Consequences and complications of peritoneal adhesions

Comparative stability of the bioresorbable ferric crosslinked hyaluronic acid adhesion prevention solutions

The Intergel® ferric crosslinked hyaluronate (FeHA) adhesion prevention solution (APS) (FDA) is associated with serious post-operative complications (Henley, http://www.lawyersandsettlements.com/features/gynecare-intergel/intergel-timeline.html, 2007; FDA, 2003; Roman et al., Fertil Steril 2005, 83 Suppl 1:1113-1118; Tang et al., Ann Surg 2006;243(4):449-455; Wiseman, Fertil Steril 2006;86(3):771; Wiseman, Fertil Steril 2006;85(4):e7). This prompted us to examine the in situ stability of crosslinked HA materials to hyaluronidase lyase degradation. Variables such as ferric ionic crosslink density, HA concentration, gel geometry, and molecular weight (MW) of HA polymer were studied. Various formulations of the crosslinked "in house" [Isayeva et al., J Biomed Mater Res: Part B - Appl Biomater 2010, 95B (1):9-18] FeHA (0.5%, w/v; 30, 50, 90% crosslinked), the Intergel® FeHA (0.5%, w/v; 90%), and the non-crosslinked HA (0.05-0.5%, w/v) were degraded at a fixed activity of hyaluronidase lyase from Streptomyces hyalurolyticus (Hyase) at 37°C over time according to the method [Payan et al., J Chrom B: Biomed Sci Appl 1991;566(1):9-18]. Under our conditions, the data show that the crosslink density affects degradation the most, followed by HA concentration and then gel geometry. We found that MW has no effect. Our results are one possible explanation of the observations that the Intergel® FeHA APS (0.5%, w/v; 90%) material persisted an order of magnitude longer than expected [t1/2 = 500 hrs vs. t1/2 = 50 hrs (FDA; Johns et al., Fertil Steril 1997;68(1):37-42)]. These data also demonstrate the sensitivity of the in vitro hyaluronidase assay to predict the in situ stability of crosslinked HA medical products as previously reported [Sall et al., Polym Degrad Stabil 2007;92(5):915-919].

New hepatectomy-induced postoperative adhesion model in rats, and evaluation of the efficacy of anti-adhesion materials

PURPOSE

Repeated hepatic resections are not uncommon during the surgical management of liver tumors. Postoperative adhesions induced by hepatectomies can have a significant negative impact on subsequent surgeries. We recently developed a new hepatectomy-induced postoperative adhesion animal model to evaluate the anti-adhesion efficacy of commercially available sheet materials (Seprafilm(®) and Interceed(®)) and the recently reported hyaluronan-based in situ cross-linkable hydrogels.

METHODS

The median lobe (ML) and the left lateral lobe (LLL) of the liver (approximately 70 % of the total liver) of 43 male Sprague-Dawley rats were resected based on the classical procedure; anti-adhesion materials were then applied. A relaparotomy was performed 1 week later to evaluate the adhesions and histopathological findings.

RESULTS

The rats without the application of anti-adhesion materials (n = 14) showed the most severe adhesions (grade 3) between the cut surface of the liver and the small bowel or omentum. All the barrier materials produced slight anti-adhesion effects. Adhesions between the liver surface and the diaphragm and adhesions around the hepatic hilum were less severe, but were not remarkably reduced, by the anti-adhesion materials.

CONCLUSION

We successfully established a new hepatectomy-induced animal adhesion model, which may be useful for the development of new anti-adhesion materials.

Cross-linked sodium hyaluronate, an anti-adhesion barrier gel in gynaecological endoscopic surgery

OBJECTIVES

In the context of common adhesion prevention in laparotomic, laparoscopic and hysteroscopic surgery this article details the effects of a cross-linked sodium hyaluronate anti-adhesion barrier gel. The observed adhesion score is expressed in the following three measurements: Severity, extent and incidents of adhesions.

MATERIAL AND METHODS

From a total of 85 patients treated by laparoscopy and hysteroscopy, a second look endoscopic procedure could be performed in 35 cases.

RESULTS

Our preliminary, short evaluation of 35 patients submitted to a second look laparoscopy or hysteroscopy revealed the beneficial effect of the applied HYAcorp endo gel, showing only a minimal amount of adhesions at the second look observation.

CONCLUSION

Cross-linked sodium hyaluronate is highly effective in the prevention of adhesions at laparoscopic and hysteroscopic surgery.

Novel powdered anti-adhesion material: preventing postoperative intra-abdominal adhesions in a rat model

BACKGROUND

Although laparoscopic surgery has decreased postoperative adhesions, complications induced by adhesions are still of great concern. The aim of this study was to investigate the anti-adhesive effects of a novel powdered anti-adhesion material that can be applied during laparoscopic surgery in comparison with other anti-adhesion materials.

METHODS

Our novel powdered anti-adhesion material is composed of aldehyde dextran and ε-poly(L-lysine). In 40 male rats, a 2.5×2.0-cm abdominal wall resection and cecum abrasion were performed. The rats were randomized into four groups based on the anti-adhesion treatments: normal saline; Seprafilm(®); Interceed(®); and novel powdered anti-adhesion material. The animals were euthanized on days 7 and 28 to evaluate the adhesion severity, area of adhesion formation, gross appearance, and pathological changes.

RESULTS

The adhesion severities on both days 7 and 28 were significantly lower for all anti-adhesion material groups compared with the normal saline group (p<0.05). Pathologically, all groups showed inflammatory cell infiltration on day 7 and complete regeneration of the peritoneum on day 28.

