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Torres-de la Roche LA, Catena U, Clark TJ, Devassy R, Leyland N, De Wilde RL. Perspectives in adhesion prevention in gynaecological surgery. Facts Views Vis Obgyn 2023; 15:291-296. [PMID: 38128088 PMCID: PMC10832654 DOI: 10.52054/fvvo.15.4.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Adhesions are a frequent, clinically relevant, and often costly complication of surgery that can develop in any body location regardless of the type of surgical procedure. Adhesions result from surgical trauma inducing inflammatory and coagulation processes and to date cannot be entirely prevented. However, the extent of adhesion formation can be reduced by using good surgical technique and the use of anti-inflammatory drugs, haemostats, and barrier agents. Strategies are needed in the short-, medium- and longer-term to improve the prevention of adhesions. In the short-term, efforts are needed to increase the awareness amongst surgeons and patients about the potential risks and burden of surgically induced adhesions. To aid this in the medium- term, a risk score to identify patients at high risk of adhesion formation is being developed and validated. Furthermore, available potentially preventive measures need to be highlighted. Both clinical and health economic evaluations need to be undertaken to support the broad adoption of such measures. In the longer- term, a greater understanding of the pathogenic processes leading to the formation of adhesions is needed to help identify effective, future treatments to reliably prevent adhesions from forming and lyse existing ones.
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Chemically Modified Hyaluronic Acid for Prevention of Post-Surgical Adhesions: New Aspects of Gel Barriers Physical Profiles. J Clin Med 2022; 11:jcm11040931. [PMID: 35207204 PMCID: PMC8874822 DOI: 10.3390/jcm11040931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022] Open
Abstract
This study was conducted to provide information regarding the chemistry—including structure, synthesis, formulation, and mechanical properties—of two types of chemically modified anti-adhesion gels made of hyaluronic acid. Gel A (Hyalobarrier®) and gels B and C (HyaRegen® and MetaRegen®) that are used in postsurgical adhesion prevention. To date, little information is available on their physicochemical attributes. This information is necessary in order to understand the differences in their in vivo behavior. Methods: Comparative analyses were conducted under laboratory-controlled conditions, including measuring the shear viscosity, storage modulus G’, peel strength, and extrusion forces. Results: All polymers exhibited viscoelastic behavior. Polymer A showed a shear viscosity approximately three times larger than both polymers B and C (114 Pa.s−1 vs. 36–38 Pa.s−1) over the shear-rate range measured, indicating a possible better ability to resist flows and potentially remain in place at the site of application in vivo. The results of storage modulus (G’) measurements showed 100 Pa for polymer A and 16 Pa and 20 Pa for polymers B and C, respectively. This translated into a weaker elastic behavior for gels B and C, and a lower ability to resist sudden deformation. The peel test results showed a rupture strength of 72 mN (0.016 lbf) for polymer A, 39.6 mN (0.0089 lbf) for polymer B, and 38.3 mN (0.0086 lbf) for polymers C, indicating possible higher adhesive properties for polymer A. Tests measuring the extrudability of the hyaluronic acid gels in their commercial syringes showed an average extrusion force of 20 N (4.5 lbf) for polymer A, 28 N (6.33 lbf) for polymer B, and 17 N (3.79 lbf) for polymer C. Conclusions: Modified anti-adhesion gels made of hyaluronic acid differed in mechanical properties and concentration. Further clinical studies are needed to confirm whether these differences make one polymer easier to apply during surgery and more likely to stay in place longer after in vivo application, and to determine which is potentially superior in terms of preventing adhesions.
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Fatehi Hassanabad A, Zarzycki AN, Jeon K, Dundas JA, Vasanthan V, Deniset JF, Fedak PWM. Prevention of Post-Operative Adhesions: A Comprehensive Review of Present and Emerging Strategies. Biomolecules 2021; 11:biom11071027. [PMID: 34356652 PMCID: PMC8301806 DOI: 10.3390/biom11071027] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023] Open
Abstract
Post-operative adhesions affect patients undergoing all types of surgeries. They are associated with serious complications, including higher risk of morbidity and mortality. Given increased hospitalization, longer operative times, and longer length of hospital stay, post-surgical adhesions also pose a great financial burden. Although our knowledge of some of the underlying mechanisms driving adhesion formation has significantly improved over the past two decades, literature has yet to fully explain the pathogenesis and etiology of post-surgical adhesions. As a result, finding an ideal preventative strategy and leveraging appropriate tissue engineering strategies has proven to be difficult. Different products have been developed and enjoyed various levels of success along the translational tissue engineering research spectrum, but their clinical translation has been limited. Herein, we comprehensively review the agents and products that have been developed to mitigate post-operative adhesion formation. We also assess emerging strategies that aid in facilitating precision and personalized medicine to improve outcomes for patients and our healthcare system.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2N9, Canada; (A.F.H.); (A.N.Z.); (J.A.D.); (V.V.); (J.F.D.)
| | - Anna N. Zarzycki
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2N9, Canada; (A.F.H.); (A.N.Z.); (J.A.D.); (V.V.); (J.F.D.)
| | - Kristina Jeon
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R7, Canada;
| | - Jameson A. Dundas
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2N9, Canada; (A.F.H.); (A.N.Z.); (J.A.D.); (V.V.); (J.F.D.)
| | - Vishnu Vasanthan
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2N9, Canada; (A.F.H.); (A.N.Z.); (J.A.D.); (V.V.); (J.F.D.)
| | - Justin F. Deniset
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2N9, Canada; (A.F.H.); (A.N.Z.); (J.A.D.); (V.V.); (J.F.D.)
- Department of Physiology and Pharmacology, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Paul W. M. Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2N9, Canada; (A.F.H.); (A.N.Z.); (J.A.D.); (V.V.); (J.F.D.)
- Correspondence:
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Saridogan E. Role of general gynaecologists in the prevention of infertility. Best Pract Res Clin Obstet Gynaecol 2019; 59:132-136. [PMID: 30837119 DOI: 10.1016/j.bpobgyn.2019.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/26/2019] [Accepted: 01/31/2019] [Indexed: 11/25/2022]
Abstract
Gynaecologists are frequently involved in the management of conditions that may result in reduced fertility or treatments they administer can lead to infertility. Sexually transmitted infections and pelvic inflammatory disease are the most common cause of tubal damage. Gynaecologists can play an important role in the identification and early treatment of these diseases. Pelvic surgery for conditions such as leiomyoma, ovarian cysts and endometriosis can lead to pelvic adhesions and iatrogenic infertility. By avoiding unnecessary operations by careful assessment of women with these conditions and by identifying those who can be managed without surgery, the future risk of infertility can be avoided. When surgery is clinically indicated, primary prevention of pelvic adhesions would be of paramount importance. A reliable surgical technique and the use of anti-adhesion agents may reduce the development of pelvic adhesions. Ovarian surgery for endometriomas and other benign cysts should be performed in the hands of experienced surgeons or in 'centres of clinical expertise', and maximum efforts should be made to preserve normal ovarian tissue as much as possible.
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Affiliation(s)
- Ertan Saridogan
- Consultant in Reproductive Medicine and Minimal Access Surgery, University College London Hospitals, UK.
