Contemporary adhesion prevention

Tissue adhesion after surgical interventions (Review)

Tissue adhesion after surgical procedures is a common postoperative complication that affects a significant number of patients across all surgical disciplines. In pelvic surgical procedures, second-look surgeries have revealed adhesions in more than half of all patients weeks to several months after surgery. Adhesions can be asymptomatic, but they can also cause a wide range of complications, such as severe pain, nausea, vomiting, constipation, ileus and reproductive dysfunction. Undetected adhesions that lead to problems in subsequent surgical interventions are also of high clinical importance. Lysis of these adhesions before the actual surgery leads to loss of time and possible additional complications, such as trocar injuries in laparoscopies or inadvertent enterotomies during adhesiolysis, during the originally planned intervention. The health care associated with adhesion-related problems are significant. Because of the widely varying manifestations of symptoms, the already concerning figure of patients with significant adhesions is likely to increase. Outpatient healthcare expenditures are further increased because of undetected adhesions. Adhesions therefore represent a major surgical and health economic problem; however, yet there are currently few options for prophylaxis and treatment.

Robot-assisted radical cystectomy for bladder cancer after low anterior resection: A case report

Radical cystectomy after low anterior resection is rare, and no cases of robotic surgery have been reported. Cystectomy in patients who have undergone a previous pelvic surgery, whether open or endoscopic, requires caution to avoid damaging other organs due to anatomical changes caused by adhesions in a limited space. Additionally, the curative nature of the treatment must be maintained. We describe a 69-year-old man with a history of open low anterior resection for rectal cancer who underwent robot-assisted radical cystectomy with extracorporeal ileal conduit construction. Although this procedure is challenging, it was performed safely with the collaboration of colorectal surgeons. The patient was discharged without perioperative complications and remained recurrence-free for 5 years.

Isthmocele and Infertility

Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman's quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5-3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted.

Optimizing Traumatic Limb Salvage: Ectopic Implantation and Staged Rotationplasty

Rotationplasty, a limb-saving procedure involving a 180-degree ankle rotation to function as a knee joint, is now standard for treating distal femur osteosarcoma. However, challenges related to self-identification persist within the Asian population. This study presents a case involving the successful application of temporary ectopic implantation followed by staged rotationplasty after a severe traumatic amputation, resulting in a favorable outcome. Additionally, a systematic review is conducted to summarize the various difficulties and complications encountered in different studies. This approach improves the feasibility of rotationplasty in traumatic cases and enhances patient and family comprehension.

Risk factors for small-bowel obstruction after colectomy for colorectal cancer: a retrospective study

PURPOSE

Postoperative adhesions are a concerning complication of abdominal surgery with major implications on quality of life. This study aimed to investigate the risk factors for postoperative small-bowel obstruction (SBO) after colectomy for colorectal cancer.

METHODS

We reviewed the clinicopathological variables of 1646 patients who underwent colectomy for colorectal cancer between 2009 and 2018.

RESULTS

SBO occurred following primary tumor resection for colorectal cancer in 67 (4.1%) of the 1646 patients. The median observation period was 7.5 (range: 3.0-12.0) years. Multivariate analysis revealed that rectal tumors, anastomotic leakages, previous abdominal surgeries, and longer operating times were all correlated with postoperative SBO, but there were no differences in the incidence of SBO between laparoscopic vs. open surgery. The use of adhesion prevention material had no effect on SBO. Our data showed that the onset of SBO tended to be relatively early, within a year after surgery (89.5%).

CONCLUSIONS

Tumor localization in the rectum is associated with several problems, including a wide resection area, prolonged operative duration, and high risk of anastomotic leakage, which may increase the risk of SBO. Laparoscopic surgery and adhesion prevention material did not demonstrate a clear preventive effect against SBO.

Light-Activated Chemically Reactive Fibrous Patch Revolutionizes Wound Repair Through the Prevention of Postoperative Adhesion

A light-activated chemically reactive fibrous patch (ChemPatch) with tissue adhesion and wound healing activity was developed for preventing postoperative peritoneal adhesion. ChemPatch was constructed by an integrative electrospinning fabrication strategy, generating multifunctional PCL-NHS fibers encapsulating antioxidant curcumin and MnO₂ nanoparticles. ChemPatch exhibited excellent photothermal conversion, which not only reformed the physical state to match the tissue but also improved conjugation between ChemPatch and tissues, allowing for strong attachment. Importantly, ChemPatch possessed good antioxidant and radical scavenging activity, which protected cells in an oxidative microenvironment and improved tissue regeneration. Particularly, ChemPatch acted as a multifunctional barrier and could not only promote reepithelialization and revascularization in wound defect model but simultaneously ameliorate inflammation and prevent postoperative peritoneal adhesion in a mouse cecal defect model. Thus, ChemPatch represents a dual-active bioadhesive barrier for reducing the incidence and severity of peritoneal adhesions.

Increasing incidence and severity of post-hepatectomy adhesion around the liver may be influenced by the hepatectomy-related operative procedures

BACKGROUND

The incidence of postoperative adhesions is directly correlated with the difficulty level of repeat hepatectomies. However, the incidence, location, and severity of postoperative adhesions in relation to hepatectomy-related operative procedures are yet unclear.

METHODS

First hepatectomy-induced hard dense adhesions were evaluated from the surgical records and/or videos of 168 patients who underwent second hepatectomies.

RESULTS

The incidence of postoperative hard dense adhesions around the liver was significantly associated with locations, such as the hepatic cut surface, dissected areas around the liver, and peri-incision peritoneum, and hepatectomy-related operative procedures, such as Pringle maneuver and cholecystectomy. The incidence of hard dense adhesions after dissection was higher around the right liver than in the left infraphrenic space. Further, the incidence of hard dense adhesions around the hepatoduodenal ligament or Morison pouch was greater than 30% even in patients who did not undergo Pringle maneuver, cholecystectomy, or hepatorenal ligament dissection. Although the incidence of hard dense adhesions of the peritoneum around the incision was higher after open hepatectomy than after laparoscopic hepatectomy, adhesion barrier use reduced the incidence of such adhesions in patients after open hepatectomy.

CONCLUSION

Hepatectomy-related operative procedures such as peri-hepatic dissection, Pringle maneuver and cholecystectomy are directly associated with postoperative hard dense adhesions. However, the incidence of postoperative hard dense adhesions around the hepatoduodenal ligament and Morison pouch was high even when the above-mentioned operative procedures were not performed. These findings may help inform clinical decisions regarding the indications and sites for adhesion barrier use during hepatectomies.

Nomogram of intra-abdominal infection after surgery in patients with gastric cancer: A retrospective study

Background

Surgical resection is still the primary way to treat gastric cancer. Therefore, postoperative complications such as IAI (intra-abdominal infection) are major problems that front-line clinical workers should pay special attention to. This article was to build and validate IAI’s RF (regression function) model. Furthermore, it analyzed the prognosis in patients with IAI after surgery for stomach cancer. The above two points are our advantages, which were not involved in previous studies.

Methods

The data of this study was divided into two parts, the training data set and the validation data set. The training data for this article were from the patients treated surgically with gastric cancer in our center from December 2015 to February 2017. We examined IAI’s morbidity, etiological characteristics, and prognosis in the training data set. Univariate and multivariate logistic regression analyses were used to screen risk factors, establish an RF model and create a nomogram. Data from January to March 2021 were used to validate the accuracy of the RF model.

Results

The incidence of IAI was 7.2%. The independent risk factors for IAI were hypertension (Odds Ratio [OR] = 3.408, P = 0.001), history of abdominal surgery (OR = 2.609, P = 0.041), combined organ excision (OR = 4.123, P = 0.010), and operation time ≥240 min (OR = 3.091, P = 0.005). In the training data set and validation data set, the area under the ROC curve of IAI predicted by the RF model was 0.745 ± 0.048 (P<0.001) and 0.736 ± 0.069 (P=0.003), respectively. In addition, IAI significantly extended the length of hospital stay but had little impact on survival.

