Prevention of postoperative abdominal adhesions by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable membrane: a prospective, randomized, evaluator-blinded multicenter study

What Should I Use? Impact of Adhesion Barriers on Postoperative Abdominal Complications: A Systematic Review

BACKGROUND

Adhesions are a feared complication of abdominal surgery. There have been many new adhesion barriers developed and tested; however, there is no recent systematic review analyzing all the published literature. To address this, we aimed to analyze the different types of adhesion barriers, and determine their effects on postoperative outcomes in patients.

METHODS

A total of 14,038 articles utilizing adhesion barriers in abdominal surgery were retrieved from the PubMed, EMBASE, and Scopus databases. Inclusion criteria were: patients undergoing abdominal surgery, patients receiving an adhesion barrier, and reported postoperative outcomes. Two reviewers independently screened titles/abstracts and full-text articles using Covidence. The ROBINS-I tool was used to assess the quality of the included studies. Study protocol: Prospero CRD42023458230.

RESULTS

A total of 20 studies, with no overall high risk of bias, with 171,792 patients were included. Most studies showed an equivocal benefit for adhesion barriers, with no singular adhesion barrier type that had definitive superior outcomes compared to the others. Bioresorbable barriers emerged as the most extensively researched adhesion barrier type, exhibiting promising results in colorectal surgery. Starch-based adhesion barriers also exhibited a reduction in overall postoperative bowel obstructions and may be beneficial for stoma sites and port closures. On the other hand, many studies raised concerns regarding complications, including risk of abscess formation, fistula development, peritonitis, and anastomotic leakage.

CONCLUSIONS

Adhesion barriers should be considered on a case-by-case basis, however, they should not be utilized prophylactically in all abdominal surgeries due to their risk of complications.

Effects of composition and pH on the degradation of hyaluronate and carboxymethyl cellulose gels and release of nanocrystalline silver

Adhesions are fibrous tissue connections which are a common complication of surgical procedures and may be prevented by protecting tissue surfaces and reducing inflammation. The combination of biodegradable polymers and nanocrystalline silver can be used to create an anti-inflammatory gel to be applied during surgery. In this study, sodium hyaluronate and sodium carboxymethyl cellulose were added in concentrations from 0.25% to 1% w/v to aqueous nanocrystalline silver solutions to create viscous gels. Gels were loaded into dialysis cassettes and placed in PBS for 3 days. pH was adjusted using potassium phosphate monobasic and sodium hydroxide. Release of silver into the PBS was measured at several time points. Polymer degradation was compared by measuring the viscosity of the gels before and after the experiment. Gels lost up to 84% of initial viscosity over 3 days and released between 24% and 41% of the added silver. Gels with higher initial viscosity did not have a greater degree of degradation, as measured by percent viscosity reduction, but still resulted in a higher final viscosity. Silver release was not significantly impacted by pH or composition, but still varied between experimental groups.

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.

Effects of anchoring sutures at diverting ileostomy after rectal cancer surgery on peritoneal adhesion at following ileostomy reversal

Purpose

During diverting ileostomy reversal for rectal cancer patients who underwent previous sphincter-saving surgery, the extent of adhesion formation around the ileostomy site affects operative and postoperative outcomes. Anchoring sutures placed at the time of the ileostomy procedure may reduce adhesions around the ileostomy. This study aimed to evaluate the effects of anchoring sutures on the degree of adhesion formation and the postoperative course at the time of ileostomy reversal.

Methods

Patients who underwent sphincter-saving surgery with diverting ileostomy for rectal cancer between January 2013 and December 2017 were enrolled. Variables including the peritoneal dhesion index (PAI) score, operation time, the length of resected small bowel, operative complications, and postoperative hospital stay were collected prospectively and compared between the anchoring group (AG) and non-anchoring group (NAG).

Results

A total of 90 patients were included in this study, with 60 and 30 patients in the AG and NAG, respectively. The AG had shorter mean operation time (46.88 ± 16.37 minutes vs. 61.53 ± 19.36 minutes, P = 0.001) and lower mean PAI score (3.02 ± 2.53 vs. 5.80 ± 2.60, P = 0.001), compared with the NAG. There was no significant difference in the incidence of postoperative complications between the AG and NAG (5.0% vs. 13.3%, respectively; P = 0.240).

Conclusion

Anchoring sutures at the formation of a diverting ileostomy could decrease the adhesion score and operation time at ileostomy reversal, thus may be effective in improving perioperative outcomes.

