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Alharbi RM, Almutairi AM, Alsharari KK, Almarwani WK, Hussamuldin AB, Alsaadi FM, Alhazmi WM. Awareness of Anti-adhesive Barriers Among Surgeons in Saudi Arabia. Cureus 2024; 16:e57942. [PMID: 38738085 PMCID: PMC11082479 DOI: 10.7759/cureus.57942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Post-operative adhesions present a number of difficulties, including intestinal obstruction and infertility, and they frequently require readmission due to adhesion-related problems. Notwithstanding these ramifications, there are surprisingly few thorough national surveys that address surgeons' awareness of adhesives. By assessing Saudi surgeons' knowledge of post-operative adhesions and their use of anti-adhesive medications, this study aims to close this knowledge gap. Methods This study is a cross-sectional observational research study aimed at Saudi Arabian surgeons utilizing a self-administered, semi-structured online questionnaire. The questionnaire was distributed to participants via social media and in-person email using basic random selection. It included adhesion morbidity and prevalence, pre-operative informed consent issues, adhesion preventive viewpoints, and anti-adhesive chemical use. Results There were 111 participants in total, of 41% were experienced surgeons with more than five years of experience. According to the survey, the majority of surgeons occasionally employed anti-adhesive compounds, especially during laparotomies (28%), and 38% never used them during laparoscopies. The study found that participants varied in what they informed patients regarding adhesion complications: 25% of participants informed 5%-10% of the patients about the possible adhesion complications in laparotomy procedures, whereas 26% of participants informed 10-25% of the patients in laparoscopic procedures. Compared with their specialist peers, general surgeons agreed more on the clinical significance of adhesions and prevention. Notably, three-quarters of participants were unclear about when to use anti-adhesive compounds. Conclusion While acknowledging the clinical significance of post-operative adhesions and recognizing the potential for prevention, most surveyed surgeons did not include adhesions as a post-operative complication in informed consent. The study underscores a belief in the efficacy of anti-adhesives yet reveals a widespread lack of clarity regarding specific indications for their use. Recommendations include implementing educational sessions during surgical training to heighten awareness of adhesions as a major post-operative complication and to encourage the appropriate utilization of available barriers and pharmacological anti-adhesive products.
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Affiliation(s)
| | | | | | - Wejdan K Almarwani
- College of Medicine, Jordan University of Science and Technology, Irbid, JOR
| | | | - Fahad M Alsaadi
- College of Medicine, Jordan University of Science and Technology, Irbid, JOR
| | - Wedyan M Alhazmi
- Department of General Surgery, King Fahad General Hospital, Jeddah, SAU
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Ozturk UK, Keles E, Akış S, Alınca CM, Acar S, Ozyurek SE, Api M. Evaluation of the Preoperative Slide Test in the Prediction of Intra-Abdominal Adhesions: A Single-Center, Double-Blinded, Prospective Observational Study. Surg Innov 2023; 30:557-563. [PMID: 37518021 DOI: 10.1177/15533506231186071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
BACKGROUND To evaluate the efficacy of the preoperative ultrasonographic sliding sign in predicting intra-abdominal adhesions. METHODS This was a single-center, double-blinded, prospective observational study undertaken from March and September 2021 on 110 patients with a history of previous abdominal surgery. All patients who were scheduled for laparoscopy underwent slide test in 5 zones of abdomen: right lower quadrant, left lower quadrant, previous operation site, vesicouterine pouch, and rectovaginal pouch. Adhesions were assessed by the same gynecologic surgeon using ultrasonography before the surgery and by gynecological surgeons during surgery, and by a third gynecologic surgeon to compare the preoperative slide test findings and laparoscopic findings after the surgery. RESULTS Seventy-three (66.4%) patients underwent laparoscopic surgery, and 37 (33.6%) patients underwent laparotomy. The mean age of patients was 46.9 ± 1.0 years. Sensitivity, specificity, and positive and negative predictive values of preoperative ultrasonography in predicting adhesions were 89.5%, 91.7%, 97.5%, and 71.0%, respectively. The accuracy of the slide test was calculated as 90.0%. It was found that as the total number of cesarean sections increased the estimates of vesicouterine adhesions and actual adhesions increased (P = .008). Also, the prediction of intra-abdominal adhesions and actual adhesions significantly increased as the total number of surgical operations increased (P = .002). CONCLUSIONS Intra-abdominal adhesions can be detected with the slide test, which is a non-invasive and well-tolerated procedure. Slide test can guide the physician before the elective operation in patients with previous abdominal surgery and may assist in counseling patients.
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Affiliation(s)
- Ugur K Ozturk
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Esra Keles
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Kartal Dr Lutfi Kırdar City Hospital, Istanbul, Turkey
| | - Serkan Akış
- Department of Gynecologic Oncology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Cihat M Alınca
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Sami Acar
- Department of General Surgery, University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Sefik E Ozyurek
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - Murat Api
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Istanbul, Turkey
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3
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Esber S, Etrusco A, Laganà AS, Chiantera V, Arsalan HM, Khazzaka A, Dellino M, Sleiman Z. Clinical Outcomes after the Use of Antiadhesive Agents in Laparoscopic Reproductive Surgery. Gynecol Obstet Invest 2023; 88:325-335. [PMID: 37757758 PMCID: PMC10794970 DOI: 10.1159/000534170] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Intra-abdominal adhesions are abnormal fibrous attachments between tissues and organs that can be congenital or acquired. Adhesion formation is a critical postoperative complication that may lead to bowel obstruction, chronic abdominal pain, and infertility. Physical barrier agents separate opposing peritoneal surfaces in the critical 5-day period of remesotheliazation. These agents are subdivided into solid or liquid/gel. Liquid agents seem easier to use in laparoscopic procedures than solid agents. METHODS The search for suitable articles published in English was carried out using the following databases: MEDLINE, Embase, Global Health, the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register (ClinicalTrial.gov). Only studies reporting data about the impact of the use of an antiadhesive agent on adhesion formation after a primary gynecologic laparoscopic surgery were considered eligible. RESULTS Twenty-two papers that met the inclusion criteria were included in this systematic review. CONCLUSIONS Surgeons should consider applying antiadhesive agents after gynecologic surgery to help reduce adhesion formation and its adverse effects. However, further studies are still needed to confirm their impact on reproductive outcome and to implement clear guidelines on their per-operative application.
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Affiliation(s)
- Sabine Esber
- Department of Obstetrics and Gynecology, Saint Joseph University, Beirut, Lebanon
| | - Andrea Etrusco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy,
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | | | - Aline Khazzaka
- Laboratory of Science and Research, Saint Joseph University, Beirut, Lebanon
| | - Miriam Dellino
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Zaki Sleiman
- Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
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Toneman MK, Krielen P, Jaber A, Groenveld TD, Stommel MW, Griffiths EA, Parker MC, Bouvy ND, van Goor H, Ten Broek RP. Predicting long-term risk of reoperations following abdominal and pelvic surgery: a nationwide retrospective cohort study. Int J Surg 2023; 109:1639-1647. [PMID: 37042312 PMCID: PMC10389206 DOI: 10.1097/js9.0000000000000375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/24/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND The risk of reoperations after abdominal and pelvic surgery is multifactorial and difficult to predict. The risk of reoperation is frequently underestimated by surgeons as most reoperations are not related to the initial procedure and diagnosis. During reoperation, adhesiolysis is often required, and patients have an increased risk of complications. Therefore, the aim of this study was to provide an evidence-based prediction model based on the risk of reoperation. MATERIALS AND METHODS A nationwide cohort study was conducted including all patients undergoing an initial abdominal or pelvic operation between 1 June 2009 and 30 June 2011 in Scotland. Nomograms based on multivariable prediction models were constructed for the 2-year and 5-year overall risk of reoperation and risk of reoperation in the same surgical area. Internal cross-validation was applied to evaluate reliability. RESULTS Of the 72 270 patients with an initial abdominal or pelvic surgery, 10 467 (14.5%) underwent reoperation within 5 years postoperatively. Mesh placement, colorectal surgery, diagnosis of inflammatory bowel disease, previous radiotherapy, younger age, open surgical approach, malignancy, and female sex increased the risk of reoperation in all the prediction models. Intra-abdominal infection was also a risk factor for the risk of reoperation overall. The accuracy of the prediction model of risk of reoperation overall and risk for the same area was good for both parameters ( c -statistic=0.72 and 0.72). CONCLUSIONS Risk factors for abdominal reoperation were identified and prediction models displayed as nomograms were constructed to predict the risk of reoperation in the individual patient. The prediction models were robust in internal cross-validation.
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Affiliation(s)
- Masja K. Toneman
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | - Pepijn Krielen
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | - Ahmed Jaber
- Department of Surgery, Shamir Medical Center, Be’er Ya’akov, Israel
| | - Tjitske D. Groenveld
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | - Martijn W.J. Stommel
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | - Ewen A. Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham
| | | | - Nicole D. Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
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Chizen DR, Rislund DC, Robertson LM, Lim HJ, Tulandi T, Gargiulo AR, De Wilde RL, Velygodskiy A, Pierson RA. A Randomized Double-Blind Controlled Proof-of-Concept Study of Alanyl-Glutamine for Reduction of Post-Myomectomy Adhesions. Eur J Obstet Gynecol Reprod Biol 2023; 284:180-188. [PMID: 37023559 DOI: 10.1016/j.ejogrb.2023.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 03/16/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
STUDY OBJECTIVE To test the hypothesis that intraperitoneal instillation of a single bolus dose of l-alanyl-l-glutamine (AG) will reduce the incidence, extent and/or severity of adhesions following myomectomy and establish preliminary safety and tolerability of AG in humans. DESIGN Phase 1,2 Randomized, double-blind, placebo-controlled study (DBRCT). SETTING Tertiary care gynecology surgical centre. PATIENTS Thirty-eight women who underwent myomectomies by laparoscopy (N = 38; AG-19 vs Placebo-19) or laparotomy (N = 10; AG-5 vs Placebo-5) with a scheduled second-look laparoscopy (SLL) 6-8 weeks later. Thirty-two patients in the laparoscopy arm completed SLL. INTERVENTIONS Bolus dose of AG or normal saline solution control (0.9% NaCl) administered intraperitoneally immediately prior to suture closure of the laparoscopic ports. The average dose was 170 mL of AG or control based on a dosing scheme of 1 g/kg bodyweight. MEASUREMENTS Digital recordings obtained for all procedures. The primary endpoint was reduction in the incidence, severity and extent of post-operative adhesions analyzed by intention-to-treat (ITT) approach. Three independent, blinded reviewers evaluated all operative video recordings to assess presence of adhesions. Post-hoc analysis assessed presence or absence of adhesions in the peritoneal cavity. Secondary endpoints assessed safety and tolerability of AG. MAIN RESULTS Administration of AG reduced the incidence, severity and/or extent of post-operative adhesions (p = 0.046). The presence of adhesions in the AG group was lower than in the Control group (p = 0.041). Adhesion improvement was achieved in 15 of 15 (100%) in the AG group versus 5 of 17 (29.6%) in the placebo group. No serious adverse events were reported. No differences in safety parameters were observed. CONCLUSIONS Intraperitoneal l-alanyl-l-glutamine reduced adhesion formation in all patients following laparoscopic myomectomy. Complete absence of adhesions was achieved at all abdominal sites in 93% of patients. Results confirm AG's known effects on cellular mechanisms of adhesiogenesis and lay the foundation for new adhesion prophylaxis research and treatment.