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Spens K, Bird L, Bright P. Transabdominal ultrasound: Can it be used to detect and quantify adhesions/reported pain, following Caesarean section? J Bodyw Mov Ther 2018; 22:733-740. [PMID: 30100305 DOI: 10.1016/j.jbmt.2017.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 07/30/2017] [Accepted: 09/06/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Caesarean section is common in the UK with post-procedural adhesions causing life-long clinical symptoms and impacting future pregnancies. This study's aim was to explore associations between these surgical adhesions, via transabdominal ultrasound findings, and perceived symptoms. METHOD Females demonstrating 1-3 transverse, lower-segment Caesareans were included. Visceral slide transabdominal ultrasound elicited positive adhesions (<1 cm movement) and negative adhesions (>1 cm movement). Scar tissue quality was assessed by the Patient and Observer Scar Assessment Scale (POSAS) and Numerical rating scales (NRS) described pain symptoms. The relationship between adhesions was explored using Fisher's exact test and multiple regression analysis. RESULTS Twenty-two subjects (mean-age 35) were recruited; twenty participants (91%) had undergone 1 Caesarean, one each of the remainder had undergone 2 and 3 Caesareans respectively. Increased Visceral slide (>1 cm) was seen as predictive of increased scar pain (R2 = 0.76 (95% CI 0.12-0.28), P < 0.001). CONCLUSION Caesarean adhesion scans showed significant associations with pain symptomology. Comprehensive adhesion assessment needs to be developed to improve long term outcomes of adhesions. Transabdominal Ultrasound can be considered a useful, quick and non-deleterious alternative diagnostic tool to Laparoscopy, therefore preventing further adhesion formation.
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Affiliation(s)
- Katharine Spens
- European School of Osteopathy, Boxley House, The Street, Boxley, Maidstone, Kent, ME14 3DZ, UK(1).
| | - Lance Bird
- European School of Osteopathy, Boxley House, The Street, Boxley, Maidstone, Kent, ME14 3DZ, UK(1)
| | - Philip Bright
- European School of Osteopathy, Boxley House, The Street, Boxley, Maidstone, Kent, ME14 3DZ, UK(1)
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Cho DH. Strangulated adnexa due to adhesion band after hysterectomy. BMJ Case Rep 2018; 2018:bcr-2018-226240. [PMID: 30061144 DOI: 10.1136/bcr-2018-226240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Dong Hyu Cho
- Department of Obstetrics and Gynecology, Chonbuk National University Medical School, Jeonju, Korea
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Kai M, Maeda K, Tasaki M, Kira S, Nakamura S, Chino N, Hagiwara H, Nishida H, Kawanishi T. Evaluation of a Spray-type, Novel Dextrin Hydrogel Adhesion Barrier Under Laparoscopic Conditions in a Porcine Uterine Horn Adhesion Model. J Minim Invasive Gynecol 2018; 25:447-454. [DOI: 10.1016/j.jmig.2017.09.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/23/2017] [Accepted: 09/26/2017] [Indexed: 01/02/2023]
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Preventing postoperative tissue adhesion using injectable carboxymethyl cellulose-pullulan hydrogels. Int J Biol Macromol 2017; 105:886-893. [DOI: 10.1016/j.ijbiomac.2017.07.103] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/10/2017] [Accepted: 07/17/2017] [Indexed: 11/20/2022]
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Factors for a Successful Laparoscopic Hysterectomy in Very Large Uteri. Case Rep Med 2017; 2017:1637472. [PMID: 29056970 PMCID: PMC5606097 DOI: 10.1155/2017/1637472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/09/2017] [Accepted: 08/02/2017] [Indexed: 11/17/2022] Open
Abstract
Minimally invasive hysterectomy is a standard procedure. Different approaches, as laparoscopically assisted vaginal hysterectomy, vaginal hysterectomy, and subtotal and total laparoscopic hysterectomy, have been described and evaluated by various investigations as safe and cost-effective methods. In particular, in comparison to abdominal hysterectomy, the minimally invasive methods have undoubted advantages for the patients. The main reason for a primary abdominal hysterectomy or conversion to abdominal hysterectomy during a minimal invasive approach is the uterine size. We describe our course of action in the retrospective analysis of five cases of total minimal-access hysterectomy, combining the laparoscopic subtotal hysterectomy and the vaginal extirpation of the cervix in uterine myomatosis with a uterine weight of more than 1000 grams, and discuss the factors that limit the use of laparoscopy in the treatment of big uteri. Trail Registration. The case report is registered in Research Registry under the UIN researchregistry743.
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Christopoulos G, Vlismas A, Salim R, Islam R, Trew G, Lavery S. Fibroids that do not distort the uterine cavity and IVF success rates: an observational study using extensive matching criteria. BJOG 2016; 124:615-621. [PMID: 27921379 DOI: 10.1111/1471-0528.14362] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the impact of non-cavity-distorting fibroids on in vitro fertilisation (IVF) pregnancy outcomes. DESIGN A retrospective, matched, single-centre, cohort study was performed. SETTING The IVF unit of a tertiary, university hospital. POPULATION We analysed all women with non-cavity-distorting uterine fibroids undergoing IVF/intracytoplasmic sperm injection (ICSI) cycles from 1 January 2011 to 1 May 2015. METHODS Each woman was matched with two separate controls of the same age (±6 months), stimulation protocol (gonadotropin-releasing hormone agonist or antagonist), starting dose of follicle-stimulating hormone (FSH), number of embryos transferred (one or two), day of transfer (day 3 or day 5), and no uterine fibroids identified by transvaginal ultrasound. MAIN OUTCOME MEASURES Clinical pregnancy and live birth rates. RESULTS Our study demonstrates that the presence of non-cavity-distorting fibroids appears to negatively affect clinical pregnancy (odds ratio, OR 0.62; 95% confidence interval, 95% CI 0.41-0.94) and live birth rates (OR 0.58; 95% CI 0.48-0.78) in patients undergoing their first IVF/ICSI cycle, when matched with controls of the same age, starting dose of FSH, stimulation protocol, number of embryos, and day of embryo transfer. The deleterious effect of fibroids on live birth rates was significant in women with two or more fibroids (OR 0.47; 95% CI 0.26-0.83) and in women with fibroids of ≥30 mm in diameter (OR 0.41; 95% CI 0.19-0.89). The negative impact of non-cavity-distorting fibroids was also present in women with an embryo transfer on day 5 (OR 0.58; 95% CI 0.35-0.94). Conversely, in women with single fibroids of <30 mm in diameter, no difference in pregnancy outcomes was identified. CONCLUSIONS A well-designed, adequately powered, randomised controlled trial is required to address the role of medical or surgical interventions in patients with intramural and subserosal fibroids before undergoing fertility treatment. TWEETABLE ABSTRACT Non-cavity-distorting fibroids negatively affect pregnancy rates after IVF.