Effect of hyaluronate-based bioresorbable membrane (Seprafilm) on outcomes of abdominal surgery: a meta-analysis and trial sequential analysis of randomised controlled trials

We aimed to evaluate comparative outcomes of abdominal surgery with and without hyaluronate-based bioresorbable membrane (Seprafilm).We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Small bowel obstruction, anastomotic leak, surgical site infections, ileus, and severity of adhesions were the evaluated outcome measures. Thirteen randomised controlled trials reporting a total of 3665 patients evaluating outcomes of abdominal surgeries with (n = 1800) or without (n = 1865) use of Seprafilm were identified. Use of Seprafilm was associated with significantly lower risk of small bowel obstruction (RR 0.53, 95% CI 0.38-0.73, P = 0.0001) but significantly higher rate of anastomotic leak (RR 1.85, 95% CI 1.15-3.00 P = 0.01). Moreover, while Seprafilm resulted in significantly more adhesions-free patients (RR 5.57, 95% CI 3.37-9.19, P < 0.0001) compared to no Seprafilm, its use was associated with significantly lower grade 2 (RR 0.57, 95% CI 0.35-0.95, P = 0.003) or 3 (RR 0.31, 95% CI 0.17-0.55, P < 0.0001) adhesions. There was no significant difference in surgical site infection (RR: 1.21, 95 CI 0.86-1.70, P = 0.28), intra-abdominal abscess (RR 1.46, 95 CI 0.92-2.32, P = 0.11) or paralytic ileus (RR 0.97, 95 CI 0.68-1.38, P = 0.87) between two groups. The trial sequential analysis demonstrated that the meta-analysis findings are conclusive. Our meta-analysis demonstrated that Seprafilm reduces the risk of small bowel obstruction and severity of adhesions after abdominal surgery. However, it may increase the risk of anastomotic leak. We recommend use of Seprafilm in any abdominal surgery which does not involve an anastomosis.

Peritoneal Adhesions and their Prevention - Current Trends

The development of adhesions after gynecologic surgery is a severe problem with ramifications that go beyond the medical complications patients suffer (which most often include pain, obstruction and infertility), since they also impose a huge financial burden on the health care system and increase the workload of surgeons and all personnel involved in surgical follow-up care. Surgical techniques to avoid adhesion formation have not proven to be sufficient and pharmaceutical approaches for their prevention are even less effective, which means that the use of adhesion prevention devices is essential for achieving decent prophylaxis. This review explores the wide range of adhesion prevention products currently available on the market. Particular emphasis is put on prospective randomized controlled clinical trials that include second-look interventions, as these offer the most solid evidence of efficacy. We focused on adhesion scores, which are the most common way to quantify adhesion formation. This enables a direct comparison of the efficacies of different devices. While the greatest amount of data are available for oxidized regenerated cellulose, the outcomes with this adhesion barrier are mediocre and several studies have shown little efficacy. The best results have been achieved using adhesion barriers based on either modified starch, i.e., 4DryField® PH (PlantTec Medical GmbH, Lüneburg, Germany), or expanded polytetrafluoroethylene, i.e., GoreTex (W.L. Gore & Associates, Inc., Medical Products Division, Flagstaff, AZ), albeit the latter, as a non-resorbable barrier, has a huge disadvantage of having to be surgically removed again. Therefore, 4DryField® PH currently appears to be a promising approach and further studies are recommended.

A resorbable hyaluronic acid hydrogel to prevent adhesion in porcine model under laparotomy pelvic surgery

Surgical post-operative adhesions can lead to serious clinical complications. Barrier agent is the broad usage for the prevention of post-operative adhesions. This study aimed to evaluate the reducing adhesion efficacy of non-animal hyaluronic acid (HA) hydrogel in pigs undergoing conventional laparotomy pelvic surgery. HA hydrogel was applied to eighteen female pigs who underwent conventional laparotomy. The adhesion degrees and histopathology were evaluated in bilateral uterine horns as well as peritoneal sidewall excision. In the present study, all animals survived and had no complications after the surgery. The histopathological observations were demonstrated that HA obviously improved laparotomy pelvic surgery-induced adhesion in peritoneal sidewall and uterine horn. The anastomotic healing score of injury + HA group was significantly lower than the injury alone group. We conclude HA hydrogel can attenuate the post-operative adhesions in porcine.

A prospective multi-center registry concerning the clinical performance of laparoscopic colorectal surgery using an absorbable adhesion barrier (INTERCEED®) made of oxidized regenerated cellulose

Purpose

The aim of this prospective multi-center registry was to evaluate the safety and clinical performance of INTERCEED^® in laparoscopic colorectal surgery.

Methods

This study was a prospective, multi-center, single-arm registry wherein patients who received INTERCEED^® in laparoscopic colorectal surgery were registered consecutively (UMIN-CTR 00001872). The primary outcome was the incidence rate of postoperative adhesive small intestinal obstruction within 6 months. The secondary outcomes were reoperation related to postoperative bleeding and anastomotic leak, surgical site infection (SSI) and anastomotic leak.