CONCLUSIONS

Our novel powdered anti-adhesion material was found to be effective for reducing postoperative intra-abdominal adhesions and showed equivalent efficacy to commercial anti-adhesion materials.

Is previous same quadrant surgery a contraindication to laparoscopic adrenalectomy?

BACKGROUND

Previous abdominal surgery may present a challenge to safely completing laparoscopic adrenalectomy. We evaluated the impact of previous ipsilateral upper abdominal surgery on laparoscopic adrenalectomy outcomes.

METHODS

A retrospective analysis of prospective databases was performed for patients that underwent laparoscopic transabdominal adrenalectomy at 2 tertiary centers between 2001 and 2011. Patients with previous ipsilateral upper abdominal surgery, contralateral upper abdominal surgery, or no relevant surgery were compared.

RESULTS

Of the 217 patients, 38 (17%) had previous ipsilateral upper abdominal surgeries, 17 (8%) had contralateral upper abdominal surgeries, and 162 (75%) had no relevant surgery. Adhesions were more common in the ipsilateral upper abdominal surgery group (63% vs 24% vs 17%; P < .001). Mean operative times (173 ± 100 vs 130 ± 76 vs 149 ± 77 minutes; P = .16) and intraoperative complication rates (3% vs 0% vs 3%; P = .55) were not different. The rate of conversion to open surgery was similar for the 3 groups (11% vs 6% vs 3%; P = .08); all 4 conversions in the ipsilateral upper abdominal surgery group followed previous open procedures. Mean duration of stay and postoperative complication rates were also comparable between the 3 groups.

CONCLUSION

Laparoscopic adrenalectomy in patients with previous ipsilateral upper abdominal surgery is feasible and safe, with comparable outcomes to those without previous relevant surgery, including contralateral upper abdominal surgery.

Remote efficacy for two different forms of hyaluronate-based adhesion barriers

BACKGROUND

Chemically modified sodium hyaluronate and carboxymethylcellulose (HA/CMC) membrane clinically reduces adhesion formation following surgery but was not designed for laparoscopic use. HA/CMC powder of identical chemical composition has been developed to allow for application laparoscopically. We compared the adhesion reduction efficacy of HA/CMC powder and film when applied directly to or remote from sites of surgical trauma. We also investigated the effect of the powder on wound healing.

MATERIALS AND METHODS

Two animal models of adhesion formation were used to evaluate efficacy: a rat peritoneal sidewall defect model and a rabbit cecal abrasion/sidewall defect model. The products were applied directly to the defect or the contralateral sidewall. Adhesions were examined seven days after surgery. In a separate study, the effect of the powder on healing was evaluated at 5, 7, and 28 days using a rat incisional wound strength model.

RESULTS

HA/CMC powder and film, when applied directly to the peritoneal defect, significantly reduced adhesions relative to the untreated control in both models. Remote applications of HA/CMC powder also reduced adhesions. In contrast, remote applications of HA/CMC film had no effect. HA/CMC powder did not significantly alter incisional wound strength at any of the timepoints tested.

CONCLUSION

In our preclinical models, HA/CMC powder had similar adhesion reduction efficacy to HA/CMC film when applied directly to sites of trauma. In addition, HA/CMC powder reduced adhesions remote from the application site. Importantly, HA/CMC powder did not impair incisional wound healing. On the basis of these results, future investigation of HA/CMC powder is warranted.

The role of tissue plasminogen activator in the management of complex intra-abdominal abscesses in children

OBJECTIVE

The objective of this study is to assess the safety of fibrinolytic therapy using tissue plasminogen activator (tPA) in children with complex intra-abdominal abscesses.

SUMMARY BACKGROUND DATA

Intra-abdominal abscesses are common in children. Antibiotics and percutaneous drainage are the mainstays of treatment, but drainage may be less effective when the fluid is thick or septated. Fibrinolytic therapy using tPA is effective in a rat model of intra-abdominal abscesses, has recently been reported for the treatment of intra-abdominal abscesses in adults, and is commonly used in the treatment of empyema in children.

METHODS

This is a retrospective review of all patients over a 10-year period who had intra-abdominal collections managed with tPA abscess drainage.

RESULTS

Sixty-four children had a total of 66 drains placed and 92 doses of tPA. Appendicitis was the cause of the abscesses in 52 of 64 children. Mean length of stay pre-tPA was 11.7 ± 7.63 days, mean time from drain insertion to tPA was 4.3 ± 3.78 days, and mean time from tPA to discharge was 8.6 ± 8.85 days. Thirty patients underwent an operation before tPA administration. No patients experienced bleeding complications, anastomotic or appendiceal stump leak, or wound dehiscence after the administration of tPA, and no patients had abnormalities in coagulation studies related to tPA administration. One child died of sepsis.

CONCLUSIONS

Tissue plasminogen activator is safe for the management of thick or septated intra-abdominal abscesses in children. A prospective controlled study will be needed to evaluate the efficacy of this technique.

Bladder injuries in emergency/expedited laparoscopic surgery in the absence of previous surgery: a case series

INTRODUCTION

The use of laparoscopy as a diagnostic and therapeutic tool is being used increasingly in the emergency setting with many of these procedures being performed by trainees. While the incidence of iatrogenic injuries is reported to be low, we present six emergency or expedited cases in which the bladder was perforated by the suprapubic trocar.