Conclusions

Patients with hypertension, combined organ excision, a history of abdominal surgery, and a surgical duration of 240 min or more are prone to IAI, and the RF model may help to identify them.

Cell-Biomaterial Constructs for Wound Healing and Skin Regeneration

Over the years, conventional skin grafts, such as full-thickness, split-thickness, and pre-sterilized grafts from human or animal sources, have been at the forefront of skin wound care. However, these conventional grafts are associated with major challenges, including supply shortage, rejection by the immune system, and disease transmission following transplantation. Due to recent progress in nanotechnology and material sciences, advanced artificial skin grafts-based on the fundamental concepts of tissue engineering-are quickly evolving for wound healing and regeneration applications, mainly because they can be uniquely tailored to meet the requirements of specific injuries. Despite tremendous progress in tissue engineering, many challenges and uncertainties still face skin grafts in vivo, such as how to effectively coordinate the interaction between engineered biomaterials and the immune system to prevent graft rejection. Furthermore, in-depth studies on skin regeneration at the molecular level are lacking; as a consequence, the development of novel biomaterial-based systems that interact with the skin at the core level has also been slow. This review will discuss 1) the biological aspects of wound healing and skin regeneration, 2) important characteristics and functions of biomaterials for skin regeneration applications, and 3) synthesis and applications of common biomaterials for skin regeneration. Finally, the current challenges and future directions of biomaterial-based skin regeneration will be addressed.

Prevention of Post-Operative Adhesions: A Comprehensive Review of Present and Emerging Strategies

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.

Diagnosis and management of small bowel obstruction in virgin abdomen: a WSES position paper

Background

Small bowel obstruction (SBO) is a common surgical emergency, causing high morbidity and healthcare costs. The majority of SBOs are caused by adhesions that result from previous surgeries. Bowel obstruction, however, also occurs in patients without previous operation or known pathology, a so called virgin abdomen. It is unknown if small bowel obstruction in the virgin abdomen (SBO-VA) can be managed according to the same principles as other cases of small bowel obstruction. The aim of this position paper is to evaluate the available evidence on etiology and management of small bowel obstruction in the virgin abdomen.

Methods

This is a narrative review with scoping aspects. Clinical topics covered in this review include epidemiology and etiology of SBO-VA, diagnosis and imaging, initial assessment, the role of surgical management in SBO-VA, and the role of non-operative management in SBO-VA.

Results

Our scoping search revealed seven original studies reporting original patient data related to SBO-VA. All the included studies are retrospective cohorts, with populations ranging between 44 and 103 patients with SBO-VA. Adhesions were found to be the cause of the obstruction in approximately half of the reported cases of SBO-VA. A relatively high number of cases of SBO-VA were managed surgically with studies reporting 39–83%. However, in cases where a trial of non-operative management was started, this was generally successful.

Conclusion

The data available suggest that etiology and treatment results for patients with SBO-VA are largely comparable to the results in patients with SBO after previous abdominal surgery. We therefore propose that patients with a virgin abdomen could be treated according to existing guidelines for SBO and adhesive small bowel obstruction.

Conversions related to adhesions in abdominal surgery. Robotic versus laparoscopic approach: A multicentre experience

BACKGROUND

An advantage of robotic surgery over laparoscopy is the lower rate of unplanned conversion. One of the implicated reasons for conversion is adhesions from previous abdominal surgeries (PASs).

METHODS

A comparative analysis of 98 patients with history of open PAS treated by laparoscopic or robotic surgery was performed. Primary endpoint was the rate of conversion to open surgery related to adhesiolysis. Secondary endpoints were short-term outcomes and complications.

RESULTS

Conversion rate specifically related to adhesiolysis was significantly lower in robotic group (13 for laparoscopic group vs. 2 for robotic group; p = 0.046). Conversions occurred during adhesiolysis were significantly related to severity of adhesions expressed by peritoneal adhesion index (PAI) score (p < 0.001), number of abdominal areas involved by adhesions (p < 0.001) and severity of PAI into the target area of surgical intervention (p = 0.021).

CONCLUSIONS

Benefits of robotic surgery are more noticeable in performing procedures with increasing technical difficulties.

[Existing and forward-looking ways to prevent adhesions in IPOM hernia repair. A research overview]

IPOM intraperitoneal hernia repair, in comparison with other abdominal wall reconstruction methods, has a number of significant advantages. Among them are a reduction in operative time, low rate of surgical site infections, quick rehabilitation, and good cosmetic results. At the same time, one of the main constraining factors for its widespread use is the rather high frequency of adhesion formation between the implant and the abdominal organs. The first way to solve this serious problem is to improve the structure of the implant itself, and in the first place, its anti-adhesive layer. The second is the search for adjuvant tools that work in «problematic» areas, prone to adhesions formation, such as the points of implant fixation, its edges, or the areas of damage to antiadhesive layer due to a violation of the operative technique. It is desirable that they could exert their effect also in other parts of the abdominal cavity, which, despite the absence of a zone of «active» intervention, can also undergo adhesions. Based on this, the purpose of this review was to summarize modern data on the anti-adhesive activity of both composite implants and specialized membranes and liquid agents.

Polysaccharide-based films for the prevention of unwanted postoperative adhesions at biological interfaces

Postoperative adhesions protect, repair, and supply nutrients to injured tissues; however, such adhesions often remain permanent and complicate otherwise successful surgeries by tethering tissues together that are normally separated. An ideal adhesion barrier should not only effectively prevent unwanted adhesions but should be easy to use, however, those that are currently available have inconsistent efficacy and are difficult to handle or to apply. A robust hydrogel film composed of alginate and a photo-crosslinkable hyaluronic acid (HA) derivative (glycidyl methacrylate functionalized hyaluronic acid (GMHA)) represents a solution to this problem. A sacrificial porogen (urea) was used in the film manufacture process to impart macropores that yield films that are more malleable and tougher than equivalent films produced without the sacrificial porogen. The robust mechanical behavior of these templated alginate/GMHA films directly facilitated handling characteristics of the barrier film. In a rat peritoneal abrasion model for adhesion formation, the polysaccharide films successfully prevented adhesions with statistical equivalence to the leading anti-adhesion technology on the market, Seprafilm®. STATEMENT OF SIGNIFICANCE: Postoperative adhesions often remain permanent and complicate otherwise successful surgeries by tethering tissues together that are normally separated and pose potentially significant challenges to patients. Therefore, the generation of adhesion barriers that are easy to deploy during surgery and effectively prevent unwanted adhesions is a big challenge. In this study robust hydrogel films composed of alginate and a photo-crosslinkable hyaluronic acid (HA) derivative (glycidyl methacrylate functionalized HA, GMHA) were fabricated and investigated for their potential to act as a solution to this problem using a rat peritoneal abrasion model for adhesion formation. We observed the polysaccharide films successfully prevented adhesions with statistical equivalence to the leading anti-adhesion technology on the market, Seprafilm®, suggesting that such films represent a promising strategy for the prevention of postoperative adhesions.

Outcomes of adhesion barriers in gynecologic surgeries: A retrospective study at a medical center

During second-look surgery or hospitalization, intra-abdominal surgeries may cause severe postoperative complications, such as pelvic adhesion, postoperative ileus, and severe pain. However, only few studies have analyzed the outcomes of antiadhesive barriers in second-look surgery. This retrospective study aims to identify the outcomes of different antiadhesive barriers by analyzing surgical images. The study included patients who received an adhesion barrier during second-look surgery between January 2011 and November 2017. Four brands of adhesive barriers were used: Interceed, Seprafilm, Adept, and SurgiWrap. Adhesion scores were calculated for four quadrants of the uterus and surrounding structures before and after the use of antiadhesive barriers. The differences between the data of 2 observers and surgery times were also determined. A total of 18 patients were enrolled in the study. The adhesion scores were not significantly different before and after the placement of antiadhesive barriers. The difference in the adhesion scores between the two observers was also not significant, except in the Seprafilm group (P = .029). Furthermore, no significant change in the adhesion scores was observed between the first and second surgeries. Therefore, using adhesion barriers may not decrease the adhesion scores in the current setting.

