Adhäsionen und ihre Prävention in der gynäkologischen Chirurgie: Standortbestimmung und aktueller Konsensus basierend auf den Ergebnissen von vier Workshops

Predicting formation of adhesions after gynaecological surgery: development of a risk score

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.

Prevention of intra-abdominal adhesions in gynaecological surgery

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.

Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study

OBJECTIVE

To evaluate the efficacy and safety of Adept (4% icodextrin solution) in reducing adhesions after laparoscopic gynecological surgery involving adhesiolysis.

DESIGN

Multicenter, prospective, randomized, double-blind study comparing Adept with lactated Ringer's solution (LRS).

PATIENT(S)

Four hundred two patients randomized intraoperatively to Adept (n = 203) or LRS (n = 199) returned for second laparoscopy within 4-8 weeks. Incidence, severity, and extent of adhesions were determined on both occasions.

MAIN OUTCOME MEASURE(S)

The primary efficacy measure defined by the Food and Drug Administration was the number of patients achieving clinical success with adhesion treatment. Other measures included incidence and American Fertility Society (AFS) scores.

RESULT(S)

Significantly more Adept patients achieved clinical success than did LRS patients (49% vs. 38%). In infertility patients, Adept demonstrated particular clinical success compared with LRS (55% vs. 33%). This was reflected in the number of patients with a reduced AFS score (53% vs. 30%) and in fewer patients with a moderate/severe AFS category score (43% vs. 14%). Safety was comparable in both groups. Most events were related to the surgery, with an increase in transient labial edema in the Adept group.

CONCLUSION(S)

This is the first randomized, double-blind trial of an adhesion reduction agent. It demonstrated that Adept is a safe and effective adhesion reduction agent in laparoscopy.