CASES

Three cases were related to the management of appendicitis, two to negative diagnostic laparoscopies for lower abdominal pain and one to an ectopic pregnancy. Management of the bladder injuries varied from a urinary catheter alone to laparotomy with debridement of the abdominal wall due to sepsis and later reconstruction. Four of the six cases were performed by registrars.

CONCLUSIONS

Although the incidence of bladder injury is low, its importance is highlighted by the large number of laparoscopies being performed. In addition to catheterisation of the patient, care must be taken with the insertion of low suprapubic ports and consideration should be made regarding alternative sites. Adequate laparoscopic supervision and training in port site planning is required for surgical trainees.

Adhesion prevention in an intraperitoneal wound model: performance of two resorbable hemostats in a controlled study in rabbits

Adhesions, particularly in the abdominal and pelvic cavities, represent a significant clinical problem. Among other complications, they are considered the most common cause of intestinal obstructions in the Western world. The purpose of this study was to evaluate two commercially available hemostats for their ability to prevent adhesion formation in an abdominal wound model. The hemostats, a microfibrillar collagen-based composite and microporous polysaccharide spheres were used in a rabbit abdominal model. In the model the cecum was abraded and a peritoneal defect was created on the abdominal sidewall. The test materials were applied over the defects. Clinical and histological results were compared with control (no application of any hemostat at the defect site) on postoperative day 14. The results showed a significant reduction in the incidence, extent and severity of adhesions for both surgical hemostat materials compared with control. The microfibrillar collagen-based composite showed a total absence of adhesions and a high level of reperitonealization. This preclinical study suggests that the use of surgical hemostats may help to reduce or eliminate adhesions and may promote reperitonealization.

A sprayable hyaluronate/carboxymethylcellulose adhesion barrier exhibits regional adhesion reduction efficacy and does not impair intestinal healing

BACKGROUND

While bioresorbable solid barriers such as Seprafilm® prevent adhesions, their efficacy is limited to sites of application. The aim of this study was to assess the effectiveness of the sprayable adhesion barrier Sepraspray® in preventing adhesions to sites of direct application and to remote sites.

METHODS

Intraabdominal adhesions were induced in 30 rats by creating three ischemic buttons on each side of a midline incision. To assess efficacy, Sepraspray (5 mg/button) or Seprafilm (1 cm(2)/button) was applied over three buttons on one side of the peritoneum. Operated control animals received no treatment. On day 7, adhesions were scored as percent of buttons with adhesions. To assess safety, 81 rats underwent a colonic transection repaired with an end-to-end anastomosis. Both barriers were applied circumferentially to anastomoses. Controls received no product. The integrity of healing anastomosed colonic wounds was assessed by burst pressure and tensile strength at days 3, 5, and 7 postoperatively.

RESULTS

The direct application of both Sepraspray and Seprafilm significantly (p < 0.001) reduced adhesion formation compared to controls. While Seprafilm had no remote effect on adhesion formation, Sepraspray significantly (p < 0.001) reduced adhesion formation to contralateral ischemic buttons. Neither barrier affected anastomotic integrity at any time point.

CONCLUSIONS

Sepraspray has widespread efficacy throughout the peritoneum in reducing adhesions without compromising intestinal healing. Furthermore, this sprayable alternative offers the potential for easier intraabdominal application.

Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature

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.

Severe inflammatory reaction induced by peritoneal trauma is the key driving mechanism of postoperative adhesion formation

BACKGROUND

Many factors have been put forward as a driving mechanism of surgery-triggered adhesion formation (AF). In this study, we underline the key role of specific surgical trauma related with open surgery (OS) and laparoscopic (LS) conditions in postoperative AF and we aimed to study peritoneal tissue inflammatory reaction (TIR), remodelling specific complications of open surgery (OS) versus LS and subsequently evaluating AF induced by these conditions.

METHODS

A prospective randomized study was done in 80 anaesthetised female Wistar rats divided equally into 2 groups. Specific traumatic OS conditions were induced by midline incision line (MIL) extension and tissue drying and specific LS conditions were remodelled by intraperitoneal CO2 insufflation at the 10 cm of water. TIR was evaluated at the 24th, 72nd, 120th and 168th hour by scoring scale. Statistical analysis was performed by the non-parametric t test and two-way ANOVA using Bonferroni post-tests.

RESULTS

More pronounced residual TIR was registered after OS than after LS. There were no significant TIR interactions though highly significant differences were observed between the OS and LS groups (p < 0.0001) with regard to surgical and time factors. The TIR change differences between the OS and LS groups were pronounced with postoperative time p < 0.05 at the 24th and 72nd; p < 0.01--120th and p < 0.001--168th hrs. Adhesion free wounds were observed in 20.0 and 31.0% of cases after creation of OS and LS conditions respectively; with no significant differences between these values (p > 0.05). However larger adhesion size (41.67 ± 33.63) was observed after OS in comparison with LS (20.31 ± 16.38). The upper-lower 95% confidential limits ranged from 60.29 to 23.04 and from 29.04 to 11.59 respectively after OS and LS groups with significant differences (p = 0.03). Analogous changes were observed in adhesion severity values. Subsequently, severe TIR parameters were followed by larger sizes of severe postoperative adhesions in the OS group than those observed in the LS group.

CONCLUSIONS

MIL extension and tissue drying seem to be the key factors in the pathogenesis of adhesion formation, triggering severe inflammatory reactions of the peritoneal tissue surrounding the MIL resulting in local and systemic consequences. CO2 insufflation however, led to moderate inflammation and less adhesion formation.