Ibuprofen-Loaded Hyaluronic Acid Nanofibrous Membranes for Prevention of Postoperative Tendon Adhesion through Reduction of Inflammation

A desirable multi-functional nanofibrous membrane (NFM) for prevention of postoperative tendon adhesion should be endowed with abilities to prevent fibroblast attachment and penetration and exert anti-inflammation effects. To meet this need, hyaluronic acid (HA)/ibuprofen (IBU) (HAI) NFMs were prepared by electrospinning, followed by dual ionic crosslinking with FeCl3 (HAIF NFMs) and covalent crosslinking with 1,4-butanediol diglycidyl ether (BDDE) to produce HAIFB NFMs. It is expected that the multi-functional NFMs will act as a physical barrier to prevent fibroblast penetration, HA will reduce fibroblast attachment and impart a lubrication effect for tendon gliding, while IBU will function as an anti-inflammation drug. For this purpose, we successfully fabricated HAIFB NFMs containing 20% (HAI20FB), 30% (HAI30FB), and 40% (HAI40FB) IBU and characterized their physico-chemical properties by scanning electron microscopy, Fourier transformed infrared spectroscopy, thermal gravimetric analysis, and mechanical testing. In vitro cell culture studies revealed that all NFMs except HAI40FB possessed excellent effects in preventing fibroblast attachment and penetration while preserving high biocompatibility without influencing cell proliferation. Although showing significant improvement in mechanical properties over other NFMs, the HAI40FB NFM exhibited cytotoxicity towards fibroblasts due to the higher percentage and concentration of IBU released form the membrane. In vivo studies in a rabbit flexor tendon rupture model demonstrated the efficacy of IBU-loaded NFMs (HAI30FB) over Seprafilm® and NFMs without IBU (HAFB) in reducing local inflammation and preventing tendon adhesion based on gross observation, histological analyses, and biomechanical functional assays. We concluded that an HAI30FB NFM will act as a multi-functional barrier membrane to prevent peritendinous adhesion after tendon surgery.

Pharmacokinetic Profile and Anti-Adhesive Effect of Oxaliplatin-PLGA Microparticle-Loaded Hydrogels in Rats for Colorectal Cancer Treatment

Colorectal cancer (CRC) is one of the most malignant and fatal cancers worldwide. Although cytoreductive surgery combined with chemotherapy is considered a promising therapy, peritoneal adhesion causes further complications after surgery. In this study, oxaliplatin-loaded Poly-(d,l-lactide-co-glycolide) (PLGA) microparticles were prepared using a double emulsion method and loaded into hyaluronic acid (HA)- and carboxymethyl cellulose sodium (CMCNa)-based cross-linked (HC) hydrogels. From characterization and evaluation study PLGA microparticles showed smaller particle size with higher entrapment efficiency, approximately 1100.4 ± 257.7 nm and 77.9 ± 2.8%, respectively. In addition, microparticle-loaded hydrogels showed more sustained drug release compared to the unloaded microparticles. Moreover, in an in vivo pharmacokinetic study after intraperitoneal administration in rats, a significant improvement in the bioavailability and the mean residence time of the microparticle-loaded hydrogels was observed. In HC21 hydrogels, AUC0-48h, Cmax, and Tmax were 16012.12 ± 188.75 ng·h/mL, 528.75 ± 144.50 ng/mL, and 1.5 h, respectively. Furthermore, experimental observation revealed that the hydrogel samples effectively protected injured tissues from peritoneal adhesion. Therefore, the results of the current pharmacokinetic study together with our previous report of the in vivo anti-adhesion efficacy of HC hydrogels demonstrated that the PLGA microparticle-loaded hydrogels offer novel therapeutic strategy for CRC treatment.

Crystalloid fluid suspension results in decreased adhesion burden when compared to bioresorbable membranes in a rat model

INTRODUCTION

Adhesion formation represents a major cause of long-term morbidity. Suspension of intra-abdominal contents in fluid medium may effectively prevent adhesion formation. We compare saline hydro-flotation (NS) to hyaluronate bioresorbable membranes (HBM) for adhesion prevention following surgery.

METHODS

Animals were randomized to four groups: sham (no injury, n = 5), control (injury without intervention, n = 5), HBM (n = 20) or 10 cc NS (n = 21). Interventions were administered after standardized surgical trauma to the cecum and abdominal wall. Necropsies at two weeks were completed to compare adhesion burden using a customary scoring algorithm.

RESULTS

Significant adhesion burden was noted in all rats. HBM sustained a more significant adhesion burden with higher total adhesion scores (HBM = 10 vs NS = 8.1/15, p = 0.02). Gross adhesion scores were lower with NS (5.6/9) compared to HBM (7.1/9, p = 0.01). Neo-vascularity was more common in HBM at 2.6/3 versus 1.9/3 with NS (p = 0.01). Percent of the cecum encased with adhesion was higher with HBM (42%) compared to NS (31%, p = 0.05).

DISCUSSION

Fluid based anti-adhesion methods should be considered for abdominal adhesion formation prevention.

A new bioabsorbable polymer film to prevent peritoneal adhesions validated in a post-surgical animal model

Background

Peritoneal adhesions are a serious surgical postoperative complication. The aim of this study is to investigate, in a rat model, the anti-adhesive effects of a bioabsorbable film of polymer combining polyethylene glycol and polylactic acid.

Materials and methods

Sixty-three animals were randomized into five groups according to the anti-adhesion treatment: Hyalobarrier^®, Seprafilm^®, Polymer A (PA), Polymer B (PB), and control. The rats were euthanized on days 5 and 12 to evaluate the extent, severity and degree of adhesions and histopathological changes. Three animals were euthanized at day 2 in PA, PB and control groups to observe the in vivo elimination.

Results

Macroscopic adhesion formation was significantly lower in the PA group than in the control group at day 5 (median adhesion score 0±0 vs 9.6 ±0.5 p = 0.002) and at day 12 (0±0 vs 7.3±4 p = 0.02). Furthermore, median adhesion score at day 5 was significantly lower in the PA group than in the Seprafilm group (0±0 vs 4.2± 3.9 p = 0.03). Residence time of PA seems longer than PB.

Conclusion

The PA bioabsorbable film seems efficient in preventing the formation of peritoneal adhesions.

Role of Ovarian Suspension in Preventing Postsurgical Ovarian Adhesions in Patients with Stage III-IV Pelvic Endometriosis: A Systematic Review

Endometriosis is a benign complex gynecologic condition with high morbidity that affects women of reproductive age. Pelvic adhesion formation represents a serious clinical challenge in the management of patients with endometriosis. Several interventions aimed at reducing postoperative ovarian adhesion formation have been proposed in recent years. Here we summarize the published evidence on the efficacy of ovarian suspension in preventing postoperative ovarian adhesion formation in women undergoing laparoscopic surgery for stage III-IV endometriosis. The research was conducted using electronic databases. A review of the abstracts of all references retrieved from the search was conducted. Selection criteria for the systematic review included all randomized controlled trials (RCTs) and nonrandomized studies (NRSs) of premenopausal women diagnosed with stage III-IV pelvic endometriosis who underwent ovarian suspension or no ovarian suspension (control group). The RCTs were eligible for meta-analysis. Eight studies, 2 RCTs and 6 NRSs, were included in the systematic review. In all 8 studies, ovarian suspension was performed during surgery for stage III-IV endometriosis. The site of the suspension was the anterior abdominal wall in 76.8% of the cases. Five studies reported the use of polypropylene as suture for the suspension. Removal of the suspension suture in the postoperative period was reported in 6 studies. Pooled data from a meta-analysis of the RCTs show that women who underwent ovarian suspension had a significantly lower incidence of postoperative adhesion formation, particularly of moderate to severe adhesions. Ovarian suspension may reduce the rate and severity of postoperative adhesions formation in women undergoing laparoscopy for the treatment of stage III-IV endometriosis; however, RCTs with larger sample sizes are needed.

