resveratrol derivative, promotes glucose uptake through glucose transporter 4 translocation to plasma membrane in L6 myocytes and
[16]
[17] [18]
suppresses blood glucose levels in type 2 diabetic model db/ db mice. Biochem Biophys Res Commun 2012;422:469–75. Rahal K, Schmiedlin-Ren P, Adler J, et al. Resveratrol has antiinflammatory and antifibrotic effects in the peptidoglycanpolysaccharide rat model of Crohn’s disease. Inflamm Bowel Dis 2012;18:613–23. Leon-Galicia I, Diaz-Chavez J, Garcia-Villa E, et al. Resveratrol induces down regulation of DNA repair genes in MCF-7 human breast cancer cells. Eur J Cancer Prev 2012; 18:613–23. Fonseca-Kelly Z, Nassrallah M, Uribe J, et al. Resveratrol neuroprotection in a chronic mouse model of multiple sclerosis. Front Neurol 2012;3:84. Isken T, Ozgentas HE, Gulkesen KH, Ciftcioglu A. A randompattern skin flap model in streptozotocin diabetic rats. Ann Plast Surg 2006;57:323–9. Isken T, Serdaroglu I, Ozgentas E. The effects of the pentoxifylline on survival of the skin flaps in streptozotocin-diabetic rats. Ann PlastSurg 2009;62:446–50. Chow LW, Loo WT, Yuen K, Cheng C. The study of cytokine dynamics at the operation site after mastectomy. Wound Repair Regen 2003;11:326–30. Egemen O, Özkaya Ö, Öztürk B, et al. The biomechanical and histological effects of diabetes on tendon healing experimental study in rats. J Hand Micrusurg 2012;4:60–4. Sayin O, Arslan N, Guner G. Resveratrol and cardiovascular system. Turk J Biochem 2008;33:117–21. Das DK, Maulik N. Resveratrol in cardioprotection: a therapeutic promise of alternative medicine. Mol Interv 2006;6:36–47. Penumathsa SV, Thirunavukkarasu M, Zhan L, et al. Resveratrol enhances GLUT-4 translocation to the caveolar lipid raft fractions through AMPK/Akt/eNOS signalling pathway in diabetic myocardium. J Cell Mol Med 2008;12:2350–61. Palsamy P, Subramanian S. Resveratrol, a natural phytoalexin, normalizes hyperglycemia in streptozotocinnicotinamide induced experimental diabetic rats. Biomed Pharmacother 2008;62:598–605. Bekerecioglu M, Tercan M, Ozyazgan I. The effect of Gingko bilobaextract (Egb 761) as a free radical scavenger on the survival of skin flaps in rats. A comparative study. Scand J Plast Reconstr Surg Hand Surg 1998;32:135–9. Leite MT, Gomes HC, Percário S, et al. Dimethyl sulfoxide as a block to the deleterious effect of nicotine in a random skin flap in the rat. Plast Reconstr Surg 2007;120:1819–22. Hsieh Y, Huang S, Wei F, Hung L. Resveratrol attenuates ischemia-reperfusion-induced leukocyte-endothelial cell adhasive interactions and prolongs allograft survival across the MCH Barrier. Circ J 2007;71:423–8.
ORIGINAL ARTICLE
The effects of resveratrol on flap survival in diabetic rats N. Sinem Ciloglu1, Kayhan Zeytin1 & Fugen Aker2 Department of Plastic and Reconstructive Surgery, Istanbul, Turkey and 2Department of Pathology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by University of Utah on 06/17/14 For personal use only.