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Jain N, Srivastava S, Bayya SLP, Jain V. Jain point laparoscopic entry in contraindications of Palmers point. Front Surg 2022; 9:928081. [PMID: 36439525 PMCID: PMC9696343 DOI: 10.3389/fsurg.2022.928081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 10/03/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND This study was conducted to assess the efficacy of the Jain point to overcome the contraindications of Palmer's point. The Jain point lies on the left side of the abdomen at the L4 level, 10-13 cm lateral to the umbilicus. Due to its anatomical location, the Jain point is free from adhesions because postsurgical adhesions are encountered usually in the midline or the right side. METHODS This is a retrospective study conducted at a high-volume tertiary care referral center for advanced gynecological laparoscopic surgery, enrolling 8,586 patients who underwent laparoscopy at the center from January 2011 to March 2022. In this paper, we analyze 2,519 patients with a history of previous surgeries, who were operated using the Jain point. RESULTS In the 2,519 patients with a history of previous surgeries, the Jain point port was found to be adhesion free, regardless of the location of the scars, the number and type of previous surgeries, and those in whom Palmer's point was contraindicated. No major complications were reported, except for one case (0.04%) of small bowel injury, which was managed intraoperatively. The Jain point continued to function as the main ergonomic working port. CONCLUSION The Jain point offers an alternate safe entry port in previous surgery cases for laparoscopic surgeons of various specialties, like general surgeons, urologists, oncologists, and bariatric surgeons, to overcome the contraindications of Palmer's point. The Jain point also acts as the main ergonomic working port, whereas Palmer's point becomes redundant after initial entry.
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Affiliation(s)
- Nutan Jain
- Department of Obstetrics and Gynaecology, Vardhman Trauma and Laparoscopy Centre Pvt. Ltd., Muzaffarnagar, (UP), India
| | - Sakshi Srivastava
- Department of Gynae Endoscopy,Vardhman Trauma and Laparoscopy Centre Pvt. Ltd. Muzaffarnagar, (UP), India
| | - Sri Lakshmi Prasanna Bayya
- Department of Gynae Endoscopy,Vardhman Trauma and Laparoscopy Centre Pvt. Ltd. Muzaffarnagar, (UP), India
| | - Vandana Jain
- Department of Obstetrics and Gynaecology, Vardhman Trauma and Laparoscopy Centre Pvt. Ltd., Muzaffarnagar, (UP), India
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Barambio J, García-Arranz M, Campos PV, Pinto JFV, Clemente LV, Gómez-Heras SG, Guadalajara H, García-Olmo D. Chemical Scalpel: An Experimental Collagenase-Based Treatment for Peritoneal Adhesions. BIOLOGY 2022; 11:biology11081159. [PMID: 36009786 PMCID: PMC9404777 DOI: 10.3390/biology11081159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022]
Abstract
(1) Background: Abdominal adhesions are a common disease appearing after any type of abdominal surgery and may prolong surgical time and cause intestinal obstruction, infertility, or chronic pain. We propose the use of intraperitoneal collagenase to perform chemical adhesiolysis based on the pathophysiology and histology of adhesions. (2) Methods: We generated an adhesion model with intraperitoneal polypropylene meshes. Four months later, we evaluated the efficacy of the treatment in blinded form, i.e., 0.05% collagenase vs. placebo at 37 °C for 20 min. Protocol 1: Ten rats with ten mesh fragments, in which an attempt was made to remove the maximum number of meshes in a 5-min period. Protocol 2: Six rats with four mesh fragments in the sides of the abdominal cavity in which adhesiolysis was performed using a device that measures burst pressure. (3) Results: Protocol 1: 42% efficacy in the collagenase group versus 8% in the control group (p < 0.013). Protocol 2: 188.25 mmHg (SD 69.65) in the collagenase group vs. 325.76 mmHg (SD 50.25) in the control group (p < 0.001). (4) Conclusions: Collagenase allows for the safe and effective chemical adhesiolysis in this experimental model of adhesions.
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Affiliation(s)
- Javier Barambio
- Fundación Jiménez Díaz University Hospital, 28033 Madrid, Spain; (M.G.-A.); (P.V.C.); (J.F.V.P.); (L.V.C.); (H.G.); (D.G.-O.)
- Correspondence: ; Tel.: +34-915504800
| | - Mariano García-Arranz
- Fundación Jiménez Díaz University Hospital, 28033 Madrid, Spain; (M.G.-A.); (P.V.C.); (J.F.V.P.); (L.V.C.); (H.G.); (D.G.-O.)
- Department of Surgery, Faculty of Medicine, Universidad Autónoma de Madrid, 28029 Madrid, Spain
| | - Pedro Villarejo Campos
- Fundación Jiménez Díaz University Hospital, 28033 Madrid, Spain; (M.G.-A.); (P.V.C.); (J.F.V.P.); (L.V.C.); (H.G.); (D.G.-O.)
| | - Juan Felipe Vélez Pinto
- Fundación Jiménez Díaz University Hospital, 28033 Madrid, Spain; (M.G.-A.); (P.V.C.); (J.F.V.P.); (L.V.C.); (H.G.); (D.G.-O.)
| | - Luz Vega Clemente
- Fundación Jiménez Díaz University Hospital, 28033 Madrid, Spain; (M.G.-A.); (P.V.C.); (J.F.V.P.); (L.V.C.); (H.G.); (D.G.-O.)
| | - Soledad García Gómez-Heras
- Department of Human Histology, Faculty of Health Sciences, Rey Juan Carlos University, 28922 Madrid, Spain;
| | - Héctor Guadalajara
- Fundación Jiménez Díaz University Hospital, 28033 Madrid, Spain; (M.G.-A.); (P.V.C.); (J.F.V.P.); (L.V.C.); (H.G.); (D.G.-O.)
| | - Damián García-Olmo
- Fundación Jiménez Díaz University Hospital, 28033 Madrid, Spain; (M.G.-A.); (P.V.C.); (J.F.V.P.); (L.V.C.); (H.G.); (D.G.-O.)
- Department of Surgery, Faculty of Medicine, Universidad Autónoma de Madrid, 28029 Madrid, Spain
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8
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Krielen P, Ten Broek RPG, van Dongen KW, Parker MC, Griffiths EA, van Goor H, Stommel MWJ. Adhesion-related readmissions after open and laparoscopic colorectal surgery in 16 524 patients. Colorectal Dis 2022; 24:520-529. [PMID: 34919765 DOI: 10.1111/codi.16024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 02/08/2023]
Abstract
AIM Colorectal surgery is associated with a high risk of adhesion formation and subsequent complications. Laparoscopic colorectal surgery reduces adhesion formation by 50%; however, the effect on adhesion-related complications is still unknown. This study aims to compare differences in incidence rates of adhesion-related readmissions after laparoscopic and open colorectal surgery. METHOD Population data from the Scottish National Health Service were used to identify patients who underwent colorectal surgery between June 2009 and June 2011. Readmissions were registered until December 2017 and categorized as being either directly or possibly related to adhesions, or as reoperations potentially complicated by adhesions. The primary outcome measure was the difference in incidence of directly adhesion-related readmissions between the open and laparoscopic cohort. RESULTS Colorectal surgery was performed in 16 524 patients; 4455 (27%) underwent laparoscopic surgery. Patients undergoing laparoscopic surgery were readmitted less frequently for directly adhesion-related complications, 2.4% (95% CI 2.0%-2.8%) versus 7.5% (95% CI 7.1%-7.9%) in the open cohort. Readmissions for possibly adhesion-related complications were less frequent in the laparoscopic cohort, 16.8% (95% CI 15.6%-18.0%) versus 21.7% (95% CI 20.9%-22.5%), as well as reoperations potentially complicated by adhesions, 9.7% (95% CI 8.9%-10.5%) versus 16.9% (95% CI 16.3%-17.5%). CONCLUSION Overall, any adhesion-related readmissions occurred in over one in three patients after open colorectal surgery and one in four after laparoscopic colorectal surgery. Compared with open surgery, incidence rates of adhesion-related complications decrease but remain substantial after laparoscopic surgery.
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Affiliation(s)
- Pepijn Krielen
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Koen W van Dongen
- Department of Surgery, Maasziekenhuis Pantein Boxmeer, Beugen, The Netherlands
| | - Mike C Parker
- Consultant Surgeon, Darent Valley Hospital, Dartford, UK.,Honorary Professor of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Ewen A Griffiths
- Department of Upper GI Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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9
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Ziegler N, De Wilde RL. Reduction of adhesion formation after gynaecological adhesiolysis surgery with 4DryField PH - a retrospective, controlled study with second look laparoscopies. J OBSTET GYNAECOL 2021; 42:658-664. [PMID: 34392782 DOI: 10.1080/01443615.2021.1928030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Adhesions are a common consequence of abdomino-pelvic surgery. Efficacy of available adhesion prevention agents is discussed controversially. Here, we used the adhesion barrier 4DryField PH: a powder, which is transformed into a barrier gel with saline solution. The study includes 40 consecutive patients with surgeries for adhesiolysis, endometriosis and other gynaecological pathologies and subsequent second look interventions. The intervention group (n = 17) received 4DryField PH gel while control patients (n = 23) did not receive any adhesion prevention. Severity and extent of adhesion formation were scored during both interventions using an established score. Direct comparison between first and second interventions showed that extent and severity of adhesions could be reduced significantly using 4DryField PH gel. In contrast, in the control group, extent was not reduced and severity was even significantly higher. Direct comparison of second look laparoscopies revealed that adhesion extent and severity were significantly lower in the 4DryField PH than in the control group.Impact StatementWhat is already known on this subject? Adhesion formation after gynaecologic surgeries is known to be frequent and highly problematic as it directly induces complications and additionally makes subsequent surgeries more difficult. The effectiveness of established adhesion barriers is not sufficient to tackle these problems adequately.What the results of this study add? This is the first controlled study using the relatively new adhesion barrier 4DryField PH. It yields a significant reduction of extent as well as severity of adhesions, while adhesiolysis surgery alone does not solve the problem.What the implications are of these findings for clinical practice and/or further research? Usage of 4DryField PH gel seems to be a good approach to solve the adhesion problem of gynaecologic surgery in general and the reformation problem of adhesiolysis surgery specifically. The results should be confirmed in a larger prospective randomised controlled trial.