The effect of mesenchymal stem cell use on intra-abdominal adhesions in a rat model

Purpose

Intra-abdominal adhesions (IAA) are among the most frequently seen pathologies in general surgery practice with an increased morbidity and mortality. In the present study, we investigated the effect of locally applied mesenchymal stem cells (MSCs) on IAA.

Methods

Twenty-four Wistar Albino rats were used in the study. The rats were divided into three groups including: Sham, control, and MSCs group. On day 0, cecum was reached under anesthesia in all groups, except the Sham group. Scraping with a sponge was performed until petechial bleeding occurred. The control group received no treatment. In the stem cell group, MSCs were applied topically immediately after surgery on adhesions. The rats were sacrificed on day 10 and colon tissues and blood samples were collected for macroscopic, histopathological, and biochemical analysis.

Results

In our study, E-selectin, P-selectin, TNF-α and IL-1 levels were statistically significantly lower in the MSC group than the control group, while the sham group has the lowest levels. In both the macroscopic and histopathological analyses (Zühlke's scale), the least amount of adhesion was observed in the Sham group. In addition, although there was less adhesion in the MSC group than the control group, the difference did not reach statistical significance.

Conclusion

Topical MSC application immediately after surgery suppresses the inflammatory process. However it was found to be ineffective in histopathological and macroscopic examinations performed on the 10th day.

Stem Cells for Mesothelial Repair: An Understudied Modality

Adhesions are bands of fibrous tissue that form between opposing organs and the peritoneum, restricting vital intrapleural and abdominal movement. They remain a major problem in abdominal surgery, occurring in more than three fourths of patients following laparotomy. Adhesions result when injury to the mesothelium is not repaired by mesothelial cells and can be viewed as scar tissue formation. The mechanism of mesothelial healing suggested the involvement of stem cells in the process. It has long been known that peritoneal wounds heal in the same amount of time regardless of size. Therefore, the mesothelium could not regenerate solely by proliferation and centripetal migration of cells at the wound edge as occurs in the healing of skin epithelium. Several studies suggest the presence of i) mesothelial stem cells that can differentiate into mesothelial cells and a few other phenotypes and/or ii) that mesothelial cells are themselves stem cells. Other studies have suggested that adult stem cells in the muscle underlying the peritoneum can differentiate into mesothelial cells and contribute to healing. Prevention of abdominal adhesions have been accomplished by delivery of autologous mesothelial cells and multipotent adult stem cells isolated from skeletal muscle. Adult stem cells from sources other than the serosal tissue offer an alternative treatment modality to prevent the formation of abdominal adhesions.

Anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility

BACKGROUND

Observational evidence suggests a potential benefit with several anti-adhesion therapies in women undergoing operative hysteroscopy (e.g. insertion of an intrauterine device or balloon, hormonal treatment, barrier gels or human amniotic membrane grafting) for decreasing intrauterine adhesions (IUAs).

OBJECTIVES

To assess the effectiveness of anti-adhesion therapies versus placebo, no treatment or any other anti-adhesion therapy, following operative hysteroscopy for treatment of female subfertility.

SEARCH METHODS

We searched the following databases from inception to June 2017: the Cochrane Gynaecology and Fertility Group Specialised Register; the Cochrane Central Register of Studies (CRSO); MEDLINE; Embase; CINAHL and other electronic sources of trials, including trial registers, sources of unpublished literature and reference lists. We handsearched the Journal of Minimally Invasive Gynecology, and we contacted experts in the field. We also searched reference lists of appropriate papers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of anti-adhesion therapies versus placebo, no treatment or any other anti-adhesion therapy following operative hysteroscopy in subfertile women. The primary outcome was live birth. Secondary outcomes were clinical pregnancy, miscarriage and IUAs present at second-look hysteroscopy, along with mean adhesion scores and severity of IUAs.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, extracted data and evaluated quality of evidence using the GRADE method.

MAIN RESULTS

The overall quality of the evidence was low to very low. The main limitations were serious risk of bias related to blinding of participants and personnel, indirectness and imprecision. We identified 16 RCTs comparing a device versus no treatment (two studies; 90 women), hormonal treatment versus no treatment or placebo (two studies; 136 women), device combined with hormonal treatment versus no treatment (one study; 20 women), barrier gel versus no treatment (five studies; 464 women), device with graft versus device without graft (three studies; 190 women), one type of device versus another device (one study; 201 women), gel combined with hormonal treatment and antibiotics versus hormonal treatment with antibiotics (one study; 52 women) and device combined with gel versus device (one study; 120 women). The total number of participants was 1273, but data on 1133 women were available for analysis. Only two of 16 studies included 100% infertile women; in all other studies, the proportion was variable or unknown.No study reported live birth, but some (five studies) reported outcomes that were used as surrogate outcomes for live birth (term delivery or ongoing pregnancy). Anti-adhesion therapy versus placebo or no treatment following operative hysteroscopy.There was insufficient evidence to determine whether there was a difference between the use of a device or hormonal treatment compared to no treatment or placebo with respect to term delivery or ongoing pregnancy rates (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.42 to 2.12; 107 women; 2 studies; I² = 0%; very-low-quality evidence).There were fewer IUAs at second-look hysteroscopy using a device with or without hormonal treatment or hormonal treatment or barrier gels compared with no treatment or placebo (OR 0.35, 95% CI 0.21 to 0.60; 560 women; 8 studies; I² = 0%; low-quality evidence). The number needed to treat for an additional beneficial outcome (NNTB) was 9 (95% CI 5 to 17). Comparisons of different anti-adhesion therapies following operative hysteroscopyIt was unclear whether there was a difference between the use of a device combined with graft versus device only for the outcome of ongoing pregnancy (OR 1.48, 95% CI 0.57 to 3.83; 180 women; 3 studies; I² = 0%; low-quality evidence). There were fewer IUAs at second-look hysteroscopy using a device with or without graft/gel or gel combined with hormonal treatment and antibiotics compared with using a device only or hormonal treatment combined with antibiotics, but the findings of this meta-analysis were affected by evidence quality (OR 0.55, 95% CI 0.36 to 0.83; 451 women; 5 studies; I² = 0%; low-quality evidence).

AUTHORS' CONCLUSIONS

Implications for clinical practiceThe quality of the evidence ranged from very low to low. The effectiveness of anti-adhesion treatment for improving key reproductive outcomes or for decreasing IUAs following operative hysteroscopy in subfertile women remains uncertain. Implications for researchMore research is needed to assess the comparative safety and (cost-)effectiveness of different anti-adhesion treatments compared to no treatment or other interventions for improving key reproductive outcomes in subfertile women.

Use of methylene blue in the prevention of recurrent intra-abdominal postoperative adhesions

Objective

To evaluate the efficacy of methylene blue in preventing recurrent symptomatic postoperative adhesions.

Methods

Patients with a history of >2 surgeries for intra-abdominal adhesion-related complications were selected for this study. Adhesiolysis surgery was subsequently performed using administration of 1% methylene blue. The follow-up period was 28.5 ± 11.1 months.

Results

Data were available from 20 patients (seven men and 13 women) whose mean ± SD age was 51.2 ± 11.4 years. Adhesions took longer to become symptomatic after the first abdominal surgery when the initial pathology was malignant compared with benign. However, the recurrence of adhesions after a previous adhesiolysis surgery had a similar time onset regardless of the initial disease. Following adhesiolysis surgery with methylene blue, the majority of patients did not present with symptoms associated with adhesion complications (i.e., chronic abdominal pain, bowel obstruction) for the length of the follow-up period.