Less adhesiolysis and hernia repair during completion proctocolectomy after laparoscopic emergency colectomy for ulcerative colitis

BACKGROUND

The aim of this study was to determine whether the need for adhesiolysis during completion proctectomy (CP) with ileopouch anal anastomosis (IPAA) is influenced by the surgical approach of the initial emergency colectomy for ulcerative colitis and the hospital setting.

METHODS

One hundred consecutive patients who underwent CP with IPAA in our center between January 1999 and April 2010 were included. Emergency colectomy had been performed laparoscopically in 30 of 52 patients at the Academic Medical Center Amsterdam and in 6 of 48 patients at referring hospitals. Case files of these patients were retrospectively reviewed.

RESULTS

Significantly more extensive adhesiolysis was performed after open compared to laparoscopic colectomy (47 vs. 6%, P < 0.001). In univariate analysis, emergency colectomy at a referring hospital was also predictive for adhesiolysis (P = 0.003), but the open approach for the initial colectomy was the only independent predictive factor for the need for adhesiolysis (P < 0.001) in a multivariable ordinal logistic regression analysis. Operating time of CP was significantly longer when limited [18 (95% CI = 0-36) min] or extensive [55 (35-75) min] adhesiolysis had to be performed. The interval to CP was longer after open colectomy and after colectomy performed at a referring hospital. Significantly more incisional hernia corrections during CP were performed after open emergency colectomy (14 vs. 0%, P = 0.024). Overall morbidity and postoperative hospital stay of CP were not related to the surgical approach or the hospital setting of the emergency colectomy.

CONCLUSION

Laparoscopic as opposed to open emergency colectomy is associated with less adhesiolysis, fewer incisional hernias, and a shorter interval to completion proctectomy.

Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain

Chronic pelvic pain in women is a debilitating, costly condition often treated by physical therapists. The etiology of this condition is multifactorial and poorly understood, given the complex interplay of muscles, bones, and soft tissue that comprise the pelvis. There are few guidelines directing treatment interventions for this condition. In the last decade, several investigators have highlighted the role of psychological variables in conditions such as vulvodynia and painful bladder syndrome. Pain-related fear is the focus of the fear-avoidance model (FAM) of pain, which theorizes that some people are more likely to develop and maintain pain after an injury because of their emotional and behavioral responses to pain. The FAM groups people into 2 classes on the basis of how they respond to pain: people who have low fear, confront pain, and recover from injury and people who catastrophize pain-a response that leads to avoidance/escape behaviors, disuse, and disability. Given the presence of pain-related cognitions in women with chronic pelvic pain, including hypervigilance, catastrophizing, and anxiety, research directed toward the application of the FAM to guide therapeutic interventions is warranted. Isolated segments of the FAM have been studied to theorize why traditional approaches (ie, medications and surgery) may not lead to successful outcomes. However, the explicit application of the FAM to guide physical therapy interventions for women with chronic pelvic pain is not routine. Integrating the FAM might direct physical therapists' clinical decision making on the basis of the pain-related cognitions and behaviors of patients. The aims of this article are to provide information about the FAM of musculoskeletal pain and to provide evidence for the relevance of the FAM to chronic pelvic pain in women.

Efficacy of polyethylene glycol adhesion barrier after gynecological laparoscopic surgery: Results of a randomized controlled pilot study

Postoperative adhesions are the most frequent complication of peritoneal surgery, causing small bowel obstruction, female infertility and chronic pain. This pilot study assessed the efficacy of a sprayable polyethylene glycol (PEG) barrier in the prevention of de novo adhesions. 16 patients undergoing laparoscopic gynecological surgery were randomly assigned by shuffled sealed envelopes to receive either the adhesion barrier or no adhesion prevention. Incidence and severity of adhesions were scored at eight sites in the pelvis and reassessed by second look laparoscopy. Adhesion prevention was considered successful if no de novo adhesion were found at second look laparoscopy. One patient was excluded before randomization. Nine patients were randomized to treatment and six patients to control group. De novo adhesions were found in 0/9 patients who received the PEG barrier compared to 4/6 without adhesion prevention (0% vs. 67%, P = 0.01). Reduction in adhesion score was significantly greater in patients receiving PEG barrier (−2.6 vs. −0.06, P = 0.03). Meta-analysis of three randomized trials demonstrated that PEG barrier reduces the incidence of adhesions (odds ratio [OR] = 0.27; 95% CI 0.11–0.67). From this study, PEG barrier seems effective in reducing postoperative formation of de novo adhesions.

Laparoscopy Entry in Patients With Previous Abdominal and Pelvic Surgery

Background: The background of this investigation is based on a common surgical problem: The access in laparoscopic surgery is more difficult in women with previous abdominopelvic surgery, since adhesions and viscera could be close to the point of trocar insertion. Purpose: The authors analyzed the safety and the efficacy of a modified direct optical entry (DOE) method versus the Hasson’s method by open laparoscopy (OL) in women with previous abdominopelvic surgery in a preliminary prospective case–control study. Materials and methods: A total of 168 women underwent laparoscopic surgery in university-affiliated hospitals: 86 were assigned to abdominal DOE (group A) and 82 to OL (group B). The main outcome measures were statistically compared: time required for entry into abdomen, blood loss, and occurrence of vascular and/or bowel injury. All patients had an intraperitoneal view of the primary port site during surgical procedure. Results: Statistical differences, in favor of the DOE group ( P < .01), were found in duration of entry and blood loss. The vascular and bowel injuries in OL versus DOE were not statistically different. Conclusions: Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in patients with previous abdominopelvic surgery, since it can become a difficult, time-consuming, and occasionally hazardous procedure. The study results suggest that DOE is advantageous when compared with OL in terms of saving time enabling a safe and expeditious visually guided entry for laparoscopy.