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Affiliation(s)
- Nicole Ziegler
- Pius Hospital, University Hospital for Gynaecology, Medical University Oldenburg, Oldenburg, Germany
| | - Rudy Leon De Wilde
- Pius Hospital, University Hospital for Gynaecology, Medical University Oldenburg, Oldenburg, Germany
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10
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Aka AA, Wright JP, DeBeche-Adams T. Small Bowel Obstruction. Clin Colon Rectal Surg 2021; 34:219-226. [PMID: 34305470 DOI: 10.1055/s-0041-1725204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Small bowel obstruction (SBO) remains a common problem for surgeons and nonsurgeons alike. Management of SBO has shifted from primarily being surgical to a nonoperative approach, which can be attributed to a multitude of reasons, including better understanding of the pathophysiology of SBO, the advent of laparoscopy, and improvement in diagnostic imaging. But given the nature of SBO, the need for surgical consultation continues to remain a necessity. This article will review the etiology, diagnosis, and management of SBO.
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Affiliation(s)
- Allison A Aka
- Department of Colon and Rectal Surgery, AdventHealth Orlando, Orlando, Florida
| | - Jesse P Wright
- Department of Colon and Rectal Surgery, AdventHealth Orlando, Orlando, Florida
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11
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Purcell LN, Reiss R, Mtalimanja M, Kuyenda P, Msosa V, Westmoreland KD, Charles A. Patient-Reported Quality of Life Following Laparotomy in a Resource-Limited Setting. World J Surg 2021; 45:1971-1978. [PMID: 33755753 DOI: 10.1007/s00268-021-06050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The burden of surgical diseases is high in sub-Saharan Africa. Despite limitations to surgical care access, health-related quality of life (HRQoL) data following surgical intervention are scarce. METHODS We performed a 3-month prospective observational study of adult patients undergoing an abdominal operation. We administered the Patient-Reported Outcome Measurement Information System (PROMIS)-25 and Index of Independence in Activities of Daily Living questionnaire preoperatively (to postoperative day [POD] #1), POD#7, and POD#30. PROMIS-25 HRQoL domains were measured and converted to standardized T-scores (median 50, minimal important clinical difference 3). RESULTS Of the 117 laparotomy patients who were enrolled, 89 (76.1%) were male with a median age of 39 years (IQR 27-54). Operations were primarily for intestinal volvulus (n = 30, 28.3%) and intestinal perforation (n = 29, 27.4%). We completed a total of 80 (68.4%), 95 (81.2%), and 77 (65.8%) surveys preoperatively, at POD#7, and POD#30, respectively. Preoperatively patients showed high median levels of anxiety (56), depression (60), fatigue (63), and pain interference (62), which all improved postoperatively. Mobility was poor preoperatively (31) and showed improvement during recovery but remained poor [POD#7: 32, POD#30: 39]. Pain intensity was high (10/10) preoperatively and improved to 3/10 by POD#30. Patients with complications compared to those without had clinically significant worse HRQoL in all domains measured by POD#30. DISCUSSION Abdominal surgery patients in a resource-limited setting present with poor HRQoL, which improves postoperatively. Mobility remained poor throughout follow-up despite improved pain scores. Our findings highlight the need for improved HRQoL and pain control among surgical patients.
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Affiliation(s)
- Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Rachel Reiss
- School of Medicine, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, Chapel Hill, CB, 7228, USA
| | | | | | | | - Katherine D Westmoreland
- University of North Carolina Project-Malawi, Lilongwe, Malawi.,Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, USA. .,School of Medicine, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, Chapel Hill, CB, 7228, USA. .,Kamuzu Central Hospital, Lilongwe, Malawi.
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12
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Ovariopexy-Before and after Endometriosis Surgery. Biomedicines 2020; 8:biomedicines8120533. [PMID: 33255531 PMCID: PMC7759852 DOI: 10.3390/biomedicines8120533] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/12/2020] [Accepted: 11/19/2020] [Indexed: 11/17/2022] Open
Abstract
Endometriosis surgery is often very challenging. Key to complete resection of endometriosis is access to the retroperitoneum. Endometriosis can involve the ureter and uterine vessels, and ovary on the lateral pelvic wall makes retroperitoneal access difficult. Primary and post-surgical adhesions prevalence in endometriosis is very high. Ovariopexy, transposition of ovaries temporarily, is done for better surgical access and to reduce postoperative adhesions. We concluded that although limited evidence, ovariopexy is an excellent tool to aid endometriosis surgery and prevent postoperative adhesions. It is cost effective, simple and complication rate almost nil. More robust trials are required to substantiate evidence for its impact on preventing postoperative adhesions and its effect on fertility. In this review, we describe our technique of ovariopexy supplemented with a video, with the aim to put light on this useful and important technique, which is beneficial both for surgeons and patients.
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13
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Akentyeva TN, Mukhamadiyarov RA, Krivkina EO, Luzgarev SV, Kudryavtseva YA. [Influence of unmodified and modified sutures on experimental abdominal adhesive process]. Khirurgiia (Mosk) 2020:29-34. [PMID: 32271734 DOI: 10.17116/hirurgia202003129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Experimental assessment of the effect of modified and unmodified surgical suture material on abdominal adhesive process. MATERIAL AND METHODS The study was performed on male rats of the Wistar subpopulation. There were 5 animals in each group. In all animals, midline abdominal incision was followed by suturing the parietal peritoneum with modified and unmodified suture material. All animals were euthanized with carbon dioxide vapors in 14 days after surgery. Macro- and microscopic assessment of severity of abdominal adhesive process was carried out. Two types of preparation of excised complexes 'peritoneum-suture material-adhesion' were applied for histological examination: paraffin sections and embedding in epoxy resin. Specimens were stained by Van Gieson and with methylene blue solution. Histological specimens were examined using Axio Imager A1 light microscope (Zeiss, Germany). RESULTS Polypropylene filaments result extensive adhesions occupying about 75% of the area. Adhesions have a dense structure with signs of vascularization. Modification of suture material with solution of polyhydroxybutyrate/hydroxyvalerate and heparin reduce severity of adhesions. The use of modified suture material was followed by adhesions with more loose structure, no signs of vascularization. Adhesions occupied less than 25% of the area. Histological examination of excised complexes 'peritoneum-suture material-adhesion' revealed accumulation of inflammatory cells around the unmodified suture material, while there were no signs of tissue inflammatory process around the modified sutures. CONCLUSION Application of polyhydroxybutyrate/hydroxyvalerate and heparin on the surface of surgical sutures is an effective method for prevention of abdominal adhesions.
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Affiliation(s)
- T N Akentyeva
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - R A Mukhamadiyarov
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - E O Krivkina
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - S V Luzgarev
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - Yu A Kudryavtseva
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
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14
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Clinical adhesion score (CLAS): development of a novel clinical score for adhesion-related complications in abdominal and pelvic surgery. Surg Endosc 2020; 35:2159-2168. [PMID: 32410083 PMCID: PMC8057995 DOI: 10.1007/s00464-020-07621-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/02/2020] [Indexed: 02/07/2023]
Abstract
Background Adhesions are a major cause of long-term postsurgical complications in abdominal and pelvic surgery. Existing adhesion scores primarily measure morphological characteristics of adhesions that do not necessarily correlate with morbidity. The aim of this study was to develop a clinical adhesion score (CLAS) measuring overall clinical morbidity of adhesion-related complications in abdominal and pelvic surgery. Methods An international Delphi study was performed to identify relevant score items for adhesion-related complications, including small bowel obstruction, female infertility, chronic abdominal or pelvic pain, and difficulties at reoperation. The CLAS includes clinical outcomes, related to morbidity of adhesions, and weight factors, to correct the outcome scores for the likelihood that symptoms are truly caused by adhesions. In a pilot study, two independent researchers retrospectively scored the CLAS in 51 patients to evaluate inter-observer reliability, by calculating the Intraclass correlation coefficient. During a feasibility assessment, we evaluated whether the CLAS completely covered different clinical scenarios of adhesion-related morbidity. Results Three Delphi rounds were performed. 43 experts agreed to participate, 38(88%) completed the first round, and 32 (74%) the third round. Consensus was reached on 83.4% of items. Inter-observer reliability for the CLAS was 0.95 (95% CI 0.91–0.97). During feasibility assessment, six items were included. As a result, the CLAS includes 22 outcomes and 23 weight factors. Conclusion The CLAS represents a promising scoring system to measure and monitor the clinical morbidity of adhesion-related complications. Further studies are needed to confirm its utility in clinical practice. Electronic supplementary material The online version of this article (10.1007/s00464-020-07621-5) contains supplementary material, which is available to authorized users.
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15
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Cui N, Liu J, Tan H. Comparison of laparoscopic surgery versus traditional laparotomy for the treatment of emergency patients. J Int Med Res 2019; 48:300060519889191. [PMID: 31847654 PMCID: PMC7604990 DOI: 10.1177/0300060519889191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To investigate the clinical efficacy of laparoscopic gastrointestinal
emergency surgery and postoperative complications. Methods Data for 604 patients undergoing emergency gastrointestinal surgery between
January 2013 and December 2018 were analyzed retrospectively. Treatment
efficacy and postoperative complications were compared between 300 patients
(control group) undergoing traditional laparotomy and 304 patients
(observation group) undergoing laparoscopic surgery. Results Clinical features were significantly better in the observation group than in
the control group, including duration of surgery (59.12 ± 10.31 minutes
vs. 70.34 ± 12.83 minutes), intraoperative blood loss
(41.21 ± 10.45 mL vs. 61.38 ± 9.97 mL), postoperative pain
score (1.25 ± 0.25 points. vs. 5.13 ± 0.43 points), length
of hospital stay (5.13 ± 0.24 days vs. 7.05 ± 0.13 days),
and time to free activity (13 ± 2.96 hours vs. 22 ± 3.02
hours). The total complication incidence in the observation group was 3.9%,
compared with 16% in the control group (16%). No significant differences in
direct medical costs were recorded between the observation and control
groups. Conclusions For patients undergoing emergency gastrointestinal surgery, laparoscopic
surgery resulted in better clinical outcomes than traditional laparotomy
without incurring additional costs. The potential clinical benefits of
emergency laparoscopic gastrointestinal surgery warrant further study.