Conclusions

The use of methylene blue during adhesiolysis surgery appears to reduce the recurrence of adhesion-related symptoms, suggesting a beneficial effect in the prevention of adhesion formation.

Biodegradable and injectable thermoreversible xyloglucan based hydrogel for prevention of postoperative adhesion

Peritoneal adhesion is very common after abdominal and pelvic surgery, which leads to a variety of severe complications. Although numerous pharmacological treatments and barrier-based devices have been investigated to minimize or prevent postoperative adhesion, the clinical efficacy is not very encouraging. In this work, a biodegradable and thermoreversible galactose modified xyloglucan (mXG) hydrogel was developed and the efficacy of mXG hydrogel in preventing postoperative peritoneal adhesion was investigated. The 4% (w/v) mXG solution was a free flowing sol at low temperature, but could rapidly convert into a physical hydrogel at body temperature without any extra additives or chemical reactions. In vitro cell tests showed that mXG hydrogel was non-toxic and could effectively resist the adhesion of fibroblasts. Moreover, in vitro and in vivo degradation experiments exhibited that mXG hydrogel was degradable and biocompatible. Finally, the rat model of sidewall defect-cecum abrasion was employed to evaluate the anti-adhesion efficacy of the mXG hydrogel. The results demonstrated that mXG hydrogel could effectively prevent postoperative peritoneal adhesion without side effects. The combination of suitable gel temperature, appropriate biodegradation period, and excellent postoperative anti-adhesion efficacy make mXG hydrogel a promising candidate for the prevention of postsurgical peritoneal adhesion.

STATEMENT OF SIGNIFICANCE

Despite numerous drugs or barrier-based devices have been developed to prevent postoperative adhesion, few solutions have proven to be uniformly effective in subsequent clinical trials. In the present study, we developed a biodegradable and thermoreversible galactose modified xyloglucan (mXG) hydrogel by green enzymatic reaction without using any organic reagents. The developed physical mXG hydrogel not only showed excellent injectability, appropriate gelation time and temperature, but also exhibited excellent biocompatibility and biodegradability both in vitro and in vivo. In addition, mXG hydrogel was easy to handle and could effectively prevent postoperative adhesion without side effects in a rat model of sidewall defect-bowel abrasion. Our study provide a safe and effective postoperative anti-adhesion material which may have potential applications in clinical practice.

Extensive Adhesions in Living Donor Liver Transplantation: A Retrospective Analysis

BACKGROUND

Adhesions are abnormal fibrous bands of scar tissue between internal organs and tissues. With respect to recipient hepatectomy in living donor liver transplantation (LDLT), we defined extensive adhesions as adhesions in at least two separate locations that required more than 5 % of the total surgical time to lyse. We aimed to identify the etiology and consequences of this preventable burden.

METHODS

A simple retrospective case-control study of all cases with extensive adhesions from August 2011 to September 2014 matched by age, sex, and diagnosis at surgery.

RESULTS

A total of 380 cases were studied. Thirty-eight and five patients had extensive adhesions from surgical and non-surgical causes, respectively. The incidence and complications in pediatric patients were far less than in adults. In the adult group, the mean operative time was increased by 75 min (12.3 %) and blood loss by 2.5 L.The incidence of bowel perforation and biliary infections were increased in adults, while there was no significant difference in the rate of ascitic or wound infections. The 1-year survival was slightly less (92 %) than the control group (100 %).

CONCLUSIONS

The most common cause of extensive adhesions at LDLT was prior liver resection. Extensive adhesions caused increased morbidity by increased blood loss, transfusion requirements, and increased cold ischemia time. There is also a higher risk of bowel perforation during enterolysis. The use of commercially available barrier techniques is advisable in adults at high risk of developing adhesions with a possibility of liver transplantation, such as liver resection for HCC.

Dual crosslinked hyaluronic acid nanofibrous membranes for prolonged prevention of post-surgical peritoneal adhesion

A HA NFM crosslinked with FeCl₃and BDDE shows prolonged degradation to prevent peritoneal adhesion.

Evaluation of the Effectiveness of Peritoneal Adhesion Prevention Devices in a Rat Model

BACKGROUND

Abdominal operations are followed by adhesions, a prevalent cause of abdominal pain, and the most frequent cause for bowel obstruction and secondary female infertility. This rat study addresses adhesion prevention capability of Adept(®), Interceed(®), Seprafilm(®), and a novel device, 4DryField(®) PH which is provided as powder and generates its effect as gel.

METHODS

Sixty-eight male Lewis rats had cecal abrasion and creation of an equally sized abdominal wall defect, and were grouped randomly: A control group without treatment (n=10); two groups treated with 4DryField(®) PH using premixed gel (n=15) or in-situ gel technique (n=16); one group each was treated with Seprafilm(®) (n=8), Interceed(®) (n=9), or Adept(®) (n=10). Sacrifice was on day 7 to evaluate incidence, quality, and quantity of adhesions, as expressed via adhesion reduction rate (AR). Histologic specimens were evaluated. Statistical analyses used ANOVA and unpaired t-tests.

RESULTS

4DryField(®) PH significantly reduced incidence and severity of adhesions both as premixed gel (AR: 85.2%) and as in-situ made gel (AR: 100%), a comparison between these two application techniques showed no differences in efficacy. Seprafilm(®) did not reduce incidence but severity of adhesions significantly (AR: 53.5%). With Interceed(®) (AR: 3.7%) and Adept(®) (AR: 16.1%) no significant adhesion-reduction was achieved. Except for inflammatory response with Interceed(®), histopathology showed good tissue compatibility of all other devices.

CONCLUSION

4DryField(®) PH and Seprafilm(®) showed significant adhesion prevention capabilities. 4DryField(®) PH achieved the highest adhesion prevention effectiveness without restrictions concerning mode of application and compatibility and, thus, is a promising strategy to prevent abdominal adhesions.

Anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility

BACKGROUND

Limited observational evidence suggests potential benefit for subfertile women undergoing operative hysteroscopy with several anti-adhesion therapies (e.g. insertion of an intrauterine device (IUD) or balloon, hormonal treatment, barrier gels or human amniotic membrane grafting) to decrease intrauterine adhesions (IUAs).

OBJECTIVES

To assess the effectiveness of anti-adhesion therapies versus placebo, no treatment or any other anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility.

SEARCH METHODS

We searched the following databases from inception to March 2015: the Cochrane Menstrual Disorders and Subfertility Specialised Register, the Cochrane Central Register of Controlled Trials (2015, Issue 2), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and other electronic sources of trials, including trial registers, sources of unpublished literature and reference lists. We handsearched The Journal of Minimally Invasive Gynecology, and we contacted experts in the field.

SELECTION CRITERIA

Randomised comparisons of anti-adhesion therapies versus placebo, no treatment or any other anti-adhesion therapy following operative hysteroscopy in subfertile women. The primary outcome was live birth or ongoing pregnancy. Secondary outcomes were clinical pregnancy, miscarriage and IUAs present at second look, along with their mean adhesion scores or severity.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, extracted data and evaluated quality of the evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) method.