Urinary tract injures: recognition and management

Iatrogenic injury to the urinary tract during colorectal surgery can be a source of significant morbidity. Although most cases of ureteral injury occur in patients without significant risk factors, the incidence of urinary tract injuries increases in patients with prior pelvic operations, inflammatory bowel disease, infection, and in patients with extensive neoplasms causing distortion of normal surgical planes. The most commonly injured locations are the ureter, bladder, and urethra. Mechanisms of injury include ligation, transection, devascularization, and energy induced. Early identification of urinary tract injuries is paramount in minimizing morbidity and preservation of renal function. Anatomic considerations for preventing injuries, diagnostic techniques for localizing and staging injuries, as well as reconstructive techniques and principles of repair are discussed.

Using percutaneous transhepatic cholangioscopic lithotripsy for intrahepatic calculus in hostile abdomen

BACKGROUND

Hepatolithiasis is a challenging condition to treat especially in patients with previous hepatobiliary surgery. Percutaneous Transhepatic Cholangioscopic Lithotripsy (PTCSL) is an attractive salvage option for the treatment of recurrent hepatolithiasis. We reviewed our experience using PTCSL in treating 4 patients with previous complex abdominal surgery.

METHODS

We studied the 4 patients who underwent PTCSL from October 2007 to July 2009. We reviewed the operative procedures, workflow of performing PTCSL in our institution and the outcome of the procedure. PTCSL was performed in our institution using 3 mm cholangioscope (Dornier MedTech(®)) and Holmium laser with setting at 0.8 J, 20 Hz and 16 W. This was performed through a Percutaneous Transhepatic Cholangio-catheter inserted by interventional radiologists.

RESULTS

There were 4 patients with a median age of 50 (43-69) years. The median duration of the condition prior to PTCSL was 102 (60-156) months. Three patients had recurrent pyogenic cholangitis (RPC) with recurrent intrahepatic stone. They all had prior complex hepatobiliary operations. The median duration of surgery was 130 (125-180) min. There was minimal intra-operative blood loss. The first procedure was performed under local anaesthesia and sedation, however, with experience the subsequent 3 patients had the procedure performed under general anaesthesia. The median size of bile duct was 18 (15-20) mm prior to the procedure. The number of stones ranged from one to three with the largest size of stone comparable to the size of bile duct. The median follow up was 18 (10-24) months. All patients were symptom free with neither stone recurrence or cholangitis at the last follow up.

CONCLUSION

PTCSL is a feasible and an effective treatment method for patients with recurrent biliary stone following complex abdominal surgery as the success rates from open surgery and endoscopic procedures are limited. Excellent results can be expected with this minimally invasive technique.

Administration of a novel penicillamine-bound membrane: a preventive and therapeutic treatment for abdominal adhesions

BACKGROUND

Adhesions formation is a significant postsurgical complication. At present, there is no effective method for preventing adhesions formation 1, although barrier products such as Dextran (Dex) 2 and sodium hyaluronate (SH) 3 have proved the most clinically successful 456, This study is designed to investigate the preventive and therapeutic potential of a novel penicillamine-bound membrane for abdominal adhesions formation.

METHODS

150 rats were involved in the present study. All animals were randomly divided into 6 groups (1 vehicle group and 5 test groups respectively treated with dextran, sodium hyaluronate, penicillamine, penicillamine-bound membrane or non-penicillamine-bound membrane). The occurrence, grade and score of abdominal adhesions were compared between the different groups. The breaking strength of incision was compared between the vehicle group and the penicillamine, membrane with/without penicillamine - treated groups. Expression of collagen type I was compared between the vehicle and penicillamine-treated group. The occurrence of adhesions was compared between the Dextran (Dex), sodium hyaluronate (SH), penicillamine-treated group and membrane with or without penicillamine- treated groups.

RESULTS

Penicillamine and penicillamine-bound membrane had significant preventive effects on abdominal adhesions formation, better than dextran, sodium hyaluronate and non-penicillamine-bound membrane. However, neither of them influenced incision healing, although they insignificantly decreased the breaking strength of the incision. Penicillamine-bound membrane, which can be loaded locally and more efficaciously, shows greater advantages than penicillamine.

CONCLUSIONS

Penicillamine-bound membrane can be applied as an effective therapeutic intervention for abdominal adhesions with inconsequential side effects.

Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery

Background

There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications.

Methods

A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1^st International Congress of the World Society of Emergency Surgery and 9^th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus.

Recommendations

In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay.

NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended.

Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment.

Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.

Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

Two-component polyethylene glycol surgical sealant influence on intraperitoneal infection in a refined rodent model

OBJECTIVE

This study determined the influence of a 2-component polyethylene glycol surgical sealant (Coseal) as an adhesion prevention device on sepsis-related mortality and/or systemic bacterial translocation to the spleen.

STUDY DESIGN

A bacterial inoculum and telemetry probe were implanted in 50 treated and 49 untreated rats. Telemetry probes monitored core-body temperature to determine time of death. Spleens were collected on day 3 for quantitative bacteriology of Escherichia coli and Bacteroides fragilis.

RESULTS

Median survival time and mortality of treated rats (37.0 hours, 54.0%) were noninferior to untreated rats (47.5 hours, 55.1%). Median E coli titers in treated rats (2.24 log colony forming units/spleen) were significantly less than untreated rats (4.32 log colony forming units/spleen). B fragilis titers were not different.

