CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 3, May/June 2014
104
AFRICA
responses are believed to be important in the pathogenesis of
adhesion formation.
The inflammatory response is a complex pathophysiological
process including many chemical and cytokine mediators
that cause extravascular plasma leakage (as a consequence of
increased vascular permeability) and the formation of fibrin. This
leads to the formation of serosanguineous exudate, which in turn
initiates adhesion formation.
16
Fibrin provides a framework for
fibroblast proliferation, the synthesis of collagen and adhesion
formation.
18
Increase in reactive oxygen species (ROS) after endothelial
tissue damage, which occurs during open surgery, may play a
role in postoperative adhesion formation. Evidence has shown
that ROS scavengers could reduce adhesion formation in animal
models.
16,21
Subsequently, if these initial adhesions are not lysed,
they are organised into fibrous adhesions by activated fibroblasts.
However, in a state of imbalance between fibrin deposition and
dissolution, deposited fibrin may persist and fibrinous adhesions
may develop.
16,21
Unfortunately, despite continuous advances and research, an
ideal method and material to decrease postoperative pericardial
adhesion formation have not been found. A number of anti-
adhesive interventions have been developed and many have
been tested clinically and experimentally in cardiac applications.
Various methods and agents have been used with controversial
results.
22
Somestudieshavefocusedprimarilyonsubstitutes(autogenous,
heterogenous and synthetic) providing a barrier between the
epicardium and pericardium or overlying sternum, while other
work has evaluated the ability of a variety of pharmacological
agents to decrease or prevent pericardial adhesion formation
after cardiac surgery.
16,23-25
Anti-inflammatory drugs, antibiotics
and topical application of fibrinolytic agents have also been
shown to decrease pericardial adhesion formation.
16,26,27
ABS is a herbal extract attained from five different plants:
Thymus vulgaris
(thyme),
Glycyrrhiza glabra
(licorice),
Vitis
vinifera
(unriped grape),
Alpinia officinarum
(galangal) and
Urtica dioica
(stinging nettle). It has been folklorically used
in traditional Turkish medicinal practice. ABS represents an
alternative treatment modality for many kinds of bleeding that
are resistant to conventional methods.
Today, topical ABS is used and has provided positive results in
spontaneous or secondary bleeding (gastrointestinal, orthopedic,
nasal, dermal) due to body injuries, traumas, and minor or
major surgical interventions and wound healing.
28
Besides its
homeostatic activity, Kocak
et al
.
29
reported that Ankaferd might
also have anti-inflammatory effects.
7
Tests have demonstrated its
safety, efficacy, sterility and non-toxicity for external usage.
8,30
Al
et al
.
7
showed that Ankaferd was not efficient in reducing
postoperative intra-abdominal adhesions. Conversely, Cömert
et al
.
8
reported that there was less intra-peritoneal adhesion
formation in the Ankaferd than in the control group. However,
the safety and non-toxicity of Ankaferd for intra-pericardial
usage and the effects of Ankaferd on postoperative pericardial
adhesion have yet to be assessed.
In the present study, fibrosis score measurements showed
no statistically significant difference between the Ankaferd
and control groups (
p
=
0.234). However when the groups
were compared according to the prevalence of fibrosis, there
were statistically significant differences between the groups (
p
=
0.028), and fibrosis scores were significantly higher in the
Ankaferd group. The results of our study showed that topical
application of Ankaferd could increase pericardial adhesion after
abrasive injury of the epicardial surface in a rabbit model.
In addition to the pericardial adhesion and visibility of
coronary vessels score, histological evaluation was used to
evaluate the effect of Ankaferd on inflammation and fibrosis in
the rabbit model. However, there were no statistically significant
differences between the groups in terms of inflammatory scores
and degree of inflammation (
p
=
0.382,
p
=
0.220, respectively).
Hence, efficacy of Ankaferd on inflammation was not observed
in the histological evaluation.
Conclusion
We applied Ankaferd to try and reduce postoperative pericardial
adhesion in an experimental rabbit model. The use of Ankaferd
increased the adhesion and fibrosis scores. However, its efficacy
on inflammation was not demonstrated. Further studies with
Ankaferd are necessary to evaluate its efficacy in prevention of
adhesion formation in cardiac surgery.
This study was supported by the Scientific Research Fund of Fatih University.
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