MAIN RESULTS

We included 11 randomised studies on use of an inserted device versus no treatment (two studies; 84 women) or another inserted device (one study; 162 women), hormonal treatment versus no treatment or placebo (two studies; 131 women), gel versus no treatment (five studies; 383 women) and graft versus no graft (one study; 43 women). The total number of women randomly assigned was 924, but data on only 803 participants were available for analysis. The proportion of subfertile women varied from 0% (one study; 41 women), to less than 50% (six studies; 487 women), to 100% (one study; 43 women); the proportion was unknown in three studies (232 women). Most studies (9/11) were at high risk of bias with respect to one or more methodological criteria.We found no evidence of differences between anti-adhesion therapy and no treatment or placebo with respect to live birth rates (odds ratio (OR) 0.99, 95% confidence interval (CI) 0.46 to 2.13, P value = 0.98, three studies, 150 women; low-quality evidence) and no statistical heterogeneity (Chi(2) = 0.14, df = 2 (P value = 0.93), I(2) = 0%).Anti-adhesion therapy was associated with fewer IUAs at any second-look hysteroscopy when compared with no treatment or placebo (OR 0.36, 95% CI 0.20 to 0.64, P value = 0.0005, seven studies, 528 women; very low-quality evidence). We found no statistical heterogeneity (Chi(2) = 2.65, df = 5 (P value = 0.75), I(2) = 0%). The number needed to treat for an additional beneficial outcome (NNTB) was 9 (95% CI 6 to 20).No evidence suggested differences between an IUD and an intrauterine balloon with respect to IUAs at second-look hysteroscopy (OR 1.23, 95% CI 0.64 to 2.37, P value = 0.54, one study, 162 women; very low-quality evidence).

AUTHORS' CONCLUSIONS

Implications for clinical practiceThe quality of the evidence retrieved was low or very low for all outcomes. Clinical effectiveness of anti-adhesion treatment for improving key reproductive outcomes or for decreasing IUAs following operative hysteroscopy in subfertile women remains uncertain. Implications for researchAdditional studies are needed to assess the effectiveness of different anti-adhesion therapies for improving reproductive outcomes in subfertile women treated by operative hysteroscopy.

Barrier agents for adhesion prevention after gynaecological surgery

BACKGROUND

Pelvic adhesions can form as a result of inflammation, endometriosis or surgical trauma. During pelvic surgery, strategies to reduce pelvic adhesion formation include placing barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene or fibrin sheets between the pelvic structures.

OBJECTIVES

To evaluate the effects of barrier agents used during pelvic surgery on rates of pain, live birth and postoperative adhesions in women of reproductive age.

SEARCH METHODS

We searched the following databases in February 2015: the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL) and trial registries. We handsearched relevant journals, conference proceedings and grey literature sources and we contacted pharmaceutical companies for information.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of the use of barrier agents compared with other barrier agents, placebo or no treatment for the prevention of adhesions in women undergoing gynaecological surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and risk of bias and extracted the data. We calculated odds ratios (ORs) or mean differences (MD) with 95% confidence intervals (CIs) using a fixed effect model. The overall quality of the evidence was assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods.

MAIN RESULTS

Eighteen RCTs (1262 women) were included. Six RCTs randomised women; the remainder randomised pelvic organs. Laparoscopy (eight RCTs) and laparotomy (10 RCTs) were the primary surgical techniques. Indications for surgery included myomectomy (six RCTs), ovarian surgery (five RCTs), pelvic adhesions (five RCTs), endometriosis (one RCT) and mixed (one RCT). The sole indication for surgery in three of the RCTs was infertility. Twelve RCTs reported commercial funding; the rest did not state their source of funding.No studies reported either of our primary outcomes of pelvic pain and live birth. Oxidised regenerated cellulose (Interceed) versus no treatment at laparoscopy or laparotomy (13 RCTs)At second-look laparoscopy oxidised regenerated cellulose at laparoscopy was associated with reduced incidence of de novo adhesions (OR 0.50, 95% CI 0.30 to 0.83, three RCTs, 360 participants, I(2) = 75%, very low-quality evidence) and of re-formed adhesions (OR 0.17, 95% CI 0.07 to 0.41, three RCTs, 100 participants, I(2) = 36%, low quality evidence).At second-look laparoscopy no evidence was found of any difference between the groups in the incidence of de novo adhesions after laparotomy (OR 0.72, 95% CI 0.42 to 1.25, one RCT, 271 participants, I(2) = 41%, low-quality evidence). However, the incidence of re-formed adhesions was lower in the intervention group (OR 0.38, 95% CI 0.27 to 0.55, six RCTs, 554 participants, moderate-quality evidence). Expanded polytetrafluoroethylene (Gore-Tex) versus no treatment at gynaecological surgery (one RCT) The evidence suggested that at second-look laparoscopy expanded polytetrafluoroethylene was associated with a reduction in new adhesion formation (OR 0.17, 95% CI 0.03 to 0.94, one RCT, 42 participants, low-quality evidence). Expanded polytetrafluoroethylene (Gore-Tex) versus oxidised regenerated cellulose (Interceed) at gynaecological surgery (two RCTs)One RCT found no difference between the groups at second-look laparoscopy in the incidence of de novo adhesions (OR 0.93, 95% CI 0.26 to 3.41, 38 participants, very low-quality evidence). A second RCT suggested that the expanded polytetrafluoroethylene group had a lower adhesion score (out of 11) (MD -3.79, 95% CI -5.12 to -2.46, 62 participants, very low-quality evidence) and a lower risk of re-formed adhesions (OR 0.13, 95% CI 0.02 to 0.80, 23 participants, very low-quality evidence). This last finding was sensitive to choice of effect estimate and no longer suggested a difference between the groups when a risk ratio was calculated (RR 0.36, 95% CI 0.13 to 1.01). Sodium hyaluronate and carboxymethylcellulose (Seprafilm) versus no treatment at gynaecological surgery (one RCT)Sodium hyaluronate and carboxymethylcellulose was associated with a lower adhesion score (out of 4) at second-look laparoscopy (MD 0.49, 95% CI 0.53 to 0.45, one RCT, 127 participants, moderate-quality evidence). Fibrin sheet versus no treatment at laparoscopic myomectomy (one RCT)There was no evidence of a difference between the groups in the incidence of de novo adhesions at second-look laparoscopy (OR 1.20, 95% CI 0.42 to 3.41, one RCT, 62 participants) or in adhesion score (out of 4) (MD 0.14, 95% CI -0.67 to 0.39, one RCT, 48 participants, low-quality evidence).Fourteen of the 18 RCTs reported adverse events. No events directly attributed to adhesion agents were reported.

AUTHORS' CONCLUSIONS

We found no evidence on the effects of barrier agents used during pelvic surgery on either pain or fertility outcomes in women of reproductive age.Low quality evidence suggests that oxidised regenerated cellulose (Interceed), expanded polytetrafluoroethylene (Gore-Tex) and sodium hyaluronate with carboxymethylcellulose (Seprafilm) may all be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. There is no conclusive evidence on the relative effectiveness of these interventions. There is no evidence to suggest that fibrin sheet is more effective than no treatment. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. The most common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.

A systemic review of randomized controlled studies about prevention with pharmacologic agents of adhesion formation in the rat uterine horn model

INTRODUCTION

Evaluation of treatment attempts in postoperative adhesion formation is pivotal for the prevention of several morbidities including infertility, pelvic pain, bowel obstruction, and subsequent intraoperative complications. The purpose of this systemic review was to assess the literature on the rat uterine horn model for adhesion formation and treatment modalities to prevent adhesion in the most frequently used experimental animal model.

MATERIAL AND METHODS

We performed a systemic review of publications from January 1(st) 2000 to December 31(st) 2013 via a PubMed search. A high number of agents were evaluated for the prevention of postoperative adhesion formation in the rat uterine horn model.

RESULTS

According to most of the studies, adjuvants such as antiinflamatuars, antiestrogens, antioxidants were effective to prevent adhesion formation.

CONCLUSIONS

Prevention of adhesion formation is pivotal and numerous types of agents were described in the literature were summarized in this review.

Comparison of robotic surgery and laparoscopy to perform total hysterectomy with pelvic adhesions or large uterus

BACKGROUND:

Currently, benefits of robotic surgery in patients with benign gynecological conditions remain unclear. In this study, we compared the surgical outcome of robotic and laparoscopic total hysterectomies and evaluated the feasibility of robotic surgery in cases with pelvic adhesions or large uterus.