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Affiliation(s)
- Ning Cui
- Renmin Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Jun Liu
- Renmin Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Haiyan Tan
- Renmin Hospital of Wuhan University, Wuhan, Hubei, P. R. China
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16
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Adhesion reformation and the limited translational value of experiments with adhesion barriers: A systematic review and meta-analysis of animal models. Sci Rep 2019; 9:18254. [PMID: 31796777 PMCID: PMC6890766 DOI: 10.1038/s41598-019-52457-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/16/2019] [Indexed: 12/11/2022] Open
Abstract
Today, 40-66% of elective procedures in general surgery are reoperations. During reoperations, the need for adhesiolysis results in increased operative time and a more complicated convalescence. In pre-clinical evaluation, adhesion barriers are tested for their efficacy in preventing 'de novo' adhesion formation, However, it is unknown to which extent barriers are tested for prevention of adhesion reformation. The aim of this systematic review and meta-analysis is to assess the efficacy of commercially available adhesion barriers and laparoscopic adhesiolysis in preventing adhesion reformation in animal models. Pubmed and EMBASE were searched for studies which assessed peritoneal adhesion reformation after a standardized peritoneal injury (in the absence of an intra-peritoneal mesh), and reported the incidence of adhesions, or an adhesion score as outcome. Ninety-three studies were included. No study met the criteria for low risk of bias. None of the commercially available adhesion barriers significantly reduced the incidence of adhesion reformation. Three commercially available adhesion barriers reduced the adhesion score of reformed adhesions, namely Seprafilm (SMD 1.38[95% CI]; p < 0.01), PEG (SMD 2.08[95% CI]; p < 0.01) and Icodextrin (SMD 1.85[95% CI]; p < 0.01). There was no difference between laparoscopic or open adhesiolysis with regard to the incidence of adhesion reformation (RR 1.14[95% CI]; p ≥ 0.05) or the adhesion score (SMD 0.92[95% CI]; p ≥ 0.05). Neither currently commercially available adhesion barriers, nor laparoscopic adhesiolysis without using an adhesion barrier, reduces the incidence of adhesion reformation in animal models. The methodological quality of animal studies is poor.
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17
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Laparotomy closure techniques: Do surgeons follow the latest guidelines? Results of a questionnaire. Int J Surg 2019; 71:110-116. [DOI: 10.1016/j.ijsu.2019.09.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/25/2019] [Accepted: 09/19/2019] [Indexed: 02/07/2023]
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18
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Krielen P, Grutters JPC, Strik C, Ten Broek RPG, van Goor H, Stommel MWJ. Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: a modelling study. World J Emerg Surg 2019; 14:41. [PMID: 31428188 PMCID: PMC6698039 DOI: 10.1186/s13017-019-0261-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 08/05/2019] [Indexed: 02/07/2023] Open
Abstract
Background Adhesion barriers have proven to reduce adhesion-related complications in colorectal surgery. However, barriers are seldom applied. The aim of this study was to determine the cost-effectiveness of adhesion barriers in colorectal surgery. Methods A decision-tree model was developed to compare cost-effectiveness of no adhesion barrier with the use of an adhesion barrier in open and laparoscopic surgery. Outcomes were incidence of clinical consequences of adhesions, direct healthcare costs, and incremental cost-effectiveness ratio per adhesion prevented. Deterministic and probabilistic sensitivity analyses were performed. Results Adhesion barriers reduce adhesion incidence and incidence of adhesive small bowel obstruction in open and laparoscopic surgery. Adhesion barriers in open surgery reduce costs compared to no adhesion barrier ($4376 versus $4482). Using an adhesion barrier in laparoscopic procedures increases costs by $162 ($4482 versus $4320). The ICER in the laparoscopic cohort was $123. Probabilistic sensitivity analysis showed 66% and 41% probabilities of an adhesion barrier reducing costs for open and laparoscopic colorectal surgery, respectively. Conclusion The use of adhesion barriers in open colorectal surgery is cost-effective in preventing adhesion-related problems. In laparoscopic colorectal surgery, an adhesion barrier is effective at low costs.
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Affiliation(s)
- Pepijn Krielen
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- 2Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands.,3Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chema Strik
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard P G Ten Broek
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry van Goor
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn W J Stommel
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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19
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Torres-De La Roche LA, Campo R, Devassy R, Di Spiezio Sardo A, Hooker A, Koninckx P, Urman B, Wallwiener M, De Wilde RL. Adhesions and Anti-Adhesion Systems Highlights. Facts Views Vis Obgyn 2019; 11:137-149. [PMID: 31824635 PMCID: PMC6897521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The peritoneal and intrauterine cavities are lined by fragile membranes with a high-wound healing capacity, e.g. repairing the endometrium in its cyclical "injury and scar-free repair process" during menstruation. However, peritoneal and intrauterine fibrosis and adhesions can develop after surgical trauma through activation of molecular, immune and genetic mechanisms. During procedures with a high-risk of adhesions, the use of new peritoneal and intrauterine conditions in combination with anti-adhesion substances are promising measures to preserve peritoneal and endometrial function and avoid the most common complication of gynecological surgery. Highlights of adhesions and anti-adhesion prevention techniques in laparoscopic, laparotomic and hysteroscopic surgeries are discussed in this paper. Unfortunately, evidence is lacking to prove the superiority of one technique over its counterparts in terms of postoperative adhesions, such as instrumentation, type of energy, distending media, and intracavitary pressure. Additionally, there is limited evidence about the efficacy and outcomes of techniques and adjuvant measures used during adhesiolysis. The definition of a universal intrauterine adhesions classification scheme as well as a prognostic scoring system to identify women at high risk of postoperative adhesions are necessary for advising those who could benefit the most of the use of antiadhesion barriers.
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Affiliation(s)
- LA Torres-De La Roche
- University Hospital for Gynecology, Pius Hospital, University Medicine Oldenburg, Carl von Ossietzky University Oldenburg, 26121, Germany
| | - R Campo
- Leuven Institute for Fertility and Embryology, Tiensevest, 3000, Leuven
| | - R Devassy
- Dubai London Clinic and Speciality Hospital, Dubai, 3371500, UAE
| | | | - A Hooker
- Zaans Medical Centre, Zaandam, 1502, Netherlands
| | - P Koninckx
- UZ Leuven Campus Gasthuisberg, Leuven, 3000, Belgium
| | - B Urman
- Koç University Faculty of Medicine, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34330, Turkey
| | - M Wallwiener
- Heidelberg University Women's Hospital, Heidelberg, 69115, Germany
| | - RL De Wilde
- University Hospital for Gynecology, Pius Hospital, University Medicine Oldenburg, Carl von Ossietzky University Oldenburg, 26121, Germany
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20
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Multicenter Observational Study of Adhesion Formation After Open-and Laparoscopic Surgery for Colorectal Cancer. Ann Surg 2019; 267:743-748. [PMID: 28207436 DOI: 10.1097/sla.0000000000002175] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The aim of this study was to compare adhesion formation after laparoscopic and open colorectal cancer resection. SUMMARY OF BACKGROUND DATA After colorectal surgery, most patients develop adhesions, with a high burden of complications. Laparoscopy seems to reduce adhesion formation, but evidence is poor. Trials comparing open- and laparoscopic colorectal surgery have never assessed adhesion formation. METHODS Data on adhesions were gathered during resection of colorectal liver metastases. Incidence of adhesions adjacent to the original incision was compared between patients with previous laparoscopic- and open colorectal resection. Secondary outcomes were incidence of any adhesions, extent and severity of adhesions, and morbidity related to adhesions or adhesiolysis. RESULTS Between March 2013 and December 2015, 151 patients were included. Ninety patients (59.6%) underwent open colorectal resection and 61 patients (40.4%) received laparoscopic colorectal resection. Adhesions to the incision were present in 78.9% after open and 37.7% after laparoscopic resection (P < 0.001). The incidence of abdominal wall adhesions and of any adhesion was significantly higher after open resection; the incidence of visceral adhesions did not significantly differ. The extent of abdominal wall and visceral adhesions and the median highest Zühlke score at the incision were significantly higher after open resection. There were no differences in incidence of small bowel obstruction during the interval between the colorectal and liver operations, the incidence of serious adverse events, and length of stay after liver surgery. CONCLUSION Laparoscopic colorectal cancer resection is associated with a lower incidence, extent, and severity of adhesions to parietal surfaces. Laparoscopy does not reduce the incidence of visceral adhesions.
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21
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van Steensel S, van den Hil LCL, Schreinemacher MHF, ten Broek RPG, van Goor H, Bouvy ND. Adhesion awareness in 2016: An update of the national survey of surgeons. PLoS One 2018; 13:e0202418. [PMID: 30118503 PMCID: PMC6097683 DOI: 10.1371/journal.pone.0202418] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/06/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND AIMS Adhesions, that form in 60-80% of all abdominal operations, can cause complications such as chronic abdominal pain, small-bowel obstruction, female infertility, and the need for adhesiolysis in future surgeries. Our 2010 Adhesion Awareness survey demonstrated that despite the huge clinical impact of adhesions; adhesion-related complications were seldom mentioned in the informed consent. Six years later, a follow-up survey was conducted to assess the progress on awareness on adhesion-related complications in the Netherlands. MATERIAL AND METHODS The 2010 Adhesion Awareness survey was repeated after a literature update. The knowledge regarding adhesions; the use of anti-adhesive agents and involvement in the informed consent process were assessed. Surgeons and surgical trainees were contacted by e-mail. The data was analysed using a Chi-square or Mann-Whitney U test and corrected for multiple testing. RESULTS The response rate was 32.6%, similar to the survey in 2010 (34.4%). 88.1% agreed with the clinical relevance of adhesions, comparable to 2010 (89.8%). The score on the knowledge test was 38.8% (2010: 37.2%). Involvement of adhesion-related complications in the informed consent process increased, although 32.5% almost never mentions adhesions. In 2016, 42.4% reported a correct occurrence of bowel lesions during adhesiolysis, higher than in 2010 (P<0.001). CONCLUSIONS The adhesion awareness did not increase in six years, despite the efforts made. However, an increased awareness regarding adhesiolysis related complications was detected. Improvement of knowledge and behavior is essential to narrowing the gap between the impact of adhesions as a major complication of abdominal surgery and the limited adhesion awareness.