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Affiliation(s)
- G Christopoulos
- IVF Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - A Vlismas
- IVF Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - R Salim
- IVF Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - R Islam
- IVF Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - G Trew
- IVF Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - S Lavery
- IVF Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Trew GH, Pistofidis GA, Brucker SY, Krämer B, Ziegler NM, Korell M, Ritter H, McConnachie A, Ford I, Crowe AM, Estridge TD, Diamond MP, De Wilde RL. A first-in-human, randomized, controlled, subject- and reviewer-blinded multicenter study of Actamax™ Adhesion Barrier. Arch Gynecol Obstet 2016; 295:383-395. [PMID: 27844212 PMCID: PMC5281664 DOI: 10.1007/s00404-016-4211-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/22/2016] [Indexed: 01/11/2023]
Abstract
Purpose Post-surgical adhesions remain a significant concern following abdominopelvic surgery. This study was to assess safety, manageability and explore preliminary efficacy of applying a degradable hydrogel adhesion barrier to areas of surgical trauma following gynecologic laparoscopic abdominopelvic surgery. Methods This first-in-human, prospective, randomized, multicenter, subject- and reviewer-blinded clinical study was conducted in 78 premenopausal women (18–46 years) wishing to maintain fertility and undergoing gynecologic laparoscopic abdominopelvic surgery with planned clinically indicated second-look laparoscopy (SLL) at 4–12 weeks. The first two patients of each surgeon received hydrogel, up to 30 mL sprayed over all sites of surgical trauma, and were assessed for safety and application only (n = 12). Subsequent subjects (n = 66) were randomized 1:1 to receive either hydrogel (Treatment, n = 35) or not (Control, n = 31); 63 completed the SLL. Results No adverse event was assessed as serious, or possibly device related. None was severe or fatal. Adverse events were reported for 17 treated subjects (17/47, 36.2%) and 13 Controls (13/31, 41.9%). For 95.7% of treated subjects, surgeons found the device “easy” or “very easy” to use; in 54.5%, some residual material was evident at SLL. For 63 randomized subjects who completed the SLL, adjusted between-group difference in the change from baseline adhesion score demonstrated a 41.4% reduction for Treatment compared with Controls (p = 0.017), with a 49.5% reduction (p = 0.008) among myomectomy subjects (n = 34). Conclusion Spray application of a degradable hydrogel adhesion barrier during gynecologic laparoscopic abdominopelvic surgery was performed easily and safely, without evidence of clinically significant adverse outcomes. Data suggest the hydrogel was effective in reducing postoperative adhesion development, particularly following myomectomy. Electronic supplementary material The online version of this article (doi:10.1007/s00404-016-4211-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Geoffrey H Trew
- Consultant in Reproductive Medicine and Surgery, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK.
| | - George A Pistofidis
- Department of Gynecological Endoscopic Surgery, Lefkos Stavros Hospital, Athens, 115 28, Greece
| | - Sara Y Brucker
- Department of Gynecology and Obstetrics, University of Tübingen, Tübingen, 72076, Germany
| | - Bernhard Krämer
- Department of Gynecology and Obstetrics, University of Tübingen, Tübingen, 72076, Germany
| | - Nicole M Ziegler
- Department of Obstetrics, Gynecology, and Gynecology Oncology, Pius Hospital, Oldenburg, 26121, Germany
| | - Matthias Korell
- Department of Obstetrics and Gynecology, Johanna Etienne Krankenhaus, Neuss, 41462, Germany
| | - Henning Ritter
- Department of Obstetrics, Gynecology, and Gynecology Oncology, Pius Hospital, Oldenburg, 26121, Germany
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, G12 8QQ, UK
| | | | | | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, 30912, USA
| | - Rudy L De Wilde
- Department of Obstetrics, Gynecology, and Gynecology Oncology, Pius Hospital, Oldenburg, 26121, Germany
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Cezar C, Korell M, Tchartchian G, Ziegler N, Senshu K, Herrmann A, Larbig A, De Wilde RL. How to avoid risks for patients in minimal-access trials: Avoiding complications in clinical first-in-human studies by example of the ADBEE study. Best Pract Res Clin Obstet Gynaecol 2016; 35:84-96. [DOI: 10.1016/j.bpobgyn.2015.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/06/2015] [Indexed: 12/29/2022]
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Cezar C, Tchartchian G, Korell M, Ziegler N, Senshu K, De Wilde MS, Herrmann A, Larbig A, De Wilde RL. Long term follow-up concerning safety and efficacy of novel adhesion prophylactic agent for laparoscopic myomectomy in the prospective randomized ADBEE study. Best Pract Res Clin Obstet Gynaecol 2016; 35:97-112. [PMID: 27449312 DOI: 10.1016/j.bpobgyn.2016.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/28/2016] [Indexed: 01/20/2023]
Abstract
We conducted a prospective randomized single blind - subject study in the University Clinic of Gynecology of Pius-Hospital Oldenburg. The primary objective of the ADBEE study was to assess the safety and manageability of ADBLOCK when used as an adjunct to laparoscopic surgery for the primary of myomas in women wishing to improve pregnancy outcomes. The study population included 32 women aged between 18-45 years, in good general health condition, who have not completed their family planning and who are undergoing primary ('virgin') laparoscopic myomectomy with an aim to improve pregnancy outcomes. The patients were randomized in 2 groups, ADBLOCK arm with 21 patients and surgery only arm with 11 patients. The study was single blind - subject and the investigators were blinded to treatment group assignment until completion of uterine suturing and prior to removal of the endoscope. A vigorous follow-up of subjects was organized, focusing on its two critical characteristics: completeness and duration. Completeness represented the percentage of subjects who returned to every planed follow - up appointments. The patients were evaluated in a specific period of time, which defined the duration of follow-up. Safety of the ADBLOCK was estimated after analyzing and documentation of any adverse events occurred, clinical and physical examination of patients as well as evaluation of laboratory measures. There were 25 adverse events reported in ADBLOCK treatment group and 12 events in NO-ADBLOCK group over the 24-months treatment. All adverse events in both treatment arms were not anticipated, with all events in the ADBLOCK group being resolved. At 28 days, there was no significant difference in proportion of events between the two treatments (p = 0.440). Overall, the number of events reported was low and the severity of events was generally mild with an unlikely or no relationship to treatment. There were no unanticipated device related adverse events seen in both treatment groups over the immediate post-operative period or during the 24 months follow up period. By 12 weeks all patients reported their wound as healing well or healed and at 6 months all wounds were reported as healed. There were no differences between both treatment groups regarding the use of painkillers over 24 months follow up period. This clinical first - in - human study, sustained by a rigorous follow-up of the subjects has demonstrated that ADBLOCK is a safe product, presenting no additional safety risk or burden to the patients over surgery alone. The device was relatively easy to use, with a low device failure rate that had no impact on the surgical procedures.
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Affiliation(s)
- Cristina Cezar
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University Oldenburg, 26121 Oldenburg, Germany.