MATERIALS AND METHODS:

A total of 216 patients receiving total hysterectomy via robotic or laparoscopic approach were included in this study. Of all 216 patients, 88 underwent robotic total hysterectomy and 128 underwent laparoscopic total hysterectomy. All cases were grouped by surgical type, adhesion score, and uterine weight to evaluate the interaction or individual effect to the surgical outcomes. The perioperative parameters, including operation time, blood loss, postoperative pain score, time to full diet resumption, length of hospital stay, conversion rate, and surgery-related complications were compared between the groups.

RESULTS:

Operation time and blood loss were affected by both surgical type and adhesion score. For cases with severe adhesions (adhesion score greater than 4), robotic surgery was associated with a shortened operation time (113.9 ± 38.4 min versus 164.3 ± 81.4 min, P = 0.007) and reduced blood loss (187.5 ± 148.7 mL versus 385.7 ± 482.6, P=0.044) compared with laparoscopy. Moreover, robotic group showed a lower postoperative pain score than laparoscopic group, as the effect was found to be independent of adhesion score or uterine weight. The grade-II complication rate was also found to be lower in the robotic group.

CONCLUSIONS:

Comparing to laparoscopic approach, robotic surgery is a feasible and potential alternative for performing total hysterectomy with severe adhesions.

Adhesion prevention agents for gynaecological surgery: an overview of Cochrane reviews

BACKGROUND

Intraperitoneal adhesions are associated with considerable co-morbidity and have large financial and public health repercussions. They have secondary effects that include chronic pelvic pain, dyspareunia, subfertility and bowel obstruction. In women with adhesions, subsequent surgery is more difficult, often takes longer, and is associated with a higher complication rate (Broek 2013). The significant burden of adhesions has led to the development of several anti-adhesion agents, although there is disagreement as to their relative effectiveness.

OBJECTIVES

To summarise evidence derived from Cochrane systematic reviews on the clinical safety and effectiveness of solid agents, gel agents, liquid agents and pharmacological agents, used as adjuvants to prevent formation of adhesions after gynaecological pelvic surgery.

METHODS

The Cochrane Database of Systematic Reviews was searched using the keyword 'adhesion' up to August 2014. The Cochrane information management system was also searched for any titles or protocols of reviews in progress. Two review authors independently extracted information from the reviews, with disagreements being resolved by a third review author. The quality of the included reviews was described in a narrative manner, and the AMSTAR tool was used to formally assess each review included in this overview. The quality of evidence provided in the original reviews was described using GRADE methods.

MAIN RESULTS

We included two reviews, one with 18 studies comparing solid agents (oxidised regenerated cellulose expanded polytetrafluoroethylene, sodium hyaluronate and carboxymethylcellulose, and fibrin sheets) with control or with each other. The other review included 29 studies which compared liquid agents (4% icodextrin, 32% dextran, crystalloids), gel agents (carboxymethylcellulose and polyethylene oxide, polyethylene glycol gels, hyaluronic acid based gel, 0.5% ferric hyaluronate gel, sodium hyaluronate spray) and pharmacological agents (gonadotrophin-releasing hormone agonist, reteplase plasminogen activator, N,O-carboxymethyl chitosan, steroid agents, intraperitoneal noxytioline, intraperitoneal heparin, systemic promethazine) with control or each other. Both reviews met all of the criteria of the AMSTAR assessment.The reviews included as outcomes both the primary outcomes of this overview (pelvic pain, pregnancy, live birth rate and quality of life (QoL)) and our secondary outcomes (adverse effects, presence or absence of adhesions at second-look laparoscopy (SLL) and adhesion score). However, neither of the reviews identified any primary studies of solid, gel or pharmacological agents that reported any of our primary outcomes. The only studies in either review that reported any of our primary outcomes were studies comparing liquid agents versus control (saline or Hartmann's solution), which reported pelvic pain (two studies), live birth (two studies) and pregnancy (three studies).An external source of funding was stated for 25 of the 47 studies across both reviews; in 24 of these studies the funding was commercial. Solid agents (18 studies)None of our primary outcomes were reported. Adverse events were reported as an outcome by only 9 of the 18 studies. These reported no adverse events. Liquid agents (nine studies)There was no evidence of a difference between liquid agents and control (saline or Hartmann's solution) with respect to pelvic pain (odds ratio (OR) 0.65, 95% confidence interval (CI) 0.37 to 1.14, 1 study, n = 286, moderate quality evidence), pregnancy rate (OR 0.64, 95% CI 0.36 to 1.14, 3 studies, n = 310, moderate quality evidence) or live birth rate (OR 0.67, 95% CI 0.29 to 1.58, 2 studies, n = 208, moderate quality evidence). No studies of liquid agents reported QoL. Adverse events were not reported as an outcome by any of the nine studies. Gel agents (seven studies)None of our primary outcomes were reported. Adverse events were not reported as an outcome by any of the seven studies. Pharmacological agents (seven studies)None of our primary outcomes were reported. Adverse events were reported as an outcome by only one of the seven primary studies. This study reported no evidence of difference in ectopic pregnancy rates between intraperitoneal noxytioline and no treatment (OR 4.91, 95% CI 0.45 to 53.27, 1 study, n = 33, low quality evidence).

AUTHORS' CONCLUSIONS

There is insufficient evidence to allow us to draw any conclusions about the effectiveness and safety of anti-adhesion agents in gynaecological surgery, due to the lack of data on pelvic pain, fertility outcomes, quality of life or safety. A substantial proportion of research in this field has been funded by private companies that manufacture these agents, and further high powered, independent trials will be needed before definitive conclusions can be made.

Evaluation of the effects of fulvestrant and micronized progesterone on the post-operative adhesion formation and ovarian reserve in rat model with immunohistochemical and biochemical analysis

OBJECTIVE

To evaluate the effects of fulvestrant and micronized progesterone on post-operative adhesion formation and ovarian reserve in a rat uterine horn adhesion.

METHODS

In this prospective randomized controlled trial, 32 female Wistar albino rats were randomly divided into four groups including control group (Group 1), the control adhesion group (Group 2), 1 mg/kg daily intramuscular fulvestrant received group (Group 3) and 1 mg/kg daily oral micronized progesterone received group (Group 4). The extent and severity of adhesions were scored and samples were taken from adhesion areas to investigate the grades of adhesions according to the immunohistochemical scoring system. Ovarian reserves were measured with anti-Müllerian hormone (AMH) and histological ovarian follicles count.

RESULTS

The extent, severity and total adhesion scores were reduced in all treatment groups compared to control adhesion group (Group 2). Similarly, immunohistochemical adhesion scores were lower in the treatment groups. AMH and follicle count were significantly found lower in adhesion groups compared with control group. However, treatment groups were found to have higher ovarian reserve compared to control adhesion group (Group 2).

CONCLUSIONS

Fulvestrant and micronized progesterone were found to reduce post-operative adhesion formations and have decreased detrimental effects of adhesion formation on ovarian reserve.

Safety and efficacy of postoperative continuous intra-peritoneal wash with lactated Ringer's for minimizing post-myomectomy pelvic adhesions: a pilot clinical trial

OBJECTIVES

To assess efficacy and safety of post-operative intra-peritoneal wash with lactated Ringer's for 48h after myomectomy in reduction of adhesions compared to routine intra-operative irrigation. Study design A prospective, randomized trial that included 52 eligible participants who had undergone abdominal myomectomy. Participants were randomly allocated to a treatment group (n=26) which was subjected to continuous peritoneal wash for 48h via two intraperitoneal drains, and a control group (n=26). The incidence of de novo adhesions and their severity and extent were scored at a second-look laparoscopy 8-10 weeks postoperatively. Adhesions were graded using the local adhesion barrier scoring system score. Adverse effects were also assessed and reported.