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Affiliation(s)
- Sebastiaan van Steensel
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Leontine C. L. van den Hil
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | | | | | - Harry van Goor
- Department of General Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicole D. Bouvy
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- * E-mail:
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22
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Ayachi A, Bouchahda R, Derouich S, Mkaouer L, Kehila M, Abouda H, Channoufi B, Bouyahia M, Braham M, Zhioua F, Bouchahda H, Mourali M. Accuracy of preoperative real-time dynamic transvaginal ultrasound sliding sign in prediction of pelvic adhesions in women with previous abdominopelvic surgery: prospective, multicenter, double-blind study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:253-258. [PMID: 28294441 DOI: 10.1002/uog.17465] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 02/19/2017] [Accepted: 03/03/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate the role of the transvaginal sonographic (TVS) sliding sign in predicting pelvic adhesions in women with previous abdominopelvic surgery. METHODS This was a multicenter, prospective, interventional, double-blind study of patients with a history of abdominopelvic surgery who were undergoing laparoscopy or laparotomy during the 6-month period from March to August 2016 in one of three academic obstetrics and gynecology departments. Prior to surgery, patients were examined by TVS to assess the vesicouterine pouch, uterus, ovaries and pouch of Douglas, using the TVS pelvic sliding sign. Ultrasound findings and medical and surgical data were recorded. We assessed the accuracy of the preoperative TVS sliding sign in the prediction of pelvic adhesions overall and in each compartment separately. RESULTS During the study period, complete TVS sliding sign and laparoscopic or laparotomic data were available for 107 women. Their mean age was 44.0 (95% CI, 41.6-46.4; range, 20-79) years. Their mean parity was 2.0 (95% CI, 1.7-2.3; range, 0-9) and the mean number of previous abdominal surgical procedures per patient was 1.3 (95% CI, 1.2-1.5; range, 1-4). Adhesions were noted in 27/107 (25.2%) patients. The TVS sliding sign had a sensitivity of 96.3% and specificity of 92.6% in predicting pelvic adhesions. There was a significant relationship between adhesions in each compartment and the TVS sliding sign (P < 0.05). CONCLUSIONS The TVS sliding sign is an effective means to detect preoperatively pelvic adhesions in patients with previous abdominopelvic surgery. Use of such a non-invasive and well-tolerated technique could help in the planning of laparoscopy or laparotomy and counseling of these patients. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ayachi
- Department of Obstetrics and Gynaecology, University Hospital of Bougatfa, Bizerte, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - R Bouchahda
- Department of Obstetrics and Gynaecology, Taher Sfar Hospital, Mahdia, Tunisia
| | - S Derouich
- Department of Obstetrics and Gynaecology, University Hospital of Bougatfa, Bizerte, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - L Mkaouer
- Department of Obstetrics and Gynaecology, University Hospital of Bougatfa, Bizerte, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - M Kehila
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Obstetrics and Gynaecology, Neonatology and Maternity Center of Tunis, Tunis, Tunisia
| | - H Abouda
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Obstetrics and Gynaecology, Neonatology and Maternity Center of Tunis, Tunis, Tunisia
| | - B Channoufi
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Obstetrics and Gynaecology, Neonatology and Maternity Center of Tunis, Tunis, Tunisia
| | - M Bouyahia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Obstetrics and Gynaecology, Aziza Othmana Hospital, Tunis, Tunisia
| | - M Braham
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Obstetrics and Gynaecology, Aziza Othmana Hospital, Tunis, Tunisia
| | - F Zhioua
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Obstetrics and Gynaecology, Aziza Othmana Hospital, Tunis, Tunisia
| | - H Bouchahda
- Department of Obstetrics and Gynaecology, Taher Sfar Hospital, Mahdia, Tunisia
| | - M Mourali
- Department of Obstetrics and Gynaecology, University Hospital of Bougatfa, Bizerte, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
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23
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Moris D, Chakedis J, Rahnemai-Azar AA, Wilson A, Hennessy MM, Athanasiou A, Beal EW, Argyrou C, Felekouras E, Pawlik TM. Postoperative Abdominal Adhesions: Clinical Significance and Advances in Prevention and Management. J Gastrointest Surg 2017; 21:1713-1722. [PMID: 28685387 DOI: 10.1007/s11605-017-3488-9] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 06/23/2017] [Indexed: 01/31/2023]
Abstract
Postoperative adhesions remain one of the more challenging issues in surgical practice. Although peritoneal adhesions occur after every abdominal operation, the density, time interval to develop symptoms, and clinical presentation are highly variable with no predictable patterns. Numerous studies have investigated the pathophysiology of postoperative adhesions both in vitro and in vivo. Factors such as type and location of adhesions, as well as timing and recurrence of adhesive obstruction remain unpredictable and poorly understood. Although the majority of postoperative adhesions are clinically silent, the consequences of adhesion formation can represent a lifelong problem including chronic abdominal pain, recurrent intestinal obstruction requiring multiple hospitalizations, and infertility. Moreover, adhesive disease can become a chronic medical condition with significant morbidity and no effective therapy. Despite recent advances in surgical techniques, there is no reliable strategy to manage postoperative adhesions. We herein review the pathophysiology and clinical significance of postoperative adhesions while highlighting current techniques of prevention and treatment.
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Affiliation(s)
- Demetrios Moris
- Department of Surgery, Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jeffery Chakedis
- Department of Surgery, Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Amir A Rahnemai-Azar
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Ana Wilson
- Department of Surgery, Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | | | - Antonios Athanasiou
- Department of Surgery, Mercy University Hospital, Grenville Pl, Cork, Ireland
| | - Eliza W Beal
- Department of Surgery, Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Chrysoula Argyrou
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Felekouras
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Timothy M Pawlik
- Department of Surgery, Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Strik C, Stommel MWJ, Hol JC, van Goor H, Ten Broek RPG. Quality of life, functional status and adhesiolysis during elective abdominal surgery. Am J Surg 2017; 215:104-112. [PMID: 28865667 DOI: 10.1016/j.amjsurg.2017.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/28/2017] [Accepted: 08/07/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Adhesiolysis during abdominal surgery can cause iatrogenic organ injury, increased operative time and a more complicated convalescence. We assessed the impact of adhesiolysis and adhesiolysis-related complications on quality of life and functional status following elective abdominal surgery. METHODS Prospective cohort study, comparing patients requiring and not requiring adhesiolysis during an elective laparotomy or laparoscopy using the SF-36 and DASI questionnaire scores. RESULTS 518 patients were included. Pre- and postoperative quality of life did not significantly differ between both groups. Patients with adhesiolysis had a significantly lower pre- and postoperative functional status (p < 0.01). Higher age, concomitant pulmonary disease, postoperative complications, readmissions and chronic abdominal pain 6 months after surgery were all associated with a significant and independent decline in quality of life and functional status six months after surgery. CONCLUSION Adhesiolysis in itself does not affect functional status and quality of life six months after surgery. Postoperative complications, readmissions and chronic abdominal pain are associated with a lower health status.
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Affiliation(s)
- Chema Strik
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen C Hol
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Krielen P, van den Beukel BA, Stommel MWJ, van Goor H, Strik C, Ten Broek RPG. In-hospital costs of an admission for adhesive small bowel obstruction. World J Emerg Surg 2016; 11:49. [PMID: 27713763 PMCID: PMC5053022 DOI: 10.1186/s13017-016-0109-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/01/2016] [Indexed: 12/26/2022] Open
Abstract
Background Previous research on the costs of treatment for ASBO is outdated and often based on reimbursements, rather than true healthcare provider costs of the admission and related interventions. An accurate estimate of the true costs of treatment is necessary to understand the healthcare burden and to model cost-efficacy of adhesion strategies. The aim of this study was to provide an accurate cost estimate of the in-hospital costs for treatment of adhesive small bowel obstruction (ASBO) using micro-costing methods. Methods Consecutive patients admitted for ASBO to the Radboud University Medical Center from November 2013 to November 2015 were included. An episode of ASBO was defined as an admission for SBO with operative confirmation of adhesions or after radiological exclusion of other causes for SBO. For the purpose of generalization we used the costs of medication and interventions as provided by the Dutch Healthcare Authority and only if these were not available local hospital costs. We evaluated costs separately for operative and non-operative treatment for ASBO. Results During the study period 39 admissions for ASBO were eligible for analysis. An operative treatment was required in 19 patients (48.7 %). Mean hospital stay for ASBO with operative treatment was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative treatment (P = 0.003). A total of 12 patients developed complications, 2 in the non-operative group (10 %) and 10 in the operative group (52.6 %; P = 0.004). Overall costs for an admission for ASBO with operative treatment were €16 305 (SD €2 513), and for non-operative treatment € 2 277 (SD € 265) (p = <0.001). The highest expenditure with operative treatment for ASBO was made for ward stay (mean €7 856, SD €6 882), OR time (mean €2 6845, SD €1 434), ICU stay (mean €2 183, SD €4 305) and (parenteral) feeding costs (mean €1797, SD €2070). A table with correction coefficient to correct for differences in price levels for goods and services between different countries has been added. Conclusion The in-hospital costs of an admission for ASBO are higher than previously thought. These costs can be used to guide hospital reimbursement policy and for the development of a cost-effective model for the use of adhesion barriers.
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Affiliation(s)
- Pepijn Krielen
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Barend A van den Beukel
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Chema Strik
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Richard P G Ten Broek
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Mitura K, Skolimowska-Rzewuska M, Garnysz K. Outcomes of bridging versus mesh augmentation in laparoscopic repair of small and medium midline ventral hernias. Surg Endosc 2016; 31:382-388. [PMID: 27287902 DOI: 10.1007/s00464-016-4984-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/09/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Bridging of the hernia defect in laparoscopic repair (sIPOM) technique does not fully restore the abdominal wall function. Closure of hernia defect in IPOM-plus technique leads to the restoration of abdominal wall function and improved long-term treatment outcomes. Against the expectations, the studies confirm the formation of intraabdominal adhesions to the mesh. Regardless of the above, the search of the proper technique for mesh implantation and fixation is still ongoing. There have also been attempts to identify groups of patients who may still benefit from IPOM procedure. MATERIALS AND METHODS Patients with midline abdominal wall hernias up to 10 cm wide were enrolled in the study except for subxiphoid and suprapubic hernias. Between 2011 and 2014 we performed 82 hernia repairs using the laparoscopic technique with Physiomesh. Patients were divided into sIPOM and IPOM-plus groups. The study included 44M and 38F patients aged 27-84 years. After 12-months and again in August 2015 a survey was posted to all patients with questions regarding potential recurrence. RESULTS After 12 months, eight patients (20 %) in sIPOM group reported subjectively perceived recurrence and none in IPOM-plus group (p = 0.002). Six patients (14.3 %) in sIPOM group reported suspected recurrence, as compared to three patients (7.1 %) in IPOM-plus group (p = 0.13). These patients were invited for a follow-up physical examination and sonography. Eventually, four cases of hernia recurrence were confirmed in sIPOM group (10 %) and none in IPOM-plus group (p = 0.018). Other patients presented with mesh bulging. CONCLUSIONS Laparoscopic ventral hernia repair is generally safe and is associated with the low recurrence rate. Closure of fascial defects before mesh insertion offers better treatment outcomes. Non-closure of fascial defects with only bridging of the hernia defect (sIPOM) causes more frequent recurrence and bulging. As a result, patient satisfaction with treatment is lower, and they are concerned about hernia recurrence.