Results

Between March 2012 and March 2015, a total of 202 patients were enrolled from six institutions. INTERCEED^® was not applied in two patients, so 200 patients were analyzed using the full analysis set population. The incidence rate of postoperative adhesive intestinal obstruction was 1.0% (2/200). The total SSI rate was 3.5% (7/200), the deep incisional SSI rate was 0.0% (0/200), and the organ SSI rate was 0.0% (0/200). The incidence of anastomotic leak was 1.0% (2/200). Reoperation was performed in two cases: one for anastomotic leak and the other as cardiac surgery due to heart disease.

Conclusions

Using INTERCEED^® in laparoscopic colorectal surgery is safe and may be useful for preventing postoperative adhesive small intestinal obstruction.

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

Background

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

Materials and methods

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

Results

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

Conclusion

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

The Primary Result of Prospective Randomized Multicenter Trial of New Spray-Type Bio-absorbable Adhesion Barrier System (TCD-11091) Against Postoperative Adhesion Formation

BACKGROUND

Postoperative adhesions are the major cause of postoperative complications including intestinal obstruction, infertility, and chronic pelvic pain. In order to reduce postoperative adhesions, Terumo Corporation (Tokyo, Japan) has developed an adhesion barrier system (TCD-11091) which is easy to use at the treatment site in various surgical procedures including laparoscopic surgeries. We conducted a prospective randomized single-blind study in patients who underwent laparotomy with ileostomy.

METHODS AND RESULTS

One hundred twenty-six patients were randomly assigned to TCD-11091 group (n = 62) or non-treatment group (n = 62). Patient backgrounds were similar between the groups. At the time of ileostomy closure (the second-look surgery), the observation was performed on 55 in the TCD-11091 group and 43 in the control group. The incidence of adhesions observed at the second-look surgery was significantly lower in the TCD-11091 group (52.7 versus 90.7%; p < 0.001). For the secondary endpoints, the incidence of wide extent adhesions (grade 2 or higher) was significantly reduced (38.2 versus 79.1%; p < 0.001). Regarding the severity of adhesions, the incidence of grade 2 or higher adhesions was also significantly lower in the TCD-11091 group (47.3 versus 88.4%; p < 0.001). No differences in the incidence of adverse events were found between the TCD-11091 group and the non-treatment group (85.2 versus 75.4%; p = 0.225).

CONCLUSIONS

Use of TCD-11091 was safe and associated with significantly lower incidence of adhesion and severity of adhesions compared with non-treatment procedure.

Effect of polylactic film (Surgi-Wrap) on preventing postoperative ileus after major hepato-pancreato-biliary surgery

Backgrounds/Aims

Major hepato-pancreato-biliary (HPB) surgery is usually performed via an open method rather than a laparoscopic method. Postoperative ileus (POI) is a classic complication after open surgery. The purpose of this study was to determine whether polylactic film is useful in the prevention of POI.

Methods

A total of 179 patients who underwent major HPB surgery between 2005 and 2014, were retrospectively reviewed. A diagnosis of POI was made by a physical examination, laboratory, and radiological findings. Surgi-Wrap® polylactic film was preferentially used intraperitoneally by surgeons, just before wound closure.

Results

Major HPB surgery included pancreatoduodenectomy (n=48), distal or subtotal pancreatectomy (n=24), hepatectomy (n=67), other bile duct or gallbladder operations (n=35), and others (n=5). Although patients with polylactic film showed a significantly lower incidence of POI (n=3, 4.1% vs. n=14, 13.3%, p=0.041), they showed a significantly higher complication rate (n=20, 27.0% vs. n=19, 18.1%, p=0.004), particularly intra-abdominal fluid collection (n=7, 9.4% vs. n=2, 1.9%), and wound infections (n=6, 8.1% vs. n=3, 2.9%), than those who did not receive the film, respectively.

Conclusions

Although the polylactic film prevented POI, more complications other than POI were observed. Well-designed randomized controlled trials, using this anti-adhesive product, are needed to evaluate its effect on POI after major HPB surgery.

Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery

Background

One of the potential advantages of laparoscopic compared with open colorectal surgery is a reduction in postoperative bowel obstruction events. Early reports support this proposal, but accumulated evidence is lacking.

Methods

A systematic review and meta-analysis was performed of randomized clinical trials and observational studies by searching the PubMed and Cochrane Library databases from 1990 to August 2015. The primary outcomes were early and late postoperative bowel obstruction following laparoscopic and open colorectal surgery. Both ileus and bowel obstruction were defined as a postoperative bowel obstruction. Subgroup and sensitivity analyses were performed, and a random-effects model was used to account for the heterogeneity among the studies.

