Abstract

Wound infections and dehiscence is a common complication after surgical procedures. Particularly so in institutions with patient overload. Human placenta has been used as biological dressing to treat various types of wounds and ulcers.1 Hence, this study was done with Aim : To compare the efficacy of topical application of purified extract of human placenta (PlacentrexÒ) versus povidone iodine for their wound healing potential in surgical wounds.

Material and Methods : This was an open comparative randomized study comprising 82 patients above 18 years of age undergoing clean surgeries. Enrolled patients were randomized as per the PC generated randomization chart (Rando 1.2, 2004) to receive either topical application of human placenta purified extract (PE) on the surgical wound or topical application of Povidone Iodine (PI) Ointment on the surgical wound. Both preparations were applied topically on the surgical wound after the surgery, on days 3, 7 and on day 10, if required. Assessment of surgical wound was done after recovery from anaesthesia and on days 3, 7 and 10 based upon wound healing. Physicians Global Assessment of Response to Therapy (PGART) Scale, pain and adverse affects.

Results : All 82 patients completed the study as per the study protocol. 22 (52.38%) patients with PE and 19 (47.50%) patients with PI completed the study on day 10. Complete healing of the wound was observed in 40 (95.24%) patients with PE, and 36 (90.00%) patients with PI. The number of patients reporting pain on days 3, 7 and 10 were similar in both PE and PI treatments (p = 0.779). None of the patients reported any side/adverse events during the study period.

Conclusion : Both placenta extract and povidone iodine have comparative wound healing effects.

Introduction

Human placenta is a unique major organ among the different membranous organs. It serves multipurpose functions like transport of nutrition from maternal part to foetal part, excretion of excreta from foetal part to maternal part, selection to specific molecules like immunoglobulin, etc to transport it into the body of foetus from the mother, prevention of the entry of noxious elements in the foetal body, etc. Human placental extract is a topical preparation from human placenta extracted and manufactured according to a defined method. Purified extract of human placenta is commercially available in the Indian market as injections and gel for topical application.

There are many published reports of use of purified human placental extracts by various specialty doctors in clinical medicine like obstetrics and gynaecology,2,3 physicians,4,5 otorhinolaryngologists, dermatologists,6,7 ophthalmologists,8 orthopaedic surgeons, general surgeons and dentists.9,10 Purified extract of human placenta has been found to be beneficial on topical application in the management of non-healing wounds.11 Human placental extracts have shown to help collagen synthesis leading to potent healing of wounds in rats.12

Recent spectroscopic and chromatographic studies of human placental extracts pointed towards the presence of various bioactive substances in human placental extracts like NADPH,13 poly-deoxy-ribonucleotide (PDRN), RNA, DNA, fragments, peptides, amino-acids, trace elements.14 Placental extract contains growth factors and anti-inflammatory agents15 and it has shown to have anti-inflammatory and anti-platelet activity.16 A very small peptide about 6-7 kda was identified in placentrex which appears similar to human fibronectin III. This has a direct role in wound healing. It is the ground substance on which epithelialization takes place. This peptide helps in debridement of the wound. It appears to affect the immune system too.

Placental extract has shown to reduce the side effects of radiation in patients of cervical carcinoma17 and in radiation induced oral mucositis.18 Favourable results have been observed with cold placental extracts in the treatment of various surgical conditions like eschars, slow cicatrisation of wounds and post-phlebitic ulcers in 120 cases.19 Poly-deoxy-ribonucleotide (PDRN) of human placenta has shown therapeutic activity similar to that of oestrogens by both oral route and topical application in patients with dystrophic or chronic cervico-vaginitis.20 Intra-articular application of placental extract also prolongs the arthritic remissions induced by steroids in patients with rheumatoid arthritis.21

In the present study we evaluated the wound healing potential of topical application of placental extract gel versus povidone iodine ointment in surgical wounds.