1
Abstract Resveratrol is an antioxidant agent with multiple positive impacts on the body. It is known to have anti-diabetic, anti-inflammatory, anti-carcinogenic, and neuroprotective effects. The goal of this study is to demonstrate the antioxidant and anti-diabetic effects of resveratrol on flap survival in diabetic rats. Streptozotocin-induced diabetic Sprague-Dawley albino rats were treated with 10 mg/kg resveratrol following a flap surgery. Histological findings regarding polymorphonuclear leukocyte (PMNL) density, vascular proliferation, fibroblast density, and tissue necrosis were compared between resveratrol-treated and control rats. Significantly higher PMNL density was found in the control group (p = 0.005); while vascular proliferation and the fibroblast density were higher in the resveratrol group (p = 0.004 and p = 0.021, respectively). Collagen density was also higher in the resveratrol group and the difference has statistical significance (p = 0.024). Lymphocyte density was not significantly different between groups (p = 0.061). When the necrosis in the distal areas was evaluated histologically, 20% of the resveratrol group had epidermal tissue necrosis, thus 90% of the control group had epidermal or full-layer necrosis. Resveratrol improved flap survival significantly in diabetic rats. Therefore, diabetic patients requiring complex reconstructive procedures may benefit from resveratrol; so, clinical trials are required to support this study. Key Words: Repair, necrosis
Introduction Diabetes is one of the leading diseases that negatively impact wound healing. It prepares the grounds for complications such as flap necrosis, wound dehiscence, and infection, following reconstructive interventions for extremity ulcers, in particular flap surgery. These negative outcomes of diabetes are based on the increase in blood viscosity due to deformation in the erythrocyte membrane [1,2]; while the main reasons of wound healing impairment in diabetic patients are microcirculatory dysfunction and decreased angiogenesis [3]. Resveratrol (3,5,4’-trihydroxy-trans-stilbene) is a stilbenoid, a type of natural phenol, and a phytoalexin produced naturally by several plants. The first discovery of Resveratrol was due to the low incidence of cardiovascular diseases in the Bordeaux region of France, despite an increased amount of saturated fat and cholesterol intake and heavy smoking, which was known as the French paradox. It is an antioxidant agent with multiple positive impacts on the body. It is known to have anti-diabetic, anti-inflammatory, anti-carcinogenic, and neuroprotective effects [4–7]. The goal of this study is to demonstrate the antioxidant and anti-diabetic effects of resveratrol on flap survival in diabetic rats. Materials and methods This study was conducted after obtaining approval from Marmara University Experimental Animals Ethics Committee. The facilities of Marmara University Experimental Animal Laboratory and Haydarpasa Numune Training and Research Hospital, Pathology Laboratory have been used.
Sprague-Dawley albino rats weighing 250–300 g, aged between 4–5 months, and having normal blood glucose level (80–300 mg/dL) were injected with streptozotocin to induce diabetes as described below. Rats with blood glucose levels 300 mg/dl. Furthermore, after the rats have been sacrified, hematoxylin and eosin stained skin biopsies of the rats showed hyaline arteriosclerosis, which is a finding of small vessel disease in diabetes. Resveratrol is an antioxidant which also has anti-diabetic effects [4-6]. The natural antioxidant role of resveratrol is explained through three different antioxidant mechanisms. The first one is competing with coenzyme Q and reducing the oxidative chain complex at the formation area of reactive oxygen radicals. The second and third mechanisms are capturing the superoxide radical and inhibiting the lipid peroxidation induced by fenton reaction products [12]. Another study has shown that resveratrol increases the amount of associated enzymes such as glutathione peroxidase, glutathione reductase, and glutathione-S-transferase in human lymphocytes [13]. The anti-diabetic effects of resveratrol occur through various mechanisms. It increases the number and the activity of the insulin-dependent glucose transporter membrane protein GLUT-4 which is located in the cell membrane [14]. It inhibits the insulin secretion mechanism in pancreatic b-cells, which makes these temporarily resting cells regain their insulin secretion abilities. Besides, resveratrol slows down and inhibits the cell-damage induced by a number of cytokines on b-cells [15]. There are studies examining the effects of materials known to have antioxidant properties on the survival of flaps removed from the dorsal area of rats [16,17]. However, the number of flap studies conducted with diabetic rats is limited. Isken et al. [9] have reported a study on diabetic rats that has shown that pentoxifylline has positive effects on the survival of the flap. In this study we examined the effects of resveratrol on the survival of the randomly patterned flaps removed from the
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by University of Utah on 06/17/14 For personal use only.
