Adhesion prevention after endometriosis surgery - results of a randomized, controlled clinical trial with second-look laparoscopy

An In Situ UV Cross-Linking Asymmetric Adhesive Hydrogel for Noncompressible Hemostasis and Postoperative Adhesion Prevention

Noncompressible hemorrhage control is vital for clinical outcome after surgical treatment and prehospital trauma injuries. Meanwhile, wound bleeding and tissue damage could induce postoperative adhesions, leading to a severe threat to the health of patients. Considerable research had been conducted on the development of hemostatic and antiadhesive materials. However, it was still a great challenge to realize hemostasis and antiadhesion simultaneously especially in inaccessible and irregular wound sites. In this study, a kind of fluid hemostatic agent composed of gelatin methacryloyl/sulfobetaine methacrylate/oxidized konjac glucomannan (termed GOS) was developed, which spread immediately upon contacting the hepatic trauma surface and turned into hydrogels under UV radiation within 5 s, resulting in rapid hemostasis and firm adhesion to tissues (shear strength 486.08 kPa). Importantly, the surface of the as-formed GOS hydrogel exhibited lubricious and nonadhesive properties, exhibiting excellent anti-postoperative adhesion performance in a rat liver hemostasis model and a rat abdominal wall-cecum adhesion model. In addition, the GOS hydrogel reduced the postoperative secretion of inflammatory factors TNF-α and IL-6, facilitating the tissue repair. Therefore, the asymmetrical adhesive GOS hydrogel could fulfill the requirements for simultaneously rapid hemostasis, tissue adhesion, and subsequent excellent antiadhesion, which demonstrated significant potential for diverse clinical surgical operation scenarios.

Novel Minimally Invasive Surgical Approaches to Endometriosis and Adenomyosis: A Comprehensive Review

Endometriosis and adenomyosis are chronic gynecological conditions that significantly impact women's quality of life, leading to symptoms such as pelvic pain, dysmenorrhea, and infertility. Despite ongoing research, a definitive cure for these conditions remains elusive, and treatment often focuses on managing symptoms. Minimally invasive surgery is considered the gold standard for surgical management, but novel surgical techniques are continuously being developed to enhance outcomes. These innovations aim to reduce disease recurrence, improve fertility rates, and provide better long-term symptom relief. In addition, techniques like robot-assisted laparoscopy (RAS) have revolutionized the treatment of complex cases, such as deep infiltrating endometriosis (DIE), offering improved precision and effectiveness. This review explores the latest advancements in surgical approaches, their clinical efficacy, and future directions, emphasizing the need for individualized multidisciplinary care to optimize patient outcomes.

Adhesion barriers in gynecologic surgeries and cesarean section: An Asia-Pacific expert panel consensus recommendation

Adhesions arising from gynecologic surgeries and cesarean sections pose substantial clinical, social, and economic challenges, leading to issues like pelvic pain, infertility, bowel obstruction, and recurring surgeries. Preventing adhesions is a pressing unmet need, hindered by difficulties in assessing postoperative adhesions and understanding barriers. To bridge adhesion prevention gaps, statements on clinical practices were synthesized to present Asia-Pacific expert perspectives on gynecologic surgery and cesarean section adhesion prevention. An expert panel of eight physicians from various healthcare settings in the Asia-Pacific region was convened and a comprehensive literature search on topics related to adhesion prevention in gynecologic surgeries and cesarean sections was performed. Information from full-text publications was used to develop draft consensus statements, with each statement assigned the highest available evidence level based on a systematic literature review and graded using the Oxford Center for Evidence-based Medicine criteria. A modified Delphi process, involving two rounds of online voting and discussions with an extended group of 109 experts, was employed to reach a consensus on six topics related to adhesion barriers. A set of 15 consensus statements were synthesized. Key topics include adhesion incidence in Asia, cesarean section complications, barrier application status, adhesion formation and prevention, absorbable barriers' effectiveness, recommendations, and future considerations. The statements provide guidance for healthcare professionals, especially in the Asia-Pacific region, to tackle the challenges posed by postoperative adhesions and improve patient outcomes. Further research is needed to enhance understanding and prevention of adhesions in this region.

Prevention of peritoneal adhesions after gynecological surgery: a systematic review

IMPORTANCE

The formation of adhesions after gynecological surgery not only has detrimental impacts on those affected, including pain, obstruction, and infertility, but also imposes a high economic burden on healthcare systems worldwide.

OBJECTIVE

The aim of this review was to evaluate the adhesion prevention potential of all currently available adhesion barriers for gynecological surgery.