CONCLUSION

This study demonstrates intraperitoneal administration of a 2-component polyethylene glycol surgical sealant as an adhesion prevention device does not alter time to death or sepsis-related mortality and/or systemic bacterial translocation to the spleen.

The efficacy of laparoscopy in the diagnosis and management of chronic abdominal pain

BACKGROUND

Chronic abdominal pain is a difficult complaint. It leads to evident suffering and disability, both physically and psychologically. Many diagnostic and therapeutic procedures have been described in literature, but with little proof or evidence of success. Laparoscopy is one of the modalities that could be of benefit in such cases. We aim to evaluate the diagnostic and therapeutic value of laparoscopy in cases with chronic abdominal pain.

MATERIALS AND METHODS

Thirty patients with chronic abdominal pain were included in this prospective descriptive cross-sectional study. The pain in all patients was of unclear etiology despite all the investigative procedures. All patients were subjected to laparoscopic evaluation for their conditions. The findings and outcomes of the laparoscopy were recorded and analyzed.

RESULTS

The most common site of pain was the periumbilical region (30%). A definitive diagnosis was made in 25 patients (83.3%), while five patients (16.7%) had no obvious pathology. Adhesions were the most common laparoscopic findings (63.3%) followed by appendiceal pathology (10%), hernia (3.3%), gall bladder pathology (3.3%), and mesenteric lymphadenopathy (3.3%). Postoperatively, pain relief was achieved in 24 patients (80%) after two months.

CONCLUSION

Laparoscopy is an effective diagnostic and therapeutic modality in the management of patients with chronic abdominal pain.

Incidence of intraabdominal adhesions in a continuous series of 1000 laparoscopic procedures

OBJECTIVE

The objective of the study was the laparoscopic evaluation of the incidence of intraabdominal adhesions related to prior abdominal surgery.

STUDY DESIGN

This was a prospective monocentric study including a continuous series of 1000 gynecologic laparoscopic procedures. Data were collected on history of abdominal surgery. A precise initial description of intraoperative adhesions was performed.

RESULTS

Six hundred thirty-seven of the 1000 procedures (63.7%) were performed in patients with a history of 1 or more than 1 abdominal surgery. Intraoperative adhesions were found in 211 of the 1000 subjects (21.10%). Fifty-nine of the 211 cases (28%) involved bowel loops. The prior indication for surgery did not seem to influence adhesion formation. The rate of intestinal adhesions significantly increased with the number of prior abdominal surgeries. The rate of intestinal adhesions was significantly higher in cases of prior midline incisions in comparison with the other incisions.

CONCLUSION

Extensive preoperative knowledge of prior surgery is essential to evaluate the risk of adhesion formation.

Implications of late complications from adhesions for preoperative informed consent

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.

Noninvasive detection and mapping of intraabdominal adhesions: a review of the current literature

BACKGROUND

Adhesions are a well-known and very common complication to surgery. Their extent and severity varies according to type and number of surgeries, use of intraabdominal mesh, and presence of peritonitis. Adhesions cause increased morbidity and mortality, with subsequent socioeconomic consequences. This review aimed to identify existing literature on noninvasive radiologic techniques for identification of intraabdominal adhesions.

METHODS

A structured literature search of medical databases was conducted. English literature published until September 2009 and relevant references were included and assessed.

RESULTS

The search identified transabdominal ultrasonography (TAU) and cine magnetic resonance imaging (cine MRI) as relevant tools matching the search criteria. In all, 12 publications concerning TAU and 4 publications concerning cine MRI were identified. All but one of these publications had the methodologic limitation of not being blinded, which influenced the final sensitivity, specificity, and accuracy.

CONCLUSION

Both TAU and cine MRI seem able to identify intraabdominal adhesions using visceral slide with accuracy of 76% to 92%. Unfortunately, the studies are biased by being nonblinded. Accordingly, a need exists for a systematic well-conducted double-blinded comparative study to validate these radiologic techniques.

Complications in colorectal surgery: risk factors and preventive strategies

BACKGROUND

Open or laparoscopic colorectal surgery comprises of many different types of procedures for various diseases. Depending upon the operation and modifiable and non-modifiable risk factors the intra- and postoperative morbidity and mortality rate vary. In general, surgical complications can be divided into intraoperative and postoperative complications and usually occur while the patient is still in the hospital.

METHODS

A literature search (1980-2009) was carried out, using MEDLINE, PubMed and the Cochrane library.

RESULTS

This review provides an overview how to identify and minimize intra- and postoperative complications. The improvement of different treatment strategies and technical inventions in the recent decade has been enormous. This is mainly attributable to the increase in the laparoscopic approach, which is now well accepted for many procedures. Training of the surgeon, hospital volume and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise and cost effectiveness. In addition, standardization of perioperative care is essential to minimize postoperative complications.

CONCLUSION

This review summarizes the main perioperative complications of colorectal surgery and influencable and non-influencable risk factors which are important to the general surgeon and the relevant specialist as well. In order to minimize or even avoid complications it is crucial to know these risk factors and strategies to prevent, treat or reduce intra- and postoperative complications.

Open adhesiolysis is more effective in reducing adhesion reformation than laparoscopic adhesiolysis in an experimental model

BACKGROUND

This study compared adhesion reformation after open and laparoscopic adhesiolysis in a rat model.