| | - Garri Tchartchian
- Clinic for Minimal-Invasive Surgery, 14129 Berlin-Zehlendorf, Germany
| | - Matthias Korell
- Johanna-Etienne-Clinic, Department for Obstetrics and Gynecology, 41462 Neuss, Germany
| | - Nicole Ziegler
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University Oldenburg, 26121 Oldenburg, Germany
| | | | - Maya Sophie De Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University Oldenburg, 26121 Oldenburg, Germany
| | - Anja Herrmann
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University Oldenburg, 26121 Oldenburg, Germany
| | - Angelika Larbig
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University Oldenburg, 26121 Oldenburg, Germany
| | - Rudy Leon De Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University Oldenburg, 26121 Oldenburg, Germany
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Nassif J, Abbasi SA, Kechli MK, Boutary SS, Ghulmiyyah L, Khalifeh I, Abou Ghaddara H, Nassar AH. Effect of the Mode of Application of Cryopreserved Human Amniotic Membrane on Adhesion Formation after Abdomino-Pelvic Surgery in a Mouse Model. Front Med (Lausanne) 2016; 3:10. [PMID: 27066485 PMCID: PMC4810021 DOI: 10.3389/fmed.2016.00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 02/19/2016] [Indexed: 11/19/2022] Open
Abstract
Adhesions after abdomino-pelvic surgery are a cause of morbidity and reoperations. The use of human amniotic membrane (HAM) for adhesion prevention has given controversial results. The mode of administration of the amniotic membrane has not been well studied. This study assessed the efficacy of two modes of application of cryopreserved HAM, patch or fragmented in Lactated Ringer (LR) solution, for the prevention of pelvic adhesion formation postabdomino-pelvic surgery in a mice model. After a midline laparotomy incision, a small cautery lesion was done on each side of the abdominal wall peritoneum in mice. In Group A (control; n = 42), the abdomen was closed directly, Group B (n = 42) received 2.5 ml of LR prior to closure. In Groups C (n = 42) and D (n = 42), a 2 cm × 2 cm patch of HAM and another one fragmented and dispersed in 2.5 ml of LR were applied prior to closure, respectively. Two weeks later, a laparotomy was performed, and gross and pathological evaluation of adhesions, fibrosis, angiogenesis, and inflammation were conducted. Group D exhibited a significantly lower rate of gross adhesion formation. Fibrosis was significantly lowest in Group C as compared to the control. Group B had the lowest vascular formation in the adhesions. The use of HAM fragmented in LR solution is associated with a significantly lower incidence of postoperative adhesions in mice when compared to LR alone, HAM patch, or control. The mechanism of action of this reduction needs to be elucidated by future studies.
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Affiliation(s)
- Joseph Nassif
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sehrish A. Abbasi
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Karim Kechli
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Suzan S. Boutary
- Department of Anatomy, Cell Biology and Physiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Labib Ghulmiyyah
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ibrahim Khalifeh
- Department of Pathology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hussein Abou Ghaddara
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Anwar H. Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
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Use of Modified Polysaccharide 4DryField (®) PH for Adhesion Prevention and Hemostasis in Gynecological Surgery: A Two-Center Observational Study by Second-Look Laparoscopy. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3029264. [PMID: 26904672 PMCID: PMC4745300 DOI: 10.1155/2016/3029264] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 11/18/2015] [Accepted: 11/30/2015] [Indexed: 01/20/2023]
Abstract
Purpose. This study evaluates both scopes of 4DryField PH, certified for adhesion prevention and hemostasis, in patients undergoing surgery for various and severe gynecological disorders. Methods. This is a two-institutional study. Adhesion prevention efficacy was evaluated using video documentation of first-look laparoscopies (FLL) and second-look laparoscopies (SLL); other patient data were analyzed retrospectively. Twenty patients with various disorders were evaluated, 4 assigned to a uterus pathology, 10 to endometriosis, and 6 to an adhesion disease group. Nine patients received 4DryField primarily for hemostasis and 11 solely for adhesion prevention. Nineteen patients had SLL after 5 to 12 weeks and one after 13 months. Results. At FLL with 4DryField, immediate hemostasis could be achieved in diffuse bleeding. At SLL, effective adhesion prevention was observed in 18 of all 20 women, with only 2 revealing major adhesions. In particular, only 1 of the 6 women with adhesion disease as predominant disorder showed major adhesions at SLL. Conclusions. Modified polysaccharide 4DryField is not only effective in diffuse bleeding. In this cohort with extensive surgery for various gynecological pathologies, 4DryField showed effective adhesion prevention as confirmed at SLL, too. Its use as premixed gel is a convenient variant for treatment of large peritoneal wounds.
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Kössi J, Julkunen K, Setälä M, Luostarinen M. Adhesion-related readmissions after surgery for deep endometriosis with the use of icodextrin—long-term results. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s10397-015-0927-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Lundorff P, Brölmann H, Koninckx PR, Mara M, Wattiez A, Wallwiener M, Trew G, Crowe AM, De Wilde RL. Predicting formation of adhesions after gynaecological surgery: development of a risk score. Arch Gynecol Obstet 2015; 292:931-8. [PMID: 26223185 PMCID: PMC4560753 DOI: 10.1007/s00404-015-3804-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/24/2015] [Indexed: 01/29/2023]
Abstract
PURPOSE Risk factors for post-surgical adhesions following gynaecological surgery have been identified, but their relative importance has not been precisely determined. No practical tool exists to help gynaecological surgeons evaluate the risk of adhesions in their patients. The purpose of the study was to develop an Adhesion Risk Score to provide a simple tool that will enable gynaecological surgeons to routinely quantify the risk of post-surgical adhesions in individual patients. METHODS A group of European gynaecological surgeons searched the literature to identify the risk factors and the surgical operations reported as carrying a risk of post-surgical adhesions. Through consensus process of meetings and communication, a four-point scale was then used by each surgeon to attribute a specific weight to each item and collective agreement reached on identified risk factors and their relative importance to allow construct of a useable risk score. RESULTS Ten preoperative and 10 intraoperative risk factors were identified and weighed, leading to the creation of two sub-scores to identify women at risk prior to and during surgery. The Preoperative Risk Score can range from 0 to 36, and the Intraoperative Risk Score from 3 to 31. Several thresholds between these limits may be used to identify women with low, medium, and high risk of post-surgical adhesions. CONCLUSIONS Gynaecological surgeons are encouraged to use this Adhesion Risk Score to identify the risk of adhesions in their patients. This will allow better informed use of available resources to target preventive measures in women at high risk of post-surgical adhesions.
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Affiliation(s)
- Per Lundorff
- />Department of Gynaecology, Private Hospital Molholm, Vejle, Denmark
| | - Hans Brölmann
- />Department of Obstetrics and Gynaecology, VU University, Amsterdam, The Netherlands
| | - Philippe Robert Koninckx
- />Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Katholieke Universiteit, Leuven, Belgium
| | - Michal Mara
- />Department of Obstetrics and Gynaecology, Charles University, Prague, Czech Republic
| | - Arnaud Wattiez
- />Department of Obstetrics and Gynecology, Hôpital de Hautepierre, Strasbourg, France
| | - Markus Wallwiener
- />Department of Obstetrics and Gynaecology, University of Heidelberg, Heidelberg, Germany
| | - Geoffrey Trew
- />Department of Reproductive Medicine and Surgery, Hammersmith Hospital, London, UK
| | | | - Rudy Leon De Wilde
- />Department of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynaecology, Pius-Hospital, University Oldenburg, Oldenburg, Germany
| | - For the Anti-Adhesions in Gynaecology Expert Panel (‘ANGEL’)
- />Department of Gynaecology, Private Hospital Molholm, Vejle, Denmark
- />Department of Obstetrics and Gynaecology, VU University, Amsterdam, The Netherlands
- />Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Katholieke Universiteit, Leuven, Belgium
- />Department of Obstetrics and Gynaecology, Charles University, Prague, Czech Republic
- />Department of Obstetrics and Gynecology, Hôpital de Hautepierre, Strasbourg, France
- />Department of Obstetrics and Gynaecology, University of Heidelberg, Heidelberg, Germany
- />Department of Reproductive Medicine and Surgery, Hammersmith Hospital, London, UK
- />Corvus Communications Limited, Buxted, East Sussex UK
- />Department of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynaecology, Pius-Hospital, University Oldenburg, Oldenburg, Germany
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Liu C, Lu Q, Zhang Z, Xue M, Zhang Y, Zhang Y, Wang H, Li H, Zhou Y, Zhang Z, Li W, Zhai Y, Jiang Y, Sang C, Xiao S, Xiao F, Ye M, Zhang A, Jiang J, Wang G, Yang X, Cui B, Lu Q, Meng Q, Zhang Q, Lu Y, Wang Y, Ofek G. A Randomized Controlled Trial on the Efficacy and Safety of a New Crosslinked Hyaluronan Gel in Reducing Adhesions after Gynecologic Laparoscopic Surgeries. J Minim Invasive Gynecol 2015; 22:853-63. [DOI: 10.1016/j.jmig.2015.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/10/2015] [Accepted: 04/12/2015] [Indexed: 11/16/2022]
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Insufflation with humidified and heated carbon dioxide in short-term laparoscopy: a double-blinded randomized controlled trial. BIOMED RESEARCH INTERNATIONAL 2015; 2015:412618. [PMID: 25722977 PMCID: PMC4324813 DOI: 10.1155/2015/412618] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/07/2015] [Indexed: 11/18/2022]
Abstract
Background. We tested the hypothesis that warm-humidified carbon dioxide (CO2) insufflation would reduce postoperative pain and morphine requirement compared to cold-dry CO2 insufflation. Methods. A double-blinded, randomized, controlled trial was conducted to compare warm, humidified CO2 and cold-dry CO2. Patients with benign uterine diseases were randomized to either treatment (n = 48) or control (n = 49) group during laparoscopically assisted vaginal hysterectomy. Primary endpoints of the study were rest pain, movement pain, shoulder-tip pain, and cough pain at 2, 4, 6, 24, and 48 hours postoperatively, measured by visual analogue scale. Secondary outcomes were morphine consumption, rejected boli, temperature change, recovery room stay, and length of hospital stay. Results. There were no significant differences in all baseline characteristics. Shoulder-tip pain at 6 h postoperatively was significantly reduced in the intervention group. Pain at rest, movement pain, and cough pain did not differ. Total morphine consumption and rejected boli at 24 h postoperatively were significantly higher in the control group. Temperature change, recovery room stay, and length of hospital were similar. Conclusions. Warm, humidified insufflation gas significantly reduces postoperative shoulder-tip pain as well as morphine demand. This trial is registered with Clinical Trial Registration Number
DRKS00003853 (German Clinical Trials Register (DRKS)).