EVIDENCE ACQUISITION

We systematically searched MEDLINE and CENTRAL databases for randomized controlled trials (RCTs) on the use of adhesion barriers as compared with peritoneal irrigation or no treatment in gynecological surgery. Only RCTs with second-look surgery to evaluate adhesions in the pelvic/abdominal (but not intrauterine) cavity were included.

RESULTS

We included 45 RCTs with a total of 4,120 patients examining a total of 10 unique types of barriers in second-look gynecological surgery. While RCTs on oxidized regenerated cellulose (significant improvement in 6 of 14 trials), polyethylene glycol with/without other agents (4/10), hyaluronic acid and hyaluronate + carboxymethylcellulose (7/10), icodextrin (1/3), dextran (0/3), fibrin-containing agents (1/2), expanded polytetrafluoroethylene (1/1), N,O-carboxymethylchitosan (0/1), and modified starch (1/1) overall showed inconsistent findings, results for expanded polytetrafluoroethylene, hyaluronic acid, and modified starch yielded the greatest improvements regarding adhesion reduction at 75%, 0-67%, and 85%, respectively.

CONCLUSIONS AND RELEVANCE

Best results for adhesion prevention were reported after applying Gore-Tex Surgical Membrane, hyaluronic acid, and 4DryField®. As Gore-Tex Surgical Membrane is nonabsorbable, it is associated with a greater risk of new adhesion formation due to second-look surgery to remove the product. 4DryField® yielded the greatest improvement in adhesion score compared to all other barrier agents (85%). For better comparability, future studies should use standardized scores and put more emphasis on patient-reported outcome measures, such as pain and infertility.

Evaluation of 4DryField® as an Adhesion Prophylaxis in Pediatric Patients: A Propensity-Score Matched Study

INTRODUCTION

 Abdominal adhesions following surgery can lead to complications like intestinal obstruction and pelvic pain. While no molecular therapies currently target the underlying adhesion formation process, various barrier agents exist. 4DryField® has shown promise in reducing bleeding and adhesions in adults. This study aimed to assess its effectiveness in children.

METHODS

 The study examined all pediatric patients who underwent laparotomy between January 2018 and February 2022. It compared outcomes between those treated with 4DryField® and a control group. Key endpoints included surgical revision, adhesion recurrence, infections, insufficiencies, fever, C-reactive protein (CRP) levels, and time to gastrointestinal passage.

RESULTS

 In total, 233 children had surgery for bowel adhesions. After propensity score matching, 82 patients were included in the analysis: 39 in the control and 43 in the 4DryField® group. 4DryField® did not affect the readhesion rate. Children in the treatment group had significantly more complications (47 vs. 15%, p = 0.002), more often fever, and higher CRP levels.

CONCLUSIONS

 4DryField® did not show potential in reducing adhesion formation, but it was associated with significantly more complications in pediatric patients. Thus, future prospective studies are needed to evaluate the safety and effectiveness of 4DryField® in children.

Measurement of human peritoneal surface area using artificial intelligence software in abdominal computed tomography

PURPOSE

The calculation of the intraperitoneal organ surface area is important for understanding their anatomical structure and for conducting basic and clinical studies on diseases related to the peritoneum. To measure the intraperitoneal surface area in a living body by applying artificial intelligence (AI) techniques to the abdominal cavity using computed tomography and to prepare clinical indicators for application to the abdominal cavity.

METHODS

Computed tomography images of ten adult males and females with a healthy body mass index and ten adults diagnosed with colon cancer were analyzed to determine the peritoneal and intraperitoneal surface areas of the organs. The peritoneal surface was segmented and three-dimensionally modeled using AI medical imaging software. In addition to manual work, three-dimensional editing, filtering, and connectivity checks were performed to improve work efficiency and accuracy. The colon and small intestine surface areas were calculated using the mean length and diameter. The abdominal cavity surface area was defined as the sum of the intraperitoneal area and the surface areas of each organ.

RESULTS

The mean peritoneal surface area of all participants was measured as 10,039 ± 241 cm2 (males 10,224 ± 171 cm2 and females 9,854 ± 134 cm2). Males had a 3.7% larger peritoneal surface area than females, with a statistically significant difference (P < 0.001).

CONCLUSION

The abdominal cavity surface area can be measured using AI techniques and is expected to be used as basic data for clinical applications.