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Affiliation(s)
- Kryspin Mitura
- Department of General Surgery, Siedlce Hospital, ul. Starowiejska 15, 08-110, Siedlce, Poland. .,Panmed, Błonie 8, 08-110, Siedlce, Poland.
| | | | - Karolina Garnysz
- Department of General Surgery, Siedlce Hospital, ul. Starowiejska 15, 08-110, Siedlce, Poland
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Abstract
OBJECTIVE To provide a comprehensive review of recent epidemiologic data on the burden of adhesion-related complications and adhesion prevention. Second, we elaborate on economic considerations for the application of antiadhesion barriers. BACKGROUND Because the landmark SCAR studies elucidated the impact of adhesions on readmissions for long-term complications of abdominal surgery, adhesions are widely recognized as one of the most common causes for complications after abdominal surgery. Concurrently, interest in adhesion prevention revived and several new antiadhesion barriers were developed. Although these barriers have now been around for more than a decade, adhesion prevention is still seldom applied. METHODS The first part of this article is a narrative review evaluating the results of recent epidemiological studies on adhesion-related complications and adhesion prevention. In part II, these epidemiological data are translated into a cost model of adhesion-related complications and the potential cost-effectiveness of antiadhesion barriers is explored. RESULTS New epidemiologic data warrant a shift in our understanding of the socioeconomic burden of adhesion-related complications and the indications for adhesion prevention strategies. Increasing evidence from cohort studies and systematic reviews shows that difficulties during reoperations, rather than small bowel obstructions, account for the majority of adhesion-related morbidity. Laparoscopy and antiadhesion barriers have proven to reduce adhesion formation and related morbidity. The direct health care costs associated with treatment of adhesion-related complications within the first 5 years after surgery are $2350 following open surgery and $970 after laparoscopy. Costs are about 50% higher in fertile-age female patients. Application of an antiadhesion barriers could save between $328 and $680 after open surgery. After laparoscopy, the costs impact ranges from $82 in expenses to $63 of savings. CONCLUSIONS Adhesions are an important cause for long-term complications in both open and laparoscopic surgery. Adhesiolysis during reoperations seems to impact adhesion-related morbidity most. Routine application of antiadhesion barriers in open surgery is safe and cost-effective. Application of antiadhesion barriers can be cost-effective in selected cases of laparoscopy. More research is needed to develop barriers suitable for laparoscopic use.
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Guler S, Cimen S, Hu Q, Venkatachalam AB, Alwayn I. Effects of mTOR Inhibitors in Prevention of Abdominal Adhesions. J INVEST SURG 2016; 29:275-81. [DOI: 10.3109/08941939.2016.1149643] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Hinoki A, Saito A, Kinoshita M, Yamamoto J, Saitoh D, Takeoka S. Polylactic acid nanosheets in prevention of postoperative intestinal adhesion and their effects on bacterial propagation in an experimental model. Br J Surg 2016; 103:692-700. [DOI: 10.1002/bjs.10122] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/26/2015] [Accepted: 01/05/2016] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Ultrathin films (nanosheets) adhere tightly to organ surfaces but prevent adhesion to other organs. The antiadhesive effect of nanosheets and their effect on bacterial propagation were investigated in a murine intestinal adhesion model.
Methods
Polylactic acid nanosheets (approximately 80 nm thick) were produced. Serosal defects were created by peeling off the intestinal serosa; these were left open or covered with nanosheets or Seprafilm® and the formation of intestinal adhesions was analysed. To examine bacterial propagation, a nanosheet or Seprafilm® was placed on intact murine jejunum followed by Escherichia coli inoculation at the site.
Results
Treatment both with nanosheets and with Seprafilm® reduced postoperative intestinal adhesion (mean adhesion score 0·67 for nanosheets, 0·43 for Seprafilm® and 2·87 for no antiadhesive treatment; P < 0·001 for nanosheets or Seprafilm® versus no adhesive treatment). Nanosheet treatment did not affect bacterial propagation in the peritoneal cavity, whereas Seprafilm®-treated mice showed bacterial propagation, leading to increased mortality.
Conclusion
Nanosheets may be effective novel antiadhesive agents even in the presence of bacterial contamination. Surgical relevanceIntra-abdominal adhesions following surgical contamination can trigger postoperative complications and lead to deterioration in long-term quality of life. However, currently there are no effective antiadhesion materials to prevent the formation of adhesions.Treatment with ultrathin nanosheets effectively reduced postoperative intestinal adhesion in an experimental mouse model, and did not affect bacterial propagation in the peritoneal cavity.These nanosheets are potent novel antiadhesive materials that potentially can be applied even in contaminated conditions.
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Affiliation(s)
- A Hinoki
- Department of Surgery, National Defence Medical College, Tokorozawa, Japan
- Department of Paediatric Surgery, Nagoya University Graduate School of Medicine, Showa, Nagoya, Japan
| | - A Saito
- Department of Life Science and Medical BioScience, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - M Kinoshita
- Department of Immunology and Microbiology, National Defence Medical College, Tokorozawa, Japan
| | - J Yamamoto
- Department of Surgery, National Defence Medical College, Tokorozawa, Japan
| | - D Saitoh
- Department of Traumatology, National Defence Medical College, Tokorozawa, Japan
| | - S Takeoka
- Department of Life Science and Medical BioScience, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
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Dabrowski A, Lepère M, Zaranis C, Coelio C, Hauters P. Efficacy and safety of a resorbable collagen membrane COVA+™ for the prevention of postoperative adhesions in abdominal surgery. Surg Endosc 2015; 30:2358-66. [DOI: 10.1007/s00464-015-4484-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 07/31/2015] [Indexed: 10/22/2022]
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Leclercq RMFM, Van Barneveld KWY, Schreinemacher MHF, Assies R, Twellaar M, Bouvy ND, Muris JWM. Postoperative abdominal adhesions and bowel obstruction. A survey among Dutch general practitioners. Eur J Gen Pract 2015; 21:176-82. [DOI: 10.3109/13814788.2015.1055466] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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A new poly(1,3-trimethylene carbonate) film provides effective adhesion reduction after major abdominal surgery in a rat model. Surgery 2015; 157:1113-20. [DOI: 10.1016/j.surg.2015.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 02/04/2015] [Accepted: 02/13/2015] [Indexed: 12/08/2022]
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Bolnick A, Bolnick J, Diamond MP. Postoperative Adhesions as a Consequence of Pelvic Surgery. J Minim Invasive Gynecol 2015; 22:549-63. [DOI: 10.1016/j.jmig.2014.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 01/12/2023]
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Asgari Z, Hafizi L, Hosseini R, Javaheri A, Rastad H. Intrauterine synechiae after myomectomy; laparotomy versus laparoscopy: Non-randomized interventional trial. IRANIAN JOURNAL OF REPRODUCTIVE MEDICINE 2015; 13:161-8. [PMID: 26000007 PMCID: PMC4426156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 08/09/2014] [Accepted: 09/13/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Leiomyomata is the most frequent gynecological neoplasm. One of the major complications of myomectomy is intrauterine adhesion (synechiae). OBJECTIVE To evaluate and compare the rate and severity of synechiae formation after myomectomy by laparotomy and laparoscopy. MATERIALS AND METHODS In this non-randomized interventional trial, hysteroscopy was performed in all married fertile women who had undergone myomectomy (type 3-6 interamural and subserosal fibroids) via laparotomy and laparoscopy in Tehran's Arash Hospital from 2010 to 2013. Three months after the operation, the occurrence rate and severity of intrauterine synechiae, and its relationship with type, number and location of myomas were investigated and compared in both groups. RESULTS Forty patients (19 laparoscopy and 21 laparotomy cases) were studied. Both groups were similar regarding the size, type (subserosal or intramural), number and location of myoma. The occurrence rate of synechiae in the laparoscopy and laparotomy group was 21% and 19%, respectively; showing no significant difference (p=0.99). Among all patients, no significant relationship was found between the endometrial opening (p=0.92), location (p=0.14) and type of myoma (p=0.08) with the occurrence rate of synechiae. However, a significant relationship was observed between myoma's size (p=0.01) and the location of the largest myoma with the occurrence of synechiae (p=0.02). CONCLUSION With favorable suturing methods, the outcome of intrauterine synechiae formation after myomectomy, either performed by laparotomy or laparoscopy, is similar. In all cases of myomectomy in reproductive-aged women, postoperative hysteroscopy is highly recommended to better screen intrauterine synechiae.
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Affiliation(s)
- Zahra Asgari
- Department of Gynecologic Laparoscopy, Arash Women’s Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Leili Hafizi
- Department of Obstetrics and Gynecology, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Rayhaneh Hosseini
- Department of Gynecologic Laparoscopy, Arash Women’s Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Atiyeh Javaheri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
| | - Hathis Rastad
- Research Development Center, Arash Women’s Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Stommel MWJ, Strik C, ten Broek RPG, van Goor H. Efficacy and safety of the C-Qur™ Film Adhesion Barrier for the prevention of surgical adhesions (CLIPEUS Trial): study protocol for a randomized controlled trial. Trials 2014; 15:378. [PMID: 25260232 PMCID: PMC4195905 DOI: 10.1186/1745-6215-15-378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 09/15/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adhesions develop in over 90% of patients after intra-abdominal surgery. Adhesion barriers are rarely used despite the high morbidity caused by intra-abdominal adhesions. Only one of the currently available adhesion barriers has demonstrated consistent evidence for reducing adhesions in visceral surgery. This agent has limitations through poor handling characteristics because it is sticky on both sides. C-Qur™ Film is a novel thin film adhesion barrier and it is sticky on only one side, resulting in better handling characteristics. The objective of this study is to assess efficacy and safety of C-Qur™ Film to decrease the incidence of adhesions after colorectal surgery. METHODS/DESIGN This is a prospective, investigator initiated, randomized, double-blinded, multicenter trial. Eligible patients undergoing colorectal resection requiring temporary loop ileostomy or loop/split colostomy by laparotomy or hand assisted laparoscopy will be included in the trial. Before closure, patients are randomized 1:1 to either the treatment arm (C-Qur™ Film) or control arm (no adhesion barrier). Patients will return 8 to 16 weeks post-colorectal resection for take down of their ostomy. During ostomy takedown, adhesions will be evaluated for incidence, extent, and severity. The primary outcome evaluation will be assessment of adhesions to the incision site. It is hypothesized that the use of C-Qur™ Film underneath the primary incision reduces the incidence of adhesion at the incision by 30%. To demonstrate 30% reduction in the incidence of adhesions, a sample size of 84 patients (32 + 10 per group (25% drop out)) is required (two-sided test, α = 0.05, 80% power). DISCUSSION Results of this study add to the evidence on the use of anti-adhesive barriers in open and laparoscopic 'hand-assisted' colorectal surgery. We chose incidence of adhesions to the incision site as primary outcome measure since clinical outcomes such as small bowel obstruction, secondary infertility and adhesiolysis related complications are considered multifactorial and difficult to interpret. Incidence of adhesions at repeat surgery is believed to be the most valuable surrogate endpoint for clinically relevant adhesion prevention, since small bowel obstruction and adhesiolysis at repeat surgery are not likely to occur when complete adhesion reduction in a patient is accomplished. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT01872650, registration date 6 June 2013.