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Tchartchian G, Hackethal A, Herrmann A, Bojahr B, Wallwiener C, Ohlinger R, Ebert AD, De Wilde RL. Evaluation of SprayShield™ Adhesion Barrier in a single center: randomized controlled study in 15 women undergoing reconstructive surgery after laparoscopic myomectomy. Arch Gynecol Obstet 2014; 290:697-704. [DOI: 10.1007/s00404-014-3251-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 04/03/2014] [Indexed: 12/15/2022]
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Standardised models for inducing experimental peritoneal adhesions in female rats. BIOMED RESEARCH INTERNATIONAL 2014; 2014:435056. [PMID: 24809049 PMCID: PMC3997962 DOI: 10.1155/2014/435056] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 03/19/2014] [Indexed: 11/17/2022]
Abstract
Animal models for adhesion induction are heterogeneous and often poorly described. We compare and discuss different models to induce peritoneal adhesions in a randomized, experimental in vivo animal study with 72 female Wistar rats. Six different standardized techniques for peritoneal trauma were used: brushing of peritoneal sidewall and uterine horns (group 1), brushing of parietal peritoneum only (group 2), sharp excision of parietal peritoneum closed with interrupted sutures (group 3), ischemic buttons by grasping the parietal peritoneum and ligating the base with Vicryl suture (group 4), bipolar electrocoagulation of the peritoneum (group 5), and traumatisation by electrocoagulation followed by closure of the resulting peritoneal defect using Vicryl sutures (group 6). Upon second look, there were significant differences in the adhesion incidence between the groups (P < 0.01). Analysis of the fraction of adhesions showed that groups 2 (0%) and 5 (4%) were significantly less than the other groups (P < 0.01). Furthermore, group 6 (69%) was significantly higher than group 1 (48%) (P < 0.05) and group 4 (47%) (P < 0.05). There was no difference between group 3 (60%) and group 6 (P = 0.2). From a clinical viewpoint, comparison of different electrocoagulation modes and pharmaceutical adhesion barriers is possible with standardised models.
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Shahram E, Sadraie SH, Kaka G, Khoshmohabat H, Hosseinalipour M, Panahi F, Naimi-Jamal MR. Evaluation of chitosan–gelatin films for use as postoperative adhesion barrier in rat cecum model. Int J Surg 2013; 11:1097-102. [DOI: 10.1016/j.ijsu.2013.09.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 09/17/2013] [Accepted: 09/19/2013] [Indexed: 01/20/2023]
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A European survey on awareness of post-surgical adhesions among gynaecological surgeons. ACTA ACUST UNITED AC 2013; 11:105-112. [PMID: 24795546 PMCID: PMC4003340 DOI: 10.1007/s10397-013-0824-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/13/2013] [Indexed: 12/20/2022]
Abstract
The present survey was conducted among gynaecological surgeons from several European countries to assess the actual knowledge and practice related to post-surgical adhesions and measures for reduction. From September 1, 2012 to February 6, 2013, gynaecological surgeons were invited to answer an 18-item online questionnaire accessible through the ESGE website. This questionnaire contained eight questions on care settings and surgical practice and ten questions on adhesion formation and adhesion reduction. Four hundred fourteen surgeons participated; 70.8 % agreed that adhesions are a source of major morbidity. About half of them declared that adhesions represented an important part of their daily medical and surgical work. About two thirds informed their patients about the risk of adhesion. Most cited causes of adhesions were abdominal infections and extensive tissue trauma, and endometriosis and myomectomy surgery. Fewer surgeons expected adhesion formation after laparoscopy (18.9 %) than after laparotomy (40.8 %); 60 % knew the surgical techniques recommended to reduce adhesions; only 44.3 % used adhesion-reduction agents on a regular basis. This survey gives a broad picture of adhesion awareness amongst European gynaecological surgeons, mainly from Germany and the UK. The participants had a good knowledge of factors causing adhesions. Knowledge of surgical techniques recommended and use of anti-adhesion agents developed to reduce adhesions need to be improved.
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Bae SH, Son SR, Kumar Sakar S, Nguyen TH, Kim SW, Min YK, Lee BT. Evaluation of the potential anti-adhesion effect of the PVA/Gelatin membrane. J Biomed Mater Res B Appl Biomater 2013; 102:840-9. [DOI: 10.1002/jbm.b.33066] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 08/27/2013] [Accepted: 10/20/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Sang-Ho Bae
- Department of Surgery; College of Medicine; Soonchunhyang University Hospital; Cheonan Chungnam 330-090 Republic of Korea
| | - So-Ra Son
- Department of Tissue Regeneration; College of Medicine; Soonchunhyang University; Cheonan Chungnam 330-090 Republic of Korea
| | - Swapan Kumar Sakar
- Department of Tissue Regeneration; College of Medicine; Soonchunhyang University; Cheonan Chungnam 330-090 Republic of Korea
| | - Thi-Hiep Nguyen
- Department of Tissue Regeneration; College of Medicine; Soonchunhyang University; Cheonan Chungnam 330-090 Republic of Korea
| | - Shin-Woo Kim
- Department of Physiology; College of Medicine; Soonchunhyang University; Cheonan Chungnam 330-090 Republic of Korea
| | - Young-Ki Min
- Department of Physiology; College of Medicine; Soonchunhyang University; Cheonan Chungnam 330-090 Republic of Korea
| | - Byong-Taek Lee
- Department of Tissue Regeneration; College of Medicine; Soonchunhyang University; Cheonan Chungnam 330-090 Republic of Korea
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Rajab TK, Kimonis KO, Ali E, Offodile AC, Brady M, Bleday R. Practical implications of postoperative adhesions for preoperative consent and operative technique. Int J Surg 2013; 11:753-6. [PMID: 23962663 DOI: 10.1016/j.ijsu.2013.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 05/02/2013] [Accepted: 07/29/2013] [Indexed: 11/20/2022]
Abstract
Adhesions complicate most intra-peritoneal operations. Once adhesions have formed, patients are at life-long risk for complications that include small bowel obstruction, increased risks during subsequent operations and female infertility. This has two implications for the daily work of surgeons. On the one hand, surgeons need to include the risks from adhesions during pre-operative consent. On the other hand, surgeons need to use operative techniques that minimize adhesions. Therefore this review focuses on the practical implications of adhesions for preoperative consent and operative technique.