METHODS

Adhesions were induced by surgically creating ischaemic buttons on the peritoneal side wall. After 7 days the animals underwent laparoscopy with carbon dioxide insufflation or laparotomy to score and lyse adhesions. Peritoneal tissue and fluid were collected after 24 h in a subset of animals, and adhesion reformation was scored 7 days after lysis in the remainder. Tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI) 1, transforming growth factor (TGF) beta1 and tumour necrosis factor (TNF) alpha mRNA, and total fibrinolytic activity were assessed. The abdomen of non-operated animals was insufflated for 7, 15 or 30 min with carbon dioxide, after which tPA and PAI-1 mRNA and total fibrinolytic activity were measured.

RESULTS

Animals that underwent open adhesiolysis had 60 per cent fewer reformed adhesions than the laparoscopic adhesiolysis group (P < 0.001). There were no differences in tPA activity or tPA, PAI-1 and TNF-alpha mRNA between groups, but TGF-beta1 mRNA levels were significantly increased in the open group. Carbon dioxide insufflation did not affect peritoneal tPA activity.

CONCLUSION

Open adhesiolysis may be more beneficial in minimizing adhesion reformation in the management of adhesion-related complications.

A membrane slurry reduces postoperative adhesions in rat models of abdominal surgery

BACKGROUND

Sodium hyaluronate and carboxymethylcellulose (HA-CMC) membrane is an effective barrier material for limiting postoperative adhesions, but can be difficult to apply in certain situations due to its physical properties. We tested whether HA-CMC membrane hydrated in saline (slurry) is an effective alternative to HA-CMC membrane for preventing surgical adhesions in rat models of abdominal surgery.

MATERIALS AND METHODS

All studies were performed in rat cecal abrasion or sidewall defect models of adhesion formation. Adhesions were examined 7 d after surgery. In separate studies, the effects of variations in slurry composition, volume, and site of application on anti-adhesive properties were studied and compared with untreated controls. Finally, the effectiveness of HA-CMC membrane slurry for preventing adhesions was compared with that of conventional HA-CMC membrane.

RESULTS

Application of HA-CMC membrane slurry to traumatized tissue resulted in a significant reduction in the incidence of adhesions compared with untreated controls in both rat surgery models. Slurry was equally effective when applied in low and high film-to-volume formulations, but had minimal effect when applied in a small volume or at a location distal to the injury. Comparison of HA-CMC membrane slurry and conventional HA-CMC membrane indicated similar efficacy for reducing postoperative adhesions.

CONCLUSIONS

In rat models of abdominal surgery, HA-CMC membrane slurry reduced postoperative adhesion formation and may be an effective alternative for HA-CMC membrane in situations where its use is limited by its physical properties.

[Are there still contra-indications to laparoscopic treatment of endometrial carcinoma?]

Laparoscopic treatment is becoming a standard of care for early endometrial carcinoma. However, not all patients are suitable for this approach. A review of the current literature provides some arguments to differentiate absolute contra-indications from relative ones, for which, whenever possible, some options are suggested.

Intraperitoneal onlay mesh: an experimental study of adhesion formation in a sheep model

PURPOSE

Current hernia literature shows that the use of mesh in ventral hernia repair reduces the risk of recurrence significantly. In laparoscopic repair, the mesh is placed intraperitoneally. Accordingly, the close contact between mesh and viscera involves a risk of adhesion formation. In this experimental study, we examined the degree of de novo adhesion formation over time to currently available meshes.

METHODS

Sixteen sheep each received laparoscopic placement of four (10 x 10 cm) meshes on intact peritoneum. Two different mesh materials (coated vs. non-coated) and two different fixation devices (absorbable/non-absorbable) were investigated. (Parietex Composite, DynaMesh IPOM, ProTack and AbsorbaTack). After 3, 6, 12 and 18 months, four animals, respectively, underwent a new laparoscopy to determine the extent of adhesions to the mesh.

RESULTS

Parietex Composite significantly reduced the formation of intraabdominal adhesions compared to DynaMesh IPOM. The mean extent of adhesions increases over time without reaching a steady state within the first 12 months after laparoscopic placement.

CONCLUSIONS

This is the first long-term (18 months) experimental study on adhesion formation in sheep after laparoscopic placement of mesh and may serve as a template for future studies on meshes before marketing.

Cyclic motion encoding for enhanced MR visualization of slip interfaces

PURPOSE

To develop and test a magnetic resonance imaging-based method for assessing the mechanical shear connectivity across tissue interfaces with phantom experiments and in vivo feasibility studies.

MATERIALS AND METHODS

External vibrations were applied to phantoms and tissue and the differential motion on either side of interfaces within the media was mapped onto the phase of the MR images using cyclic motion encoding gradients. The phase variations within the voxels of functional slip interfaces reduced the net magnitude signal in those regions, thus enhancing their visualization. A simple two-compartment model was developed to relate this signal loss to the intravoxel phase variations. In vivo studies of the abdomen and forearm were performed to visualize slip interfaces in healthy volunteers.

RESULTS

The phantom experiments demonstrated that the proposed technique can assess the functionality of shear slip interfaces and they provided experimental validation for the theoretical model developed. Studies of the abdomen showed that the slip interface between the small bowel and the peritoneal wall can be visualized. In the forearm, this technique was able to depict the slip interfaces between the functional compartments of the extrinsic forearm muscles.

CONCLUSION

Functional shear slip interfaces can be visualized sensitively using cyclic motion encoding of externally applied tissue vibrations.