RESULTS

There was no statistically significant difference in duration of hospital stay or in the incidence of adverse events. A significantly higher proportion of adhesion-free patients was found in the treatment group [11/23, 47.8%] compared to the control group [4/21, 19%] (P<0.01). The mean number of pelvic sites covered by adhesions was significantly lower in the treatment group than in the control group (2.2±0.3 versus 4.6±0.8, P<0.05). The total adhesion score was significantly lower in the treatment group than in the control group (2.1±0.5 versus 4.8±1.4, P<0.05) and the adhesion score was significantly lower at most of the individual anatomical sites.

CONCLUSIONS

Application of postoperative intraperitoneal wash with lactated Ringer's solution for 48h may have reasonable safety and efficacy in minimizing postoperative pelvic de novo adhesions following abdominal myomectomy.

Adhesion prevention after cesarean delivery: evidence, and lack of it

In spite of the recognized occurrence of cesarean-attributable adhesions, its clinical significance is uncertain. The presence of adhesions during a repeat cesarean section can make fetal extraction lengthy and the procedure challenging and may increase the risk of injury to adjacent organs. Two methods for adhesion prevention are discussed, peritoneal closure and use of adhesion barriers. Peritoneal closure appears to be safe in the short term. In the long term, conflicting evidence arise from reviewing the literature for possible adhesion reduction benefits. A systematic review of the literature on the use of adhesion barriers in the context of cesarean section yielded only a few studies, most of which are lacking in methodology. For now, it appears that the available evidence does not support the routine use of adhesion barriers during cesarean delivery.

Comparative studies of thermogels in preventing post-operative adhesions and corresponding mechanisms

Post-surgical peritoneal adhesions constitute a classic problem in surgery, and thus anti-adhesion materials are much required. In this study, a series of polyester-PEG-polyester triblock copolymers with different biodegradable polyester compositions were synthesized, their properties were examined, and the in vivo efficacies as anti-adhesion biomaterials were evaluated in a comparative way for the first time. These samples not only exhibited various morphologies in the bulk state, but also possessed different stabilities in the sol state. All the polymer aqueous solutions with appropriate compositions and concentrations underwent sol-gel transitions with increase of temperature and formed semi-solid hydrogels at body temperature. The efficacy of PEG/polyester thermogels (25 wt%) for preventing post-operative abdominal adhesions was investigated and compared in a rabbit model of sidewall defect-bowel abrasion. Different efficacies of anti-adhesion were observed, possible mechanisms were discussed, and the importance of viscoelasticity was suggested for the first time. These results illustrated that appropriate properties of PEG/polyester thermogels including viscoelastic matrix, hydrophilic surface and moderate in vivo persistence played crucial roles in enabling an effective device to prevent post-surgical peritoneal adhesions.

Fluid and pharmacological agents for adhesion prevention after gynaecological surgery

BACKGROUND

Adhesions are fibrin bands that are a common consequence of gynaecological surgery. They are caused by various conditions including pelvic inflammatory disease and endometriosis. Adhesions are associated with considerable co-morbidity, including pelvic pain, subfertility and small bowel obstruction. Patients may require further surgery-a fact that has financial implications.

OBJECTIVES

To evaluate the role of fluid and pharmacological agents used as adjuvants in preventing formation of adhesions after gynaecological surgery.

SEARCH METHODS

The following databases were searched up to April 2014: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. Studies involving hydroflotation, gel and such pharmacological agents as steroids, noxytioline, heparin, promethazine, N,O-carboxymethyl chitosan and gonadotrophin-releasing hormone agonists were evaluated.

SELECTION CRITERIA

Randomised controlled trials investigating the use of fluid and pharmacological agents to prevent adhesions after gynaecological surgery. Gels were defined as fluid agents.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for eligibility, extracted data and evaluated risk of bias. Results were expressed as odds ratios (ORs), mean differences (MDs) or standard mean differences (SMDs) as appropriate, with 95% confidence intervals (CIs).

MAIN RESULTS

Twenty-nine trials were included (3227 participants), and nine were excluded. One study examined pelvic pain and found no evidence of a difference between use of hydroflotation agents and no treatment. We found no evidence that any of the antiadhesion agents significantly affected the live birth rate. When gels were compared with no treatment or with hydroflotation agents at second-look laparoscopy (SLL), fewer participants who received a gel showed a worsening adhesion score when compared with those who received no treatment (OR 0.16, 95% CI 0.04 to 0.57, P value 0.005, two studies, 58 women, I(2) = 0%, moderate-quality evidence) and with those given hydroflotation agents (OR 0.28, 95% CI 0.12 to 0.66, P value 0.003, two studies, 342 women, I(2) = 0%, high-quality evidence). Participants who received steroids were less likely to have a worsening adhesion score (OR 0.27, 95% CI 0.12 to 0.58, P value 0.0008, two studies, 182 women, I(2) = 0%, low-quality evidence). Participants were less likely to have adhesions at SLL if they received a hydroflotation agent or gel than if they received no treatment (OR 0.34, 95% CI 0.22 to 0.55, P value < 0.00001, four studies, 566 participants, I(2) = 0%, high-quality evidence; OR 0.25, 95% CI 0.11 to 0.56, P value 0.0006, four studies, 134 women, I(2) = 0%, high-quality evidence, respectively). When gels were compared with hydroflotation agents, participants who received a gel were less likely to have adhesions at SLL than those who received a hydroflotation agent (OR 0.36, 95% CI 0.19 to 0.67, P value 0.001, two studies, 342 women, I(2) = 0%, high-quality evidence). No studies evaluated quality of life. In all studies apart from one, investigators stated that they were going to assess serious adverse outcomes associated with treatment agents, and no adverse effects were reported.Results suggest that for a woman with a 77% risk of developing adhesions without treatment, the risk of developing adhesions after use of a gel would be between 26% and 65%. For a woman with an 83% risk of worsening of adhesions after no treatment at initial surgery, the chance when a gel is used would be between 16% and 73%. Similarly, for hydroflotation fluids for a woman with an 84% chance of developing adhesions with no treatment, the risk of developing adhesions when hydroflotation fluid is used would be between 53% and 73%.Several of the included studies could not be included in a meta-analysis: The findings of these studies broadly agreed with the findings of the meta-analyses.The quality of the evidence, which was assessed using the GRADE approach, ranged from low to high. The main reasons for downgrading of evidence included imprecision (small sample sizes and wide confidence intervals) and poor reporting of study methods.

AUTHORS' CONCLUSIONS

Gels and hydroflotation agents appear to be effective adhesion prevention agents for use during gynaecological surgery, but no evidence indicates that they improve fertility outcomes or pelvic pain, and further research is required in this area. Future studies should measure outcomes in a uniform manner, using the modified American Fertility Society (mAFS) score. Statistical findings should be reported in full.

Comparison of 2 Different Barrier Solutions (icodextrin 4% vs. dextran 70) used as Adhesion-prevention Agents after Microsurgical Adnexal Operations

In this prospective randomized clinical trial, 2 different barrier solutions (icodextrin 4% vs. dextran 70) were compared with regard to their antiadhesive properties, their tolerance and their persistence in situ. To this end, 45 patients suffering from infertility due to adnexal adhesions with indication for microsurgical adhesiolysis were randomized to 2 treatment groups. In advance of abdominal closure, patients were randomized to receive either 1,000 mL of icodextrin 4% solution (n = 23) or 300 mL dextran 70 instillation (n = 22). Serial transvaginal ultrasonographic scans were conducted on days 1, 3, 5 and 7 after surgery to measure the remaining volumes of each barrier solution. Seven days after initial surgery, a second-look laparoscopy was performed; remaining fluids were aspirated and measured and adhesions were rescored (final adhesion score). Differences between treatment groups were not significant (p = 0.775). With regard to their tolerance, the advantages of the icodextrin 4% solution became obvious, as edema of vulva and abdomen occurred more frequently after dextran 70 instillation.

In conclusion, microsurgical adhesiolysis and application of icodextrin 4% solution or dextran 70 as adhesion-prevention agent resulted in reduction of incidence, extent and severity of adhesions. Both solutions were well tolerated.