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Affiliation(s)
- Taufiek Konrad Rajab
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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28
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Wallwiener M, Brölmann H, Koninckx PR, Lundorff P, Lower AM, Wattiez A, Mara M, De Wilde RL. "Adhesions after abdominal, pelvic and intra-uterine surgery and their prevention". ACTA ACUST UNITED AC 2012; 9:465-466. [PMID: 23144644 PMCID: PMC3491202 DOI: 10.1007/s10397-012-0762-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 07/28/2012] [Indexed: 12/31/2022]
Abstract
We here present the full text of a patient leaflet we have designed, and routinely use, to provide preoperative education about adhesions to patients undergoing open or laparoscopic gynaecological surgery. The leaflet presents appropriate, patient-orientated information on the nature of adhesions, their causes and the health risks they may involve as well as on adhesiolysis and modern methods of adhesion prevention. As adhesion formation is not specific to gynaecological surgery, the leaflet can also be adapted for the purposes of general abdominal surgery.
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Affiliation(s)
- Markus Wallwiener
- Department of Obstetrics and Gynaecology, University of Heidelberg, Vosstr. 9, 69115 Heidelberg, Germany
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Ouaïssi M, Gaujoux S, Veyrie N, Denève E, Brigand C, Castel B, Duron JJ, Rault A, Slim K, Nocca D. Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature. J Visc Surg 2012; 149:e104-14. [PMID: 22261580 DOI: 10.1016/j.jviscsurg.2011.11.006] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Post-operative adhesions after gastrointestinal surgery are responsible for significant morbidity and constitute an important public health problem. The aim of this study was to review the surgical literature to determine the incidence, consequences and the variety of possible countermeasures to prevent adhesion formation. METHODS A systematic review of English and French language surgical literature published between 1995 and 2009 was performed using the keywords "adhesion" and "surgery". RESULTS Peritoneal adhesions are reported as the cause of 32% of acute intestinal obstruction and 65-75% of all small bowel obstructions. It is estimated that peritoneal adhesions develop after 93-100% of upper abdominal laparotomies and after 67-93% of lower abdominal laparotomies. Nevertheless, only 15-18% of these adhesions require surgical re-intervention. The need for re-intervention for adhesion-related complications varies depending on the initial type of surgery, the postoperative course and the type of incision. The laparoscopic approach appears to decrease the risk of adhesion formation by 45% and the need for adhesion-related re-intervention to 0.8% after appendectomy and to 2.5% after colorectal surgery. At the present time, only one product consisting of hyaluronic acid applied to a layer of carboxymethylcellulose (Seprafilm(®)) has been shown to significantly reduce the incidence of postoperative adhesion formation; but this product is also associated with a significant increase in the incidence of anastomotic leakage when the membrane is applied in direct contact with the anastomosis. The use of this product has not been shown to decrease the risk of re-intervention for bowel obstruction. CONCLUSIONS The prevention of postoperative adhesions is an important public health goal, particularly in light of the frequency of this complication. The routine use of anti-adhesion products is not recommended given the lack of studies with a high level of evidence concerning their efficacy and safety of use.
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Affiliation(s)
- M Ouaïssi
- Service de chirurgie digestive et viscérale, hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France.
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Pouly JL, Darai E, Yazbeck C, Benifla JL, Dechaud H, Wattiez A, Crowe A, Audebert A. [Postoperative abdominal adhesions and their prevention in gynaecological surgery: II. How can they be prevented?]. ACTA ACUST UNITED AC 2011; 40:419-28. [PMID: 22137338 DOI: 10.1016/j.gyobfe.2011.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 09/02/2011] [Indexed: 01/07/2023]
Abstract
This paper is the second of a two-part publication. The initial paper provided a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. There is rising evidence that surgeons can take important steps to reduce the burden of adhesions. In this second paper, we review the various strategies to reduce the impact of adhesions, improve surgical outcomes and provide some practical proposals for action on adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be considered for use particularly in high-risk surgery and in patients with adhesiogenic conditions. Further research into new strategies to prevent adhesions more effectively through an improved surgical environment, new and combination devices and pharmacological agents should be encouraged. Formal recommendations would ensure better prioritisation of adhesion-reduction within the French health system. Patients should also be better informed of the risks of adhesions.
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Affiliation(s)
- J-L Pouly
- Unité de FIV, pôle gynécologie-obstétrique et reproduction humaine, CHU Estaing, 1 place Lucie-Aubrac, Clermont-Ferrand, France.
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Audebert A, Darai E, Bénifla JL, Yazbeck C, Déchaud H, Wattiez A, Crowe A, Pouly JL. [Postoperative abdominal adhesions and their prevention in gynaecological surgery: I. What should you know?]. ACTA ACUST UNITED AC 2011; 40:365-70. [PMID: 22129851 DOI: 10.1016/j.gyobfe.2011.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 09/02/2011] [Indexed: 11/25/2022]
Abstract
Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.
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Affiliation(s)
- A Audebert
- Service d'endoscopie gynécologique, polyclinique de Bordeaux, 145, rue du Tondu, 33000 Bordeaux, France.
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Hirschelmann A, Tchartchian G, Wallwiener M, Hackethal A, De Wilde RL. A review of the problematic adhesion prophylaxis in gynaecological surgery. Arch Gynecol Obstet 2011; 285:1089-97. [PMID: 22037682 PMCID: PMC3303068 DOI: 10.1007/s00404-011-2097-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 09/21/2011] [Indexed: 01/15/2023]
Abstract
Background Adhesions lead to considerable patient morbidity and are a mounting burden on surgeons and the health care system alike. Although adhesion formation is the most frequent complication in abdominal and pelvic surgery, many surgeons are still not aware of the extent of the problem. To provide the best care for their patients, surgeons should consistently inform themselves of anti-adhesion strategies and include these methods in their daily routine. Methods Searches were conducted in PubMed and The Cochrane Library to identify relevant literature. Findings Various complications are associated with adhesion formation, including small bowel obstruction, infertility and chronic pelvic pain. Increasingly, an understanding of adhesion formation as a complex process influenced by many different factors has led to various conceivable anti-adhesion strategies. At present, a number of different anti-adhesion agents are available. Although some agents have proved effective in reducing adhesion formation in randomised controlled trials, none of them can completely prevent adhesion formation. Conclusion To fulfil our duty to provide best possible care for our patients, it is now time to regard adhesions as the most common complication in surgery. Further research is needed to fully understand adhesion formation and to develop new strategies for adhesion prevention. Large clinical efficacy trials of anti-adhesion agents will make it easier for surgeons to decide which agent to use in daily routine.