Prevention of postoperative adhesion formation by individual and combined administration of 4 per cent icodextrin and dimetindene maleate

BACKGROUND

To date, no single method has been successful in eliminating peritoneal adhesion formation after major abdominal surgery. This study evaluated the individual and possible synergistic effect of a local intraperitoneal barrier, 4 per cent icodextrin, and an intravenously administered antihistamine drug, dimetindene maleate, in the prevention of adhesion development following surgical trauma.

METHODS

De novo experimental adhesions were induced by standardized trauma of the peritoneum and large bowel in 120 New Zealand White rabbits. The animals were randomized into four groups receiving intraperitoneal saline, intraperitoneal 4 per cent icodextrin (60 ml), intravenous dimetindene maleate (0.1 mg/kg) and 4 per cent icodextrin-dimetindene in combination (n = 30 per group). Ten days later, adhesion scores and incidence were assessed by two independent surgeons. and surface area by computer-aided planimetry.

RESULTS

Treatment with either icodextrin or dimetindene maleate significantly reduced adhesion scores and increased the incidence of adhesion-free animals in an equipotent manner. The effect of combined treatment on severity, incidence and surface area of adhesions was more pronounced than that of each drug administered separately.

CONCLUSION

Combined administration of 4 per cent icodextrin and dimetindene maleate may be used safely and efficaciously to prevent surgically induced adhesions.

Non-viral Smad7 gene delivery and attenuation of postoperative peritoneal adhesion in an experimental model

BACKGROUND

Postoperative intra-abdominal adhesion is associated with high morbidity and mortality. Smad7, a protein that occupies a strategic position in fibrogenesis, inhibits the transforming growth factor (TGF) beta/Smad signalling pathway. In this study the therapeutic potential of exogenous Smad7 in preventing fibrogenesis in postoperative intra-abdominal adhesion was investigated.

METHODS

Intra-abdominal adhesion was induced in a rodent model by peritoneal abrasion. Smad7 was delivered into the peritoneal cavity by a non-viral ultrasound-microbubble-mediated naked gene transfection system. The effect of Smad7 transgene on adhesion formation was studied by measuring changes in TGF-beta, fibrogenic factors, alpha-SMA and Smad2/3 activation in the anterior abdominal wall.

RESULTS

Four weeks after surgical abrasion, all rats developed significant peritoneal adhesion with enhanced TGF-beta expression, increased levels of extracellular matrix components and activated myofibroblasts, accompanied by decreased Smad7 expression and increased Smad2/3 activation. In rats treated with the Smad7 transgene, the incidence and severity of peritoneal adhesion were significantly reduced, with biochemical downregulation of fibrogenic factors and inhibition of Smad2/3 activation. Serial quantitation using magnetic resonance imaging revealed a significant reduction in adhesion areas from day 14 onwards.

CONCLUSION

Ultrasound-microbubble-mediated gene transfection provides timely targeted gene delivery for the treatment of postoperative peritoneal adhesions.

High resolution ultrasound for pre-operative detection of intraperitoneal adhesions: An invaluable diagnostic tool for the general and laparoscopic surgeon

INTRODUCTION

The possibility of predicting the presence of intra-abdominal adhesions in post-surgical patients undergoing further laparotomy or laparoscopy is of great interest for the general and laparoscopic surgeon. Inadvertent enterotomy during re-laparotomy or trocar insertion is a feared complication with a significant associated morbidity and mortality occurring in 20% in open surgery and between 1% and 100% in laparoscopy.

MATERIALS AND METHODS

Sonographic study of the visceral slide (i.e. the "back and forth" movement of the peritoneal layer in rhythm with respiration in relation to the steady inner fascial layer) was the hallmark for free access to the peritoneal cavity. In 60 consecutive patients, aged 28-77, who had previously undergone open abdominal surgery, pre-operative ultrasound (US) was performed on Aloka 5.500 device (Aloka, Tokyo, Japan) using convex and linear multifrequency probes.

RESULTS

The possibility of safely performing trans-umbilical open laparoscopy (TUOL) was US evaluated in 35 (58.3%) patients scheduled for various abdominal laparoscopic procedures. This approach was successfully performed in 26 patients (74.3%). In 2 (5.7%) it was attempted but had to be changed due to the presence of previously undetected adhesions. In 7 patients (20%) pneumoperitoneum was induced by means of a Veress needle positioned in the upper left quadrant due to the presence of midline adhesions, which were confirmed after trocar insertion. Among the remaining 25 patients who underwent re-laparotomy (41.6%), incision was performed outside the midline in 8 patients (32%) due to the presence of suspected midline adhesions, which were confirmed in 6 patients (24%).

CONCLUSIONS

In this study, pre-operative US evaluation showed a diagnostic accuracy of 93.3%.

Adhesion-related complications are common, but rarely discussed in preoperative consent: a multicenter study

BACKGROUND

Peritoneal adhesions are recognized as an important cause for patient morbidity, but complications related to adhesions occur relatively late after the original operation. Therefore preoperative consent may not adequately reflect the proportions of the problem.

METHODS

A total of 200 patients admitted for intraperitoneal operations at six hospitals were prospectively reviewed to identify whether adhesion-related complications were documented as possible adverse events in their respective consent forms.

RESULTS

Adhesion-related complications were documented in 8.5% (n=17) of consent forms (bowel obstruction n=8, requirement for further operations n=5, difficult reoperation n=1, pain n=3). A direct relationship with adhesions was noted in n=9 of these consent forms.

CONCLUSIONS

Preoperative informed consent does not adequately reflect the magnitude of adhesion-related problems. These findings have immediate implications for clinical practice.