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Affiliation(s)
- Martijn WJ Stommel
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Chema Strik
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Richard PG ten Broek
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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ten Broek RPG, Strik C, van Goor H. Preoperative nomogram to predict risk of bowel injury during adhesiolysis. Br J Surg 2014; 101:720-7. [PMID: 24723023 DOI: 10.1002/bjs.9479] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Inadvertent bowel injury during adhesiolysis is a major cause of increased morbidity and mortality following abdominal surgery. Identification of risk factors predicting this complication would guide preoperative counselling and surgical decision-making. The aim of this study was to identify predictive preoperative factors for inadvertent bowel injury occurring during adhesiolysis. METHODS All patients undergoing elective abdominal surgery between June 2008 and June 2010 were evaluated prospectively as part of the LAPAD study. Data on adhesiolysis and inadvertent organ injury were gathered by direct observation during operation. Univariable logistic regression was used to investigate factors that increased the risk of inadvertent bowel injury. Independent predictors of bowel injury were identified using multivariable logistic regression and used to create a clinical nomogram. RESULTS Of 715 patients eligible for analysis, 48 (6.7 per cent) had inadvertent bowel injuries. In 42 patients the defect was detected during operation and in nine at a later time (3 patients had both). Bowel resection was required for almost two-thirds of the enterotomies. The number of previous laparotomies, anatomical site of the operation, presence of bowel fistula and laparotomy via a pre-existing median scar were independent predictors of bowel injury. A clinical scoring system was constructed using a nomogram incorporating these risk factors; this had a predictive discrimination, measured as the area under the receiver operating characteristic curve, of 0.85. CONCLUSION A nomogram based on four independent factors predicted the risk of inadvertent bowel injury. REGISTRATION NUMBER NCT01236625 (http://www.clinicaltrials.gov).
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Affiliation(s)
- R P G ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Mais V. Peritoneal adhesions after laparoscopic gastrointestinal surgery. World J Gastroenterol 2014; 20:4917-4925. [PMID: 24803803 PMCID: PMC4009523 DOI: 10.3748/wjg.v20.i17.4917] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/11/2014] [Accepted: 02/17/2014] [Indexed: 02/06/2023] Open
Abstract
Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation, only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue. Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis. Moreover, several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact. Experimental data in animal models have suggested that CO2 pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration. Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO2, N2O and O2 seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum. However, these experimental data have not had a significant impact on the modification of laparoscopic instrumentation. In contrast, surgeons should train themselves to perform laparoscopy quickly, and they should complete their learning curves before testing chemical anti-adhesive agents and anti-adhesion barriers. Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation, but when these agents are used alone, the concentrations needed to prevent adhesions are too high and could cause major post-operative side effects. Anti-adhesion barriers have been used mainly in open surgery, but some clinical data from laparoscopic surgeries are already available. Sprays, gels, and fluid barriers are easier to apply in laparoscopic surgery than solid barriers. Results have been encouraging with solid barriers, spray barriers, and gel barriers, but they have been ambiguous with fluid barriers. Moreover, when barriers have been used alone, the maximum protection against adhesion formation has been no greater than 60%. A recent small, randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100% effective in preventing post-operative adhesion formation. Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points, such as reduced incidences of bowel obstruction and abdominal pain and increased fertility.
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Ten Broek RPG, Stommel MWJ, Strik C, van Laarhoven CJHM, Keus F, van Goor H. Benefits and harms of adhesion barriers for abdominal surgery: a systematic review and meta-analysis. Lancet 2014; 383:48-59. [PMID: 24075279 DOI: 10.1016/s0140-6736(13)61687-6] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Formation of adhesions after peritoneal surgery results in high morbidity. Barriers to prevent adhesion are seldom applied, despite their ability to reduce the severity of adhesion formation. We evaluated the benefits and harms of four adhesion barriers that have been approved for clinical use. METHODS In this systematic review and meta-analysis, we searched PubMed, CENTRAL, and Embase for randomised clinical trials assessing use of oxidised regenerated cellulose, hyaluronate carboxymethylcellulose, icodextrin, or polyethylene glycol in abdominal surgery. Two researchers independently identified reports and extracted data. We compared use of a barrier with no barrier for nine predefined outcomes, graded for clinical relevance. The primary outcome was reoperation for adhesive small bowel obstruction. We assessed systematic error, random error, and design error with the error matrix approach. This study is registered with PROSPERO, number CRD42012003321. FINDINGS Our search returned 1840 results, from which 28 trials (5191 patients) were included in our meta-analysis. The risks of systematic and random errors were low. No trials reported data for the effect of oxidised regenerated cellulose or polyethylene glycol on reoperations for adhesive small bowel obstruction. Oxidised regenerated cellulose reduced the incidence of adhesions (relative risk [RR] 0·51, 95% CI 0·31-0·86). Some evidence suggests that hyaluronate carboxymethylcellulose reduces the incidence of reoperations for adhesive small bowel obstruction (RR 0·49, 95% CI 0·28-0·88). For icodextrin, reoperation for adhesive small bowel obstruction did not differ significantly between groups (RR 0·33, 95% CI 0·03-3·11). No barriers were associated with an increase in serious adverse events. INTERPRETATION Oxidised regenerated cellulose and hyaluronate carboxymethylcellulose can safely reduce clinically relevant consequences of adhesions. FUNDING None.
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Affiliation(s)
- Richard P G Ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Chema Strik
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
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Adhesiolysis and Adhesion Prevention in 2-Stage Surgery. Ann Surg 2013; 261:e170. [PMID: 24253144 DOI: 10.1097/sla.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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ten Broek RPG, Issa Y, van Santbrink EJP, Bouvy ND, Kruitwagen RFPM, Jeekel J, Bakkum EA, Rovers MM, van Goor H. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ 2013; 347:f5588. [PMID: 24092941 PMCID: PMC3789584 DOI: 10.1136/bmj.f5588] [Citation(s) in RCA: 336] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To estimate the disease burden of the most important complications of postoperative abdominal adhesions: small bowel obstruction, difficulties at reoperation, infertility, and chronic pain. DESIGN Systematic review and meta-analyses. DATA SOURCES Searches of PubMed, Embase, and Central, from January 1990 to December 2012, without restrictions to publication status or language. STUDY SELECTION All types of studies reporting on the incidence of adhesion related complications were considered. DATA EXTRACTION AND ANALYSIS The primary outcome was the incidence of adhesive small bowel obstruction in patients with a history of abdominal surgery. Secondary outcomes were the incidence of small bowel obstruction by any cause, difference in operative time, enterotomy during adhesiolysis, and pregnancy rate after abdominal surgery. Subgroup and sensitivity analyses were done to study the robustness of the results. A random effects model was used to account for heterogeneity between studies. RESULTS We identified 196 eligible papers. Heterogeneity was considerable for almost all meta-analyses. The origin of heterogeneity could not be explained by study design, study quality, publication date, anatomical site of operation, or operative technique. The incidence of small bowel obstruction by any cause after abdominal surgery was 9% (95% confidence interval 7% to 10%; I(2)=99%). the incidence of adhesive small bowel obstruction was 2% (2% to 3%; I(2)=93%); presence of adhesions was generally confirmed by emergent reoperation. In patients with a known cause of small bowel obstruction, adhesions were the single most common cause (56%, 49% to 64%; I(2)=96%). Operative time was prolonged by 15 minutes (95% confidence interval 9.3 to 21.1 minutes; I(2)=85%) in patients with previous surgery. Use of adhesiolysis resulted in a 6% (4% to 8%; I(2)=89%) incidence of iatrogenic bowel injury. The pregnancy rate after colorectal surgery in patients with inflammatory bowel disease was 50% (37% to 63%; I(2)=94%), which was significantly lower than the pregnancy rate in medically treated patients (82%, 70% to 94%; I(2)=97%). CONCLUSIONS This review provides detailed and systematically analysed knowledge of the disease burden of adhesions. Complications of postoperative adhesion formation are frequent, have a large negative effect on patients' health, and increase workload in clinical practice. The quantitative effects should be interpreted with caution owing to large heterogeneity. REGISTRATION The review protocol was registered through PROSPERO (CRD42012003180).
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Affiliation(s)
- Richard P G ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Center, PO Box 9101, 6500 HB Nijmegen, Netherlands
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Abstract
OBJECTIVE To determine the incidence of bowel injury in operations requiring adhesiolysis and to assess the impact of adhesiolysis on the incidence of surgical complications, postoperative morbidity, and costs. BACKGROUND Morbidity of adhesiolysis during abdominal surgery seems an important health care problem, but the direct impact of adhesiolysis on inadvertent organ damage, morbidity, and costs is unknown. METHODS In a prospective cohort study, detailed data on adhesiolysis were gathered by direct observation during elective abdominal surgery. Comparison was made between surgical procedures with and without adhesiolysis on the incidence of inadvertent bowel defects. Secondary outcomes were the effect of adhesiolysis and bowel injury on surgical complications, other morbidity, and costs. RESULTS A total of 755 (out of 844) surgeries in 715 patients were included. Adhesiolysis was required in 475 (62.9%) of operations. Median adhesiolysis time was 20 minutes (range: 1-177). Fifty patients (10.5%) undergoing adhesiolysis inadvertently incurred bowel defect, compared with 0 (0%) without adhesiolysis (P < 0.001). In univariate and multivariate analyses, adhesiolysis was associated with an increase of sepsis incidence [odds ratio (OR): 5.12; 95% confidence interval (CI): 1.06-24.71], intra-abdominal complications (OR: 3.46; 95% CI: 1.49-8.05) and wound infection (OR: 2.45; 95% CI: 1.01-5.94), longer hospital stay (2.06 ± 1.06 days), and higher hospital costs [$18,579 (15,204-21,954) vs $14,063 (12,471-15,655)]. Mortality after adhesiolysis complicated by a bowel defect was 4 out of 50 (8%), compared with 7 out of 425 (1.6%) after uncomplicated adhesiolysis (OR: 5.19; 95% CI: 1.47-18.41). CONCLUSIONS Adhesiolysis and inadvertent bowel injury have a large negative effect on the convalescence after abdominal surgery. The awareness of adhesion-related morbidity during reoperation and the prevention of postsurgical adhesion deserve priority in research and clinical practice.
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Kassir R, Blanc P, Breton C. Gastric obstruction due to adhesions 3 months after removal of an adjustable gastric band. Surg Obes Relat Dis 2013; 9:e63-5. [PMID: 23791299 DOI: 10.1016/j.soard.2013.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 03/13/2013] [Accepted: 03/15/2013] [Indexed: 10/27/2022]
Affiliation(s)
- Radwan Kassir
- Department of Digestive Surgery, CHU Hospital, Jean Monnet University, Saint Etienne, France
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Schreinemacher MHF, van Barneveld KWY, Dikmans REG, Gijbels MJJ, Greve JWM, Bouvy ND. Coated meshes for hernia repair provide comparable intraperitoneal adhesion prevention. Surg Endosc 2013; 27:4202-9. [PMID: 23749270 DOI: 10.1007/s00464-013-3021-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 05/07/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Laparoscopic incisional hernia repair with intraperitoneal mesh is associated with a certain degree of adhesion formation to the mesh. This experimental study examined the efficacy of several coated meshes for adhesion reduction. METHODS Five commercially available meshes with a layered coating were placed intraperitoneally in rats and followed up for 90 days: polypropylene and polyester meshes, both coated with absorbable collagen (Parietene Composite and Parietex Composite, respectively), and three polypropylene meshes respectively coated with absorbable omega-3 fatty acids (C-Qur Edge), absorbable cellulose (Sepramesh IP), and nonabsorbable expanded polytetrafluoroethylene (Intramesh T1). Uncoated polypropylene and collagen meshs (Parietene and Permacol, respectively) served as the control condition. Adhesions, incorporation, and tissue reaction were evaluated macro- and microscopically. Additionally, the development of the neoperitoneum was examined. RESULTS All the coated meshes performed equally well in terms of adhesion reduction. The collagen mesh performed comparably, but the uncoated polypropylene mesh performed significantly worse. The different coatings led to very differing degrees of inflammation. Ingrowth was observed only at the place of suture but was comparable for all the meshes except C-Qur Edge, which showed the weakest incorporation. Development of a neoperitoneum on the mesh surface occurred independently of whether an absorbable or nonabsorbable coating or no coating at all was present. CONCLUSIONS Commercially available meshes with a layered coating deliver comparable adhesion reduction. The physical presence of a layered coating between the intraperitoneal content and the abdominal wall seems to be more important than the chemical properties of the coating in adhesion formation.