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Affiliation(s)
- Anja Hirschelmann
- Pius-Hospital, Klinik für Frauenheilkunde und Geburtshilfe, Georgstraße 12, 26121 Oldenburg, Germany
| | - Garri Tchartchian
- Klinik für Minimal Invasive Chirurgie, Kurstraße 11, 14129 Berlin-Zehlendorf, Germany
| | - Markus Wallwiener
- Department of Obstetrics and Gynaecology, Heidelberg University Hospital, Voßstraße 9, 69115 Heidelberg, Germany
| | - Andreas Hackethal
- Giessen School of Endoscopic Surgery, Klinikstraße 32, 35392 Giessen, Germany
| | - Rudy Leon De Wilde
- Pius-Hospital, Klinik für Frauenheilkunde und Geburtshilfe, Georgstraße 12, 26121 Oldenburg, Germany
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Trew G, Pistofidis G, Pados G, Lower A, Mettler L, Wallwiener D, Korell M, Pouly JL, Coccia ME, Audebert A, Nappi C, Schmidt E, McVeigh E, Landi S, Degueldre M, Konincxk P, Rimbach S, Chapron C, Dallay D, Röemer T, McConnachie A, Ford I, Crowe A, Knight A, Dizerega G, Dewilde R. Gynaecological endoscopic evaluation of 4% icodextrin solution: a European, multicentre, double-blind, randomized study of the efficacy and safety in the reduction of de novo adhesions after laparoscopic gynaecological surgery. Hum Reprod 2011; 26:2015-27. [PMID: 21632697 DOI: 10.1093/humrep/der135] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Gynaecological laparoscopic surgery outcomes can be compromised by the formation of de novo adhesions. This randomized, double-blind study was designed to assess the efficacy and safety of 4% icodextrin solution (Adept(®)) in the reduction of de novo adhesion incidence compared to lactated Ringer's solution (LRS). METHODS Patients undergoing laparoscopic surgery for removal of myomas or endometriotic cysts were treated with randomized solution as an intra-operative irrigant and 1l post-operative instillate. De novo adhesion incidence (number of sites with adhesions), severity and extent were independently scored at a second-look procedure and the efficacy of the two solutions compared. The effect of surgical covariates on adhesion formation was also investigated. Initial exploratory analysis of individual anatomical sites of clinical importance was progressed. RESULTS Of 498 patients randomized, 330 were evaluable (160 LRS--75% myomectomy/25% endometriotic cysts; 170 Adept--79% myomectomy/21% endometriotic cysts). At study completion, 76.2% LRS and 77.6% Adept had ≥ 1 de novo adhesion. The mean (SD) number of de novo adhesions was 2.58 (2.11) for Adept and 2.58 (2.38) for LRS. The treatment effect difference was not significant (P = 0.909). Assessment of surgical covariates identified significant influences on the mean number of de novo adhesions regardless of treatment, including surgery duration (P = 0.048), blood loss in myomectomy patients (P = 0.019), length of uterine incision in myomectomy patients (P < 0.001) and number of suture knots (P < 0.001). There were 15 adverse events considered treatment-related in the LRS patients (7.2%) and 18 in the Adept group (8.3%). Of 17 reported serious adverse events (9 LRS; 8 Adept) none were considered treatment-related. CONCLUSIONS The study confirmed the safety of Adept in laparoscopic surgery. The proportion of patients with de novo adhesion formation was considerably higher than previous literature suggested. Overall there was no evidence of a clinical effect but various surgical covariates including surgery duration, blood loss, number and size of incisions, suturing and number of knots were found to influence de novo adhesion formation. The study provides direction for future research into adhesion reduction strategies in site specific surgery.
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Affiliation(s)
- G Trew
- Reproductive Medicine and Surgery, Hammersmith and Queen Charlotte's Hospital, London W12 OHS, UK.
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Hackethal A, Sick C, Szalay G, Puntambekar S, Joseph K, Langde S, Oehmke F, Tinneberg HR, Muenstedt K. Intra-abdominal adhesion formation: does surgical approach matter? Questionnaire survey of South Asian surgeons and literature review. J Obstet Gynaecol Res 2011; 37:1382-90. [PMID: 21599803 DOI: 10.1111/j.1447-0756.2011.01543.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIM The impact of postsurgical intra-abdominal adhesions, which represent a considerable burden for patients and health services, is often underestimated. Various factors influence adhesion formation, including the surgical approach. This study aimed to further understand the condition by investigating surgeons' perceptions of adhesion formation, particularly differences after laparoscopic and open surgery, and by performing a selective literature review. MATERIALS AND METHODS South Asian surgeons attending endoscopy symposia in India and in Germany completed Likert-scale-based questionnaires on awareness of adhesion formation and associated consequences in gynecology. MEDLINE and PubMed were searched for articles published in 2000-2010 comparing laparoscopy and laparotomy in relation to adhesion formation. The results of the questionnaire study were then considered in view of findings from this review. RESULTS In total, 43.1% (97/225) of questionnaires were completed. Respondents considered that laparoscopy caused fewer adhesions than laparotomy for all gynecological procedures. Although they believed their knowledge of adhesion formation was satisfactory, they widely underestimated the risk, giving estimated rates of 12.5% after laparoscopy and 36.3% after laparotomy. Twenty-eight studies were identified in the review. Most concluded that laparoscopy was less likely to cause adhesions than laparotomy but further statistical analysis was precluded because so many different definitions and classifications of adhesions had been used. CONCLUSIONS The risk of adhesion formation was widely underestimated in the study group. Both the questionnaire study and the review concluded that laparoscopy results in less adhesion than laparotomy but further statistical comparison necessitates the development of standard definitions and classifications of adhesions.
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Affiliation(s)
- Andreas Hackethal
- Department of Obstetrics and Gynaecology, Justus-Liebig-University of Giessen, Giessen, Germany.
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Pérez-Medina T, Álvarez J, Degollada M, de Santiago J, Lara A, Pascual A, Pérez Milán F, Crowe AM. Documento de consenso del Grupo de Trabajo sobre las Adherencias de la sección de endoscopia de la SEGO. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.pog.2010.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Kraemer B, Wallwiener M, Petri N, Colvin HS, Brucker S, Rothmund R, Rajab TK, Wallwiener CW. Different approaches for objective scoring of experimental post-operative adhesions in the rat model—a description. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s10397-010-0632-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Rajab TK, Ahmad UN, Kelly E. Implications of late complications from adhesions for preoperative informed consent. J R Soc Med 2010; 103:317-21. [PMID: 20610617 DOI: 10.1258/jrsm.2010.090378] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The process of informed consent is a critical aspect of the doctor-patient relationship. Doctors have a professional duty to provide patients with sufficient information if a treatment is associated with a significant risk. NHS guidelines advise doctors to mention risks that occur more frequently than 1-2% or risks that are serious even if the likelihood is very small. In the case of abdominal and pelvic surgery, risks can broadly be divided into early and late complications. Early complications, such as bleeding and infection, have a close temporal relationship with the operation. Such complications are routinely mentioned during the consent process. In contrast, postoperative adhesions cause changes in the normal anatomy that can adversely affect function many years and even decades after the original operation, leaving patients at lifelong risk for late complications. These late adhesive complications, namely bowel obstruction, mechanical female infertility and chronic pain, are often neglected during the consent process. However, the risks to patients from late adhesive complications are serious and well in excess of the accepted threshold where it could be considered a breach in the duty of care not to inform patients. This is reflected by a number of claims against the NHS based on consent issues regarding late adhesive complications of surgery. Therefore, late complications of surgery from adhesions should be included in the pre-operative consent process. This would decrease litigation costs but more importantly also underpins the doctor-patient relationship.