Material and Methods

This was an Open, Randomized, Comparative study comprising 82 patients (42 in study and 40 in control) of either sex above 18 years of age undergoing elective, clean surgery. Patients were enrolled in the study after obtaining written informed consent. Surgeries included were:

• Hernioplasty
• Hydrocoele
• Breast surgery
• Cyst Excision
• Appendicectomy
• Abdominal laparotomy
• Genitourinary Surgery
• Varicose Vein stripping
• Circumcision
• Sphincterotomy

Pregnant and lactating women, with known hypersensitivity to any of the study related drugs, with known hepatic or renal impairment, having any abnormal laboratory parameters and patients not willing to give written informed consent were excluded from the study.

Intervention

Enrolled patients were randomized as per the PC generated randomization chart (Rando 1.2, 2004) to receive either topical application of human placenta purified extract (PE) on the surgical wound or topical application of Povidone Iodine (PI) Ointment USP on the surgical wound. Both preparations were applied topically on the surgical wound after the surgery, on days 3, 7 and then on day 10, if required. Patients were allowed to receive anti-hypertensive medication if the patient was hypertensive, oral hypoglycaemic agents/insulin, if the patient has diabetes mellitus, analgesics/anti-inflammatory agents as per the institute’s protocol, pre-operative and post-operative anti-microbial prophylaxis as specified, and IV fluids.

Patients were not allowed to receive corticosteroids in any form and topical application of any anti-microbial preparations other than the study medication on surgical wound.

Outcomes

Assessment of surgical wound was done after recovery from anaesthesia and on days 3, 7 and 10 based upon redness at the site (present or absent), irritation (4 point rating scale or 0=absent, 1=mild, 2=moderate and 3=severe), wound discharge (present or absent), type of discharge (watery, serous and purulent) and smell of discharge (foul smelling or non-foul smelling), oedema (present or absent), induration (present or absent), granulation tissue (present or absent). Pain at the site was assessed on a 0-10 cm visual analogue scale (VAS). Time required for complete healing of the wound was also recorded.

Physicians Global Assessment of Response to Therapy (PGART) Scale (0=No healing, 1=Poor healing, 2=Moderate healing, 3=Good healing, 4=Excellent healing) was used for evaluation of surgical wound healing on days 3,7 and 10.

At the end of therapy global assessment of efficacy by physician and global assessment of tolerability by the patient was made on a 4-point rating scale of 1=excellent, 2=good, 3=fair and 4=poor.

Statistical Methods

Data is expressed as mean with standard deviation and proportions. Parametric data was subjected to ‘t’-test for comparison of two groups or paired comparison and one way ANOVA with Bonferroni’s post-hoc analysis for repeat measures comparison.

Non-parametric data was subjected to Mann-Whitney ‘U’ test for comparison of two groups and Kruskall-Wallis test for multiple comparisons.

An intention to treat analysis was done and the significance level was p < 0.05.

Results

All 82 patients completed the study as per the study protocol. 22 (52.38%) patients with PE and 19 (47.50%) patients with PI completed the study on day 7.20 (47.62%) patients with PE and 21 (52.50%) patients with Pl completed the study on day 10.

The two treatment groups PE and PI were similar with respect to the age, gender distribution, pulse, blood pressure (systolic and diastolic), demography (height, weight) and the types of surgeries performed on them (Table 1). Hernioplasty was the most common surgery performed. The laboratory parameters were similar in the two treatment groups on enrollment (Table 2). There were no differences in the pulse and blood pressure on days 3, 7 and 10 between the patients receiving PE and PI (p > 0.05).

Wound assessment

Complete healing of the wound was observed in 40 (95.24%) patients with PE, and 33 (90.00%) patients with PI. The number of patients reporting pain on days 3, 7 and 10 were similar in both PE and PI treatments (p, 0.779).

Wound erythema was present only in 5 (11.63%) patients on PE as against 11 (27.50%) patients on PI on day 3; whereas no patient had erythema with PI compared to 1 (2.33%) patient with PE on day 10. On day 7, only 2 (4.65%) patients on PE had erythema whereas 3 (7.50%) patients on PI had erythema; however, the differences between PE and PI were not significant statistically (p=0.375) (Table 3a).