Postoperative Peritoneal Granulomatous Inflammation After the Application of Potato Starch-Based Anti-Adhesive Agent in Laparoscopic Endometriosis Surgery

Background

Endometriosis is a chronic inflammatory oestrogen-dependent disease. It is characterised by elevated inflammatory markers in the peritoneal milieu with subsequent adhesiogenesis. Nowadays, excisional, and ablative surgeries are considered the main treatment of endometriosis, and adhesiolysis is being performed almost routinely during these procedures. Postoperative adhesion formation is a significant concern for many surgeons, especially as endometriosis patients are assumed to be predisposed to adhesiogenesis. In order to minimise adhesiogenesis after endometriosis surgery, the usage of different barrier methods have been discussed in the literature. Recent studies aim to investigate the effect of potato starch preparations on adhesion formation in endometriosis patients.

Objectives

We aim to describe the findings of a second-look laparoscopy on patients who received a starch-based anti-adhesive agent.

Materials and Methods

We present a retrospective case series that included the medical, surgical, and histopathologic data of three patients.

Main outcome measures

Intraperitoneal adhesion formation and peritoneal inflammation.

Results

All three patients had de-novo adhesions during the second-look laparoscopy. Pathological examination revealed noncaseating granulomatosis of the peritoneum in all patients.

Conclusion

The use of potato starch-based agents as a peritoneal adhesion prophylaxis in laparoscopic endometriosis surgery could lead to granulomatous peritoneal inflammation. Correct application by avoiding powder remnants through complete rinsing and transformation to gel seems to be an important factor to avoid this adverse effect.

What is new?

We aim to highlight that potato starch-based anti-adhesive agents similar to the one used in this study could be a cause of adhesiogenesis and peritoneal inflammation.

Diminished Ovarian Reserve in Endometriosis: Insights from In Vitro, In Vivo, and Human Studies-A Systematic Review

Endometriosis, a prevalent disorder in women of reproductive age, is often associated with undesired infertility. Ovarian reserve, an essential measure of ovarian function that is crucial for maintaining fecundity, is frequently diminished in women with endometriosis. Though the causative relationship between endometriosis and reduced ovarian reserve is not fully understood due to the lack of standardized and precise measurements of ovarian reserve, there is ongoing discussion regarding the impact of interventions for endometriosis on ovarian reserve. Therefore, in this review, we investigate articles that have related keywords and which were also published in recent years. Thereafter, we provide a comprehensive summary of evidence from in vitro, in vivo, and human studies, thereby shedding light on the decreased ovarian reserve in endometriosis. This research consolidates evidence from in vitro, in vivo, and human studies on the diminished ovarian reserve associated with endometriosis, as well as enhances our understanding of whether and how endometriosis, as well as its interventions, contribute to reductions in ovarian reserve. Furthermore, we explore potential strategies to modify existing therapy options that could help prevent diminished ovarian reserve in patients with endometriosis.

Efficacy and safety of purified starch for adhesion prevention in colorectal surgery

Background

Adhesions within the abdominal cavity develop in as many as 90 % of individuals following abdominal surgery. However, the true adhesive condition of patients can only be ascertained during the second surgery.

Methods

We conducted a prospective, non-randomized study to assess the anti-adhesion properties of purified starch in patients who had undergone colorectal surgery in the past and then needed a subsequent surgical intervention. Adhesion scores have been prospectively recorded in operation notes since January 2020 when patients underwent a second surgery. Patients who had received purified starch during their initial surgery constituted the purified starch group, while those who had not received anti-adhesion medical materials were the control group. The main objectives of the study were to evaluate the extent and severity of adhesions as primary outcomes, while secondary outcomes included measuring blood loss, operation time, and postoperative complications.

Results

We analyzed the data of 101 patients, with 61 in the purified starch group and 40 in the control group. In multivariate analysis, adhesion severity (Odds ratio, 0.20, 95 % confidence interval 0.08-0.54, P < 0.01) and adhesion area scores (Odds ratio, 0.13, 95 % confidence interval 0.04-0.45, P < 0.01) were significantly lower in the purified starch group than in the control group. There was no significant difference in operation times, blood loss, and postoperative complications between the two groups.

Conclusion

Purified starch is a safe and effective anti-adhesion material that can significantly reduce the severity and extent of adhesion after colorectal surgery.

Clinical Outcomes after the Use of Antiadhesive Agents in Laparoscopic Reproductive Surgery

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.

Update on antiadhesion barriers and therapeutics in gynecological surgery

PURPOSE OF REVIEW

Postoperative adhesions remain a clinical challenge to both patients and providers, as they are associated with significant complications and a high economic burden. This article provides a clinical review of currently available antiadhesive agents and promising new therapies that have advanced past animal studies.