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Affiliation(s)
- Taufiek Konrad Rajab
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School 75 Francis Street, Boston, MA 02115, USA.
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Solomon L, Dhandapani R, Brown R. Low documentation of postoperative adhesions on consent forms for laparotomy. J Perioper Pract 2010; 20:148-150. [PMID: 20446626 DOI: 10.1177/175045891002000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
AIM To assess the documentation of postoperative adhesions as a potential complication of laparotomy on consent forms. METHOD Retrospective study of hospital notes of 102 adult patients that underwent laparotomy over a two year period. RESULTS Intraperitoneal adhesions were documented as a postoperative risk on 10 consent forms (9.8%) only. CONCLUSION The results imply that most patients were not informed of this common postoperative complication and this may have medicolegal and risk management implications.
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Imai A, Suzuki N. Topical non-barrier agents for postoperative adhesion prevention in animal models. Eur J Obstet Gynecol Reprod Biol 2010; 149:131-5. [DOI: 10.1016/j.ejogrb.2009.12.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 12/08/2009] [Accepted: 12/21/2009] [Indexed: 11/28/2022]
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Awareness and perception of intra-abdominal adhesions and related consequences: survey of gynaecologists in German hospitals. Eur J Obstet Gynecol Reprod Biol 2010; 150:180-9. [PMID: 20236750 DOI: 10.1016/j.ejogrb.2010.02.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 12/02/2009] [Accepted: 02/02/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Intra-abdominal adhesion formation after abdominal surgery is the most common postsurgical complication, and the consequences are a considerable burden for patients, surgeons and health systems. Since a wide variety of factors influence adhesion formation, it is difficult to define clear guidelines on how to reduce adhesion formation in daily practice. Given this dilemma, this study assessed the awareness and perception of adhesion formation among gynaecologists in Germany in order to define a baseline for further research and education. STUDY DESIGN The Clinical Adhesion Research and Evaluation (CARE) group of the University of Giessen designed a questionnaire that was sent to the heads of all gynaecological departments in Germany. The director or one of the surgical consultants was asked to complete the questionnaire and return it for evaluation. RESULTS The completed questionnaire was returned by 279 of 833 gynaecological departments. Interviewed surgeons expected adhesions to form in 15% of cases after laparoscopy and 40% after laparotomy. Before surgery, 83.1% of the respondents told their patients about the risk of prior adhesion formation. More than 60% believed that postsurgical adhesion accounts for major morbidity. Infections within the abdomen, previous surgery and extensive tissue trauma were thought to have the most influence on adhesion formation. Risk of adhesion formation was thought to be highest in endometriosis and adhesiolysis surgery. The respondents agreed on performing adhesiolysis in symptomatic but not in all patients. Only 38.4% used adhesion reduction agents regularly. A total of 65.1% of a repertoire of adhesion prevention agents were familiar to the interviewed surgeons. Only 22.0% of them used anti-adhesion products in clinical practice. In general, the respondents were uncertain whether these products play an important role in adhesion reduction, represented by a range of 1.97+/-0.98% on a scale from 0 to 4. CONCLUSIONS Even though postoperative adhesions are recognized as a major cause for morbidity, and it is widely agreed that infections, extensive tissue trauma and surgery lead to adhesion formation, there is uncertainty about the treatment and prophylactic strategies for dealing with adhesions. This dilemma reflects the awareness and perception of gynaecologists in Germany and is an initial point for further research.
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Imai A, Takagi H, Matsunami K, Suzuki N. Non-barrier agents for postoperative adhesion prevention: clinical and preclinical aspects. Arch Gynecol Obstet 2010; 282:269-75. [DOI: 10.1007/s00404-010-1423-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Accepted: 03/01/2010] [Indexed: 11/24/2022]
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Medico-legal consequences of post-operative intra-abdominal adhesions. Int J Surg 2009; 7:187-91. [PMID: 19389492 DOI: 10.1016/j.ijsu.2009.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 03/30/2009] [Accepted: 04/14/2009] [Indexed: 12/14/2022]
Abstract
Post-operative adhesions are an almost invariable consequence of abdominal or pelvic surgery, no matter whether this is performed by the open or laparoscopic technique. Their most important morbidity is small bowel obstruction, but other sequelae include female infertility and dyspareunia, and increased risk of visceral injury at any subsequent laparotomy or laparoscopy. Whether chronic abdominal pain is truly a consequence of adhesions is still a matter of some discussion, but it is likely to be accepted as an entity both by patients and by their legal advisors. While there is currently a scarcity of published literature on the subject, a recent assessment of adhesion-related medico-legal claims dealt with by the British medical defence associations has been undertaken. Successful medico-legal claims include cases of bowel perforation after laparoscopic division of adhesions, delays in the diagnosis of adhesion obstruction of the small bowel, infertility as a result of adhesions and 'pain'. This problem is unlikely to be unique to the UK alone and general practitioners, surgeons and gynaecologists worldwide need to be aware of the increasing burden of medico-legal claims arising from the complications of intra-abdominal adhesions. Most importantly they need to consider whether it is now timely to take steps to avoid them.
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diZerega GS, Tulandi T. Prevention of intra-abdominal adhesions in gynaecological surgery. Reprod Biomed Online 2008; 17:303-6. [PMID: 18764998 DOI: 10.1016/s1472-6483(10)60211-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Important progress has been made in the field of post-surgical adhesion prevention with the development of consensus statements in gynaecology from the United Kingdom, Germany, the European Society of Gynaecological Endoscopy, Call for Action in Colorectal Surgery and a recent Technical Bulletin from The Practice Committee of the American Society of Reproductive Medicine. These reports suggest that the application of adhesion reduction devices together with the use of microsurgical principles reduces the formation of post-operative adhesions. This commentary provides additional information to assist gynaecologists in making surgical decisions. However, variation in adhesion classifications, mode of device application, lack of uniformity in surgical approaches and variations in interpretation of results make comparative assessment of the efficacy of adhesion reduction devices and surgical techniques difficult. Considering the choice of an adhesion-reduction device, one has to evaluate the cost and its clinical impact carefully. This is particularly important if one were to support routine, prophylactic use of adhesion-reduction devices. Healthcare providers should take into account the needs of individual patients, available resources, and institutional or clinical practice limitations. Good surgical technique and perhaps the use of approved devices for adhesion reduction would give patients the best chance to benefit from reproductive and gynaecological surgery.
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Affiliation(s)
- Gere S diZerega
- Department of Obstetrics and Gynecology, Livingston Reproductive Biology Laboratory, USC Keck School of Medicine, 1321 N Mission Road, Los Angeles, CA 90033, USA.
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Post-operative abdominal adhesions—awareness of UK gynaecologists—a survey of members of the Royal College of Obstetricians and Gynaecologists. ACTA ACUST UNITED AC 2008. [DOI: 10.1007/s10397-008-0409-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert consensus position. Part 2—steps to reduce adhesions. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s10397-007-0333-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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