Similarly the number of patients having oedema and discharge at the surgical wound was similar in patients on PE and PI (p=0.525 and 0.966 respectively). On day 3, 2 patients had watery discharge and 1 had serous discharge with PE, whereas 4 patients had watery discharge and 1 had serous discharge with PI. 1 patient with PI had foul smelling discharge on day 3. On day 7, only 3 patients had watery discharge and none had serous discharge with PE, whereas 4 patients had watery discharge and 1 had purulent foul smelling discharge with PI. On day 10, 2 patients had serous discharge with PE, whereas 3 had serous discharge with PI.

Mild wound irritation was present only in 1 patient with PE on day 10, whereas only 1 patient had mild wound irritation with PI on day 3 (p=0.157) (Table 3b). Wound induration was seen in 6 patients with PE and 9 patients with PI on day 3; whereas on day 7, only 1 patient with PE and 2 patients with PI had induration. On day 10, none of the patients had induration. Thus, the differences between PE and PI being not significant statistically (p=0.828) (Table 3b).

Granulation on the surgical wound was observed in 17 patients each on PE and PI on day 3; whereas on day 7, 18 patients with PE and 23 patients with PI had wound granulation. On day 10, 17 patients on PE and 22 patients on PI had granulation. Thus, the proportion of patients having granulation was similar in patients with PE and PI (p= 0.828).

Pain assessment

Mean VAS score for pain reduced from 2.55 on day 3, to 0.70 on day 10 with PE (p < 0.0001), whereas with PI the reduction was from 3.30 to 0.86 (p < 0.0001). The VAS score for pain was similar with PE and PI on day 3 (p=0.058), day 7 (p=0831) and day 10 (p=0.648). Thus, pain reduction was similar with PE and PI (Table 4).

Global evaluation

Physicians global assessment of response to therapy (PGART) as assessed on a 5-point rating scale of 0=No healing, 1=Poor healing, 2=Moderate healing, 3=Good healing, 4=Excellent healing shows better mean scores for patients with PE as compared to PI on days 3, 7 and 10.

The scores was 3.17 with PE and 3.10 with PI on day 3 (p=0.515), whereas on day 10 the scores were 3.30 with PE and 3.00 with PI (p=0.165). On day 7, the mean scores were 3.24 with PE and 3.12 with PI, the difference being not significant statistically (p=0.271) (Table 4).

Adverse events

None of the patients reported any side/adverse events during the study period. No cardiovascular, respiratory and CNS abnormalities related or unrelated to the study medication were reported in any of the patients during the study period.

Discussion

Wound infection and dehiscence are a common finding after emergency and elective operations in an institution facing the problem of patient overload. Many conservative and operative ways are suggested to combat infection as well as to enhance wound healing. Over the ages human placenta has been used as a biological dressing to treat various ailments including ulcers.1

Purified Placental extract (PE) contains biologically active substances such as vitamins, hormones and polypeptide enzymes. The extract is rich in DNA and RNA. The nucleotides are known for their tissue regeneration effect through the unique process of protein synthesis.22 It is now established that placental extract can be used as biological stimulant in surgery.1 We in our study explored this fact by using topical human placental extract for post operative wounds.

The placental extract contains peptides similar to hypothalamic factor and have corticotrophin releasing factor (CRF) like activity on the release of endogenous steroid which inhibits phospholipase A2 thus preventing the release of prostaglandins and leucotrienes- the principal chemical mediators of inflammation.14 Fraction of a nucleotide in PE suppresses the chemical mediators of inflammation derived from plasma namely the complements, the kinins and the coagulation factors. Hence these components exert multiple biological activities, including immunomodulatory and anti-inflammatory activities. They are also reported to have growth factor like activity,15 pigmenting activity,23 and keratinocyte proliferating activity.24 The study done by Shukla et al11 suggested that perceived benefits of topical placental extracts may be due to multiple effects on angiogenesis, collagen synthesis and epithelial cell proliferation.