4 N. S. Ciloglu et al. dorsal area of rats with diabetes. At the end of day 7, the histological examination of the samples removed from the distal edges of the flaps showed that 20% of the resveratrol group had necrosis areas with epidermis only. On the other hand, 90% of the control group had necrotic areas of various thicknesses. Compared to the control group, the resveratrol group had significantly lower PMNL density, and significantly higher vascular proliferation and fibroblast density. The possible mechanisms of action of resveratrol that may alter flap survival are due to its pharmacological activities that modulate platelet aggregation and the anti-inflammatory response, including downregulation of pro-inflammatory mediators [18]. It reduces ischemia-reperfusion injury and improves microcirculation. Conclusion Resveratrol is an antioxidant with anti-diabetic properties. The present study suggests that resveratrol, due to its dual effect, decreases the flap necrosis associated with ischemia and oxidative stress, and may enhance flap survival in diabetic rats. Its routine use in the clinical setting cannot be recommended at the moment, but diabetic patients requiring complex reconstructive procedures may benefit from resveratrol. Therefore, clinical trials are required to support this study. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
[5]
[6]
[7] [8] [9] [10] [11] [12] [13] [14]
[15]
References [1] Colen BL. The diabetic foot. In Cohen M, editor. Mastery of plastic and reconstructive surgery. Bosto, MA: Little, Brown; 1994. p 1839–63. [2] Colen LB, Stevenson A, Sidorov V, et al. Microvascular anastomotic thrombosisin experimental diabetes mellitus. Plast Reconstr Surg 1997;99:156–62. [3] Cho CH, Sung HK, Kim KT, et al. COMP-angiopoietin-1promotes wound healing through enhanced angiogenesis, lymphangiogenesis, and blood flow in a diabetic mouse model. Proc Natl Acad Sci USA 2006;103:4946–51. [4] Minakawa M, Miura Y, Yagasaki K. Piceatannol, a resveratrol derivative, promotes glucose uptake through glucose transporter 4 translocation to plasma membrane in L6 myocytes and
[16]
[17] [18]
suppresses blood glucose levels in type 2 diabetic model db/ db mice. Biochem Biophys Res Commun 2012;422:469–75. Rahal K, Schmiedlin-Ren P, Adler J, et al. Resveratrol has antiinflammatory and antifibrotic effects in the peptidoglycanpolysaccharide rat model of Crohn’s disease. Inflamm Bowel Dis 2012;18:613–23. Leon-Galicia I, Diaz-Chavez J, Garcia-Villa E, et al. Resveratrol induces down regulation of DNA repair genes in MCF-7 human breast cancer cells. Eur J Cancer Prev 2012; 18:613–23. Fonseca-Kelly Z, Nassrallah M, Uribe J, et al. Resveratrol neuroprotection in a chronic mouse model of multiple sclerosis. Front Neurol 2012;3:84. Isken T, Ozgentas HE, Gulkesen KH, Ciftcioglu A. A randompattern skin flap model in streptozotocin diabetic rats. Ann Plast Surg 2006;57:323–9. Isken T, Serdaroglu I, Ozgentas E. The effects of the pentoxifylline on survival of the skin flaps in streptozotocin-diabetic rats. Ann PlastSurg 2009;62:446–50. Chow LW, Loo WT, Yuen K, Cheng C. The study of cytokine dynamics at the operation site after mastectomy. Wound Repair Regen 2003;11:326–30. Egemen O, Özkaya Ö, Öztürk B, et al. The biomechanical and histological effects of diabetes on tendon healing experimental study in rats. J Hand Micrusurg 2012;4:60–4. Sayin O, Arslan N, Guner G. Resveratrol and cardiovascular system. Turk J Biochem 2008;33:117–21. Das DK, Maulik N. Resveratrol in cardioprotection: a therapeutic promise of alternative medicine. Mol Interv 2006;6:36–47. Penumathsa SV, Thirunavukkarasu M, Zhan L, et al. Resveratrol enhances GLUT-4 translocation to the caveolar lipid raft fractions through AMPK/Akt/eNOS signalling pathway in diabetic myocardium. J Cell Mol Med 2008;12:2350–61. Palsamy P, Subramanian S. Resveratrol, a natural phytoalexin, normalizes hyperglycemia in streptozotocinnicotinamide induced experimental diabetic rats. Biomed Pharmacother 2008;62:598–605. Bekerecioglu M, Tercan M, Ozyazgan I. The effect of Gingko bilobaextract (Egb 761) as a free radical scavenger on the survival of skin flaps in rats. A comparative study. Scand J Plast Reconstr Surg Hand Surg 1998;32:135–9. Leite MT, Gomes HC, Percário S, et al. Dimethyl sulfoxide as a block to the deleterious effect of nicotine in a random skin flap in the rat. Plast Reconstr Surg 2007;120:1819–22. Hsieh Y, Huang S, Wei F, Hung L. Resveratrol attenuates ischemia-reperfusion-induced leukocyte-endothelial cell adhasive interactions and prolongs allograft survival across the MCH Barrier. Circ J 2007;71:423–8.