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Affiliation(s)
- Marc H F Schreinemacher
- Department of General Surgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands,
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Adhesions after abdominal surgery: a systematic review of the incidence, distribution and severity. Surg Today 2013; 44:405-20. [PMID: 23657643 DOI: 10.1007/s00595-013-0591-8] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 02/07/2013] [Indexed: 12/20/2022]
Abstract
Abdominal adhesions are associated with increased postoperative complications, cost and workload. We performed a systematic review with statistical pooling to estimate the formation rate, distribution and severity of postoperative adhesions in patients undergoing abdominal surgery. A literature search was carried out for all articles reporting on the incidence, distribution and severity of adhesions between January 1990 and July 2011. Twenty-five articles fulfilled the inclusion criteria. The weighted mean formation rate of adhesions after abdominal surgery was 54 % (95 % confidence interval [CI] 40-68 %), and was 66 % (95 % CI 38-94 %) after gastrointestinal surgery, 51 % (95 % CI 40-63 %) after obstetric and gynaecological surgery and 22 % (95 % CI 7-38 %) after urological surgery. The mean overall severity score was 1.11 ± 0.98 according to the Operative Laparoscopy Study Group classification. Laparoscopic surgery reduced the adhesion formation rate by 25 % and decreased the adhesion severity score (laparoscopic; 0.36 ± 0.69 vs. open; 2.14 ± 0.84) for gastrointestinal surgery. Our results demonstrate that the incidence and severity of abdominal adhesions varies between surgical specialties and procedures. An increased awareness of adhesions can help in identifying the underlying mechanisms of adhesion formation and novel therapeutic approaches, while also improving the surgical consent process.
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Meuleman T, Schreinemacher MHF, van Goor H, Bakkum EA, Dörr PJ. Adhesion awareness: a nationwide survey of gynaecologists. Eur J Obstet Gynecol Reprod Biol 2013; 169:353-9. [PMID: 23628426 DOI: 10.1016/j.ejogrb.2013.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 02/28/2013] [Accepted: 03/29/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Adhesions and related complications lead to substantially increased morbidity and mortality which increase medical costs. We investigated the awareness of adhesions among Dutch gynaecologists and gynaecology residents. STUDY DESIGN A survey, assessing knowledge and opinion about adhesions, was sent to a randomly selected group of 381 gynaecologists and 256 residents. In addition, the informed consent process and application of anti-adhesive agents were questioned. RESULTS The response rate was 56.9%. Complications due to adhesions were highly underestimated, leading to low knowledge scores (mean score 35.1%). Of all respondents 73.8% agreed that adhesions exert a clinically relevant and negative effect, but only 51.2% expressed a positive opinion on adhesion prevention. This correlated with a stronger belief in the clinically relevant and negative effects of adhesions and the opinion that adhesion prevention belongs to standard care (ρ=0.212, p<0.001; ρ=0.495, p<0.001). Of all respondents 31.4% expressed a positive attitude towards anti-adhesive agents and 19.8% expressed a negative one. A negative attitude correlated with a negative view in terms of cost-benefits (ρ=0.245, p<0.001). Although 43.5% had used anti-adhesive agents in the past year, 20.9% had used them before but stopped using agents in the past year. Only 5.2% routinely included adhesions or related morbidity in the informed consent. CONCLUSIONS Awareness of adhesions is limited and informed consent is provided inadequately. Implementing adhesion prevention is related with awareness of adhesions. These findings underline the need to embed adhesions, related morbidity and prevention in educational programmes.
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Affiliation(s)
- Tess Meuleman
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.
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Chaturvedi AA, Lomme RMLM, Hendriks T, van Goor H. Prevention of postsurgical adhesions using an ultrapure alginate-based gel. Br J Surg 2013; 100:904-10. [DOI: 10.1002/bjs.9131] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 12/08/2022]
Abstract
Abstract
Background
Postoperative adhesion formation is a common consequence of abdominal surgery, and constitutes a major source of morbidity and mortality. This study evaluated an ultrapure alginate-based antiadhesive barrier gel.
Methods
Experiments were performed in a rat model with caecal abrasion and peritoneal side wall excision. The primary endpoint was the incidence of adhesions at 14 days after surgery. In experiment 1 (24 rats), animals treated with alginate gel were compared with controls that had no antiadhesive barrier. In experiment 2 (42 rats), alginate gel was compared with sodium hyaluronate carboxymethyl cellulose (HA/CMC) membrane and with no antiadhesive barrier. To check for any remote action of the gel, in experiment 3 (45 rats) application of alginate gel to the ipsilateral versus contralateral side of injury was compared with no antiadhesive barrier.
Results
In experiment 1, ultrapure alginate gel reduced the incidence of adhesions from eight of 12 in control animals to one in 12 (P = 0·009). Tissue healing assessed by histology was similar in both groups. In experiment 2, ultrapure alginate gel and HA/CMC membrane showed similar antiadhesive effectiveness, reducing the incidence of adhesions from ten of 14 rats in the control group to three of 14 (P = 0·021) and two of 14 (P = 0·006) respectively. In experiment 3, ultrapure alginate gel reduced the incidence of adhesions at the site of direct application (1 of 15) compared with controls (13 of 15; P = 0·001), but not if applied remotely (9 of 15; P = 0·214).
Conclusion
Ultrapure alginate gel decreased the incidence of postoperative adhesion formation in this rat model.
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Affiliation(s)
- A A Chaturvedi
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- European Medical Contract Manufacturing, Nijmegen, The Netherlands
| | - R M L M Lomme
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - T Hendriks
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - H van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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ten Broek RPG, van den Beukel BAW, van Goor H. Comparison of operative notes with real-time observation of adhesiolysis-related complications during surgery. Br J Surg 2012; 100:426-32. [DOI: 10.1002/bjs.8994] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2012] [Indexed: 11/07/2022]
Abstract
Abstract
Background
The operative report contains critical information for patient care, serves an educational purpose and is an important source for surgical research. Recent studies demonstrate that operative reports are unstructured and lack vital components. The accuracy of the operative notes has never been assessed. The aim of this study was to analyse the accuracy of operative reports by comparing notes with intraoperative observer-derived findings regarding adhesions and adhesiolysis-related complications.
Methods
The incidence of adhesions and adhesiolysis-induced injury were scored from the reports by a researcher blinded to operative findings obtained prospectively by direct observation. In addition, factors influencing correct reporting were analysed, including sex, surgical experience, delay in dictation, and the gradual introduction of a new report template with a focus on describing operative findings rather than actions taken.
Results
A total of 755 consecutive operative reports were analysed. Sensitivity and specificity for the incidence of adhesions was 85·1 and 72·4 per cent respectively. Six of 43 inadvertent enterotomies, and 17 of 48 other organ injuries, had not been reported. All missed bowel injuries were found in reports written in the old template. A median delay in dictating of 3 (range 1–226) working days was found for 56 reports (7·4 per cent). Documentation of inadvertent enterotomies was missing more often in delayed reports (2 of 3 versus 4 of 40 reports dictated with no delay; P = 0·022).
Conclusion
The sensitivity and specificity of operative reports noting adhesions and adhesiolysis were low. One in seven enterotomies was not reported. Effort should be put into teaching timely, meaningful, structured and accurate reporting of surgical procedures.
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Affiliation(s)
- R P G ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - B A W van den Beukel
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - H van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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ten Broek R, Kok- Krant N, Bakkum E, Bleichrodt R, van Goor H. Different surgical techniques to reduce post-operative adhesion formation: a systematic review and meta-analysis. Hum Reprod Update 2012; 19:12-25. [DOI: 10.1093/humupd/dms032] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Hirschelmann A, Wallwiener CW, Wallwiener M, Weyhe D, Tchartchian G, Hackethal A, De Wilde RL. Is Patient Education About Adhesions a Requirement in Abdominopelvic Surgery? Geburtshilfe Frauenheilkd 2012; 72:299-304. [PMID: 25284835 DOI: 10.1055/s-0031-1298425] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 02/17/2012] [Accepted: 02/28/2012] [Indexed: 12/14/2022] Open
Abstract
Background: Over the past decades, our knowledge and understanding of adhesions and adhesion-related complications has increasingly grown and it has become evident that adhesions have significant implications for patients, physicians and the healthcare system. The question arises whether this has resulted in greater awareness of adhesion-related problems among practicing physicians and appropriate patient education on this topic in daily practice. The following article provides a brief overview of the important subject of adhesions, discusses current awareness of adhesions among patients and doctors and addresses the consequences of failure to provide patient education and consent from a medical perspective. Methods: Selective literature searches were conducted in PubMed and the Cochrane Library. A patient information and consent form was developed based on several years' experience and expertise in the field of adhesions. Results: Adhesions are the most common type of complication in abdominopelvic surgery today, with devastating consequences for some patients. Surveys investigating the awareness of adhesions among physicians and patients clearly showed that even well-informed physicians fail to educate their patients adequately. Such failure could potentially lead to successful medical malpractice lawsuits against doctors. Conclusion: Considering their clear clinical impact, adhesions and related consequences should always be discussed with patients preoperatively. A newly developed consent form that specifically addresses adhesion formation may serve to thoroughly educate patients preoperatively and to adequately document the process of doing so.
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Affiliation(s)
- A Hirschelmann
- Department of Gynaecology, Obstetrics and Gynaecological Oncology, Pius-Hospital, Oldenburg
| | - C W Wallwiener
- Division of Gynaecological Surgery, Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen
| | - M Wallwiener
- Department of Obstetrics and Gynaecology, University of Heidelberg, Heidelberg
| | - D Weyhe
- Department of General and Visceral Surgery, Pius-Hospital, Oldenburg
| | - G Tchartchian
- Clinic for Minimal Invasive Surgery, Berlin-Zehlendorf
| | - A Hackethal
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women's Hospital, Herston, Queensland, Austria
| | - R L De Wilde
- Department of Gynaecology, Obstetrics and Gynaecological Oncology, Pius-Hospital, Oldenburg
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