Placental extract (PE) is claimed to be a biogenic stimulator which prevents relapse of diseases and increase body resistance. This was proved by study done by Ansari et al25 which showed that placental extract increase both humoral as well as cell mediated immunity in human as well as animal models. Placental extract acting on immune system restored dysfunction of B and T lymphocytes to normal. Bianchi et al stated that placenta is an immunologically privileged organ, hence responsible for the survival of embryo which is a parabiotic, semiallograph, containing substances which inhibit complement system.26 This group also reported that nucleotides in PE emerged as anti-inflammatory agents.

Development of an ideal wound healing drug is still a challenge to the medical scientists. The ideal drug should fulfill the criteria such as rapid contraction of wound leading to quick healing, reduction of wound index and appreciable gain of tensile strength.12 Biochemically, the tissue DNA, RNA, total protein and hydroxyproline will be the markers of good healing property of the drug. The cell proliferation can be best judged on the basis of histological study. A study conducted on rats for studying wound healing activity of human placental extract (HPE) showed maximum increase in tensile strength and nucleic acids (DNA and RNA) in human placental extract topical application and intramuscular injection treated group. This indicated the synthesis of collagen fibres in largest amount and good nuclear repairment in this group. The cytoplasmic repairment was revealed from regeneration of protein in appreciable amount. The efficiency of formation of collagen mainly depends upon Hydroxyproline,27 which was also recorded to be highest in HPE treated group indicating better healing. This was further substantiated from the picture of histopathological changes showing maximum accumulation of collagen fibrils and epithelialisation. The growth promoting role of HPE is manifested probably either by stimulation of the growth factors signal cascade system at the cellular level or itself may act as growth factors.12 Hence we can see similar effects of HPE in humans as it helps in wound healing.

Fibrogenesis, neoangiogenesis and epithelialisation are accelerated following the use of placental extract.11 Human and animal models show that placental extract has an immunotropic action both at cellular and humoral levels. It increases IgG and IgM at the humoral level and total lymphokines at the cellular level.11 It has several advantages over antibiotics and chemotherapeutic agents in terms of antibacterial activity, vascularisation of wound environment and wound healing. It is free from side effects.24 Our results also support this fact as wound erythema and discharge in PE treated group were comparable to that of PI group. Placental extract improves proliferation in primary cultures of human epidermal keratinocytes.24 This water soluble property of PE is 50 times more potent than epidermal growth factor.24 PE contains fibroblasts growth factors, naturally occurring amino acids, nucleotides and vitamins which stimulate cellular biosynthesis by favouring the turnover of collagen.11

In chronic inflammation and repair, it probably stimulates the growth factors, which are Nitric oxide (NO) dependent. The drug contains NADPH, a nucleotide that helps in wound repair.13 This NADPH is an essential factor for synthesis of NO in cells and tissues. Nitric Oxide induction property of PE by macrophages has been demonstrated in one study.28 It also regulates capillary permeability and maintains adequate tissue perfusion thereby accelerating the process of wound healing. This property is very well supported by our study as the wound healing property of PE is comparable to PI. Both global efficacy by surgeon and global tolerability by patient at study completion were also similar in both groups.

Compared with conventional therapies for wound healing. PE brings about maximum increase in the percentage of DNA, total protein and hydroxyproline values. These are required for formation of strong healing tissue. There is an increase in fibrous tissue, new blood vessel and epithelial tissue formation.12 Presence of amino acids and nucleotides in natural form stimulate cellular biosynthesis, increases turn over of collagen and extra cellular matrix of tissues. The healing velocity documents the capacity of activation of cellular biosynthesis. This is done by:

1. Promoting new blood vessel formation.
2. Causing cellular migration necessary for wound healing
3. Increasing collagen deposit.
4. Dilating the blood vessels.
5. Increasing viability of skin flaps.
6. Enhance cellular immuno-modulation and host defence locally.

Hence in conclusion, our study supports the fact that placental extract improves wound healing in post-operative wounds.

Acknowledgement

We would like to thank M/s Albert David Ltd., Calcutta, India for supporting this study. We thank Dr. Bandhopadhyay for reference search and guidance.

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*Associate Professor, Department of Surgery; **Lecturer, Department of Pharmacology; ***Professor and Head of the Department and Unit Head, Department of General Surgery, Grant Medical College and JJ Group of Hospitals, Mumbai 400 008.