RECENT FINDINGS

Several agents have been investigated on their ability to reduce adhesion formation; however, there is no widely acceptable option. The few available interventions are barrier agents and while low-quality evidence suggests that they may be more effective than no treatment, there is no general agreement on their overall efficacy. There is an abundance of research on new solutions; however, their clinical efficacy is yet to be determined.

SUMMARY

Although a wide range of therapeutics have been investigated, majority are halted in animal models with only a select few being studied in humans and ultimately available in the market. Many agents have shown effectiveness in reducing adhesion formation, however, that has not been translated to improvement in clinically relevant outcomes; hence the need for high-quality large randomized trials.

Improvement in Fertility and Pain after Endometriosis Resection and Adhesion Prevention with 4DryField® PH: Follow-up of a Randomized Controlled Clinical Trial

BACKGROUND

Adhesions after endometriosis resection are frequent and the most common causes for chronic pain and secondary infertility. Primary results of our randomized controlled trial (RCT) on adhesion prevention after deep infiltrating endometriosis (DIE) resection using the gel barrier 4DryField^® PH showed 85% adhesion reduction in second-look surgeries. Secondary endpoint data on fertility and pain development were collected during 12-month follow-ups.

METHODS

This RCT comprised 50 patients. Preoperatively and after 1, 6 and 12 months, pain scores for cycle-independent pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and dysuria, as well as the number of pregnancies, were recorded,.

RESULTS

The pregnancy rate in the intervention group was significantly higher (p < 0.05). Pain development was also improved: after 12 months, all 5 subscores were lower in the intervention group and improvements were more pronounced, most prominently concerning cycle-independent pelvic pain and dysmenorrhea, the two subcategories with the highest preoperative scores and, therefore, the highest relevance for the patients. Cycle-independent pelvic pain even recurred in the control group, while barrier application prevented this.

CONCLUSIONS

Considering the known causal link between adhesions and pain, it is apparent that the favourable outcomes in the intervention group are linked to effective adhesion prevention. The significant increase in pregnancies is remarkable.

Using a Modified Polysaccharide as a Hemostatic Agent Results in Less Reduction of the Ovarian Reserve after Laparoscopic Surgery of Ovarian Tumors-Prospective Study

Background and Objectives: The study investigated whether the method of achieving hemostasis affects the ovarian reserve in patients undergoing laparoscopic surgery due to ovarian tumors or cysts. Materials and Methods: Patients with unilateral tumors or ovarian cysts, who qualified for laparoscopic tumor enucleation, were randomly selected to receive modified polysaccharides or bipolar coagulation. Ovarian reserve was analyzed by anti-Mullerian hormone (AMH) level. Results: The study included 38 patients: 19 patients in the modified polysaccharide group and 19 in the bipolar coagulation group. Patients after bipolar coagulation treatment had statistically significantly lower AMH 6 months after surgery compared to the group treated with modified starch. The levels of AMH in the study and control groups were 3.96 +/- 2.12 vs. 2.51 +/- 1.39 ng/mL, respectively; p = 0.018. A statistically significant decrease in AMH was also demonstrated in the bipolar coagulation group as compared to the preoperative assessment (p = 0.049). There was no statistically significant decrease in AMH in the group of patients treated with the modified starch. Conclusions: Using a modified polysaccharide during laparoscopic cystectomy is effective and has a positive effect on the ovarian reserve compared to the use of bipolar coagulation. Both the AMH level 6 months after surgery and the percentage decrease in AMH were more favorable in the group of patients treated with modified starch.

Comparison of the effect of two anti-adhesion materials on the formation of postoperative adhesions after myomectomy – an experimental study on rabbit does

This study compares the effect of Hyalobarrier Gel and 4DryField® PH on the formation of postoperative adhesions after myomectomy in an experimental study on rabbit does. Thirty experimental animals were divided into three groups: group A – control, group B – use of 4DryField® PH, and group C – use of the Hyalobarrier Gel. A simulated myomectomy was performed in each group. The animals were euthanised 14 days after the procedure and the antiadhesive effect of the above-mentioned preparations was evaluated according to the criteria. Statistical evaluation clearly showed differences in the antiadhesive effect in the scoring systems for groups B and C compared to control group A at a high level of significance. We demonstrated an obvious, statistically confirmed antiadhesive effect of the Hyalobarrier Gel and 4DryField® PH in an experimental model of the rabbit uterus. Comparing both preparations, the Hyalobarrier Gel shows a higher level of effectiveness. Based on the results of the experiment, both preparations can be unambiguously recommended for routine practice.