Results

Twenty-four randomized clinical trials and 88 observational studies were included in the meta-analysis; 106 studies reported early outcome and 12 late outcome. Collectively, these studies reported on the outcomes of 148 392 patients, of whom 58 133 had laparoscopic surgery and 90 259 open surgery. Compared with open surgery, laparoscopic surgery was associated with reduced rates of early (odds ratio 0·62, 95 per cent c.i. 0·54 to 0·72; P &lt; 0·001) and late (odds ratio 0·61, 0·41 to 0·92; P = 0·019) postoperative bowel obstruction. Weighted mean values for early postoperative bowel obstruction were 8 (95 per cent c.i. 6 to 10) and 5 (3 to 7) per cent for open and laparoscopic surgery respectively, and for late bowel obstruction were 4 (2 to 6) and 3 (1 to 5) per cent respectively.

Conclusion

The reduction in postoperative bowel obstruction demonstrates an advantage of laparoscopic surgery in patients with colorectal disease.

Standard Biocompatibility Studies Do Not Predict All Effects of PVA/CMC Anti-Adhesive Gel in vivo

Purpose: PVA/CMC (polyvinyl alcohol/carboxymethyl cellulose) hydrogel fulfills various physiochemical properties required for an adhesion barrier and has shown good anti-adhesion properties in previous in vivo studies. In this investigation, we assessed the in vitro and in vivo biocompatibility of PVA/CMC gel and compared this to the functionality and promotion of wound healing for two surgical indications. Methods: Standardized ISO10993 in vitro and in vivo biocompatibility studies, comprising cytotoxicity, genotoxicity, acute systemic toxicity, delayed contact and maximization sensitization test, intracutaneous reactivity and local muscle implantation, were performed on PVA/CMC gel. In the functional studies, PVA/CMC gel was applied - on the one hand - to a rabbit abdominal wall model enforced with a polypropylene mesh for testing the anti-adhesion properties and - on the other hand - to an end- to-end anastomosis model that was selected for surveying potential influences of different dosages of PVA/CMC gel on anastomotic wound healing. Results: The ISO10993 methods indicated generally good biocompatibility properties, such as the absence of cytotoxic and mutagenic effects as well as no signs of systemic toxicity and sensitization potentials. No irritation effects were observed after the intracutaneous injection of lipophilic PVA/CMC sesame oil extract. However, the injection of hydrophilic PVA/CMC physiologic saline extract induced slight irritation. Following rabbit muscle implantation of the PVA membrane for 2, 4, 12, 26 and 52 weeks, a slight irritant effect was observed at 12 weeks due to the peak of phagocytosis. In the functionality tests, PVA/CMC gel showed good anti-adhesive effects in the abdominal wall model enforced with the mesh, with significantly lower and less tense adhesions compared to the untreated control. However, moderate signs of inflammation, especially in the spleen were observed after the intra-abdominal implantation of 3.3 ml PVA/CMC gel per kg body weight. In the end-to-end anastomosis model, PVA/CMC gel had no influence on wound healing. For dosages of 1-6 ml gel per treatment, no signs of intestinal leaks were detected, and tensile strength was equal to that of the untreated control, but again more moderate signs of inflammation in the spleen were observed at a dosage >3 ml. Conclusion: Comparing the standardized ISO10993 methods, anti-adhesive PVA/CMC gel displays good biocompatibility. However, those methods do not seem to be sensitive enough because the rabbit abdominal wall and the end-to-end anastomosis models display more effects with respect to the dosage and routes of the intra-abdominal resorption of PVA/CMC gel - with the recommended <2 ml PVA/CMC gel per kg body weight as a secure dosage.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safety and Efficacy of Sodium Hyaluronate Gel and Chitosan in Preventing Postoperative Peristomal Adhesions After Defunctioning Enterostomy: A Prospective Randomized Controlled Trials

Peristomal adhesions complicate closure of defunctioning enterostomy. The efficacy and safety of sodium hyaluronate gel and chitosan in preventing postoperative adhesion have not been extensively studied. This study aims to evaluate the safety and efficacy of sodium hyaluronate gel and chitosan in the prevention of postoperative peristomal adhesions.This was a prospective randomized controlled study. One hundred and fourteen patients undergoing defunctioning enterostomy were enrolled. Patients were randomly assigned to receive sodium hyaluronate gel (SHG group) or chitosan (CH group) or no antiadhesion treatment (CON group) during defunctioning enterostomy. The safety outcomes included toxicities, stoma-related complications, and short-term and long-term postoperative complications. Eighty-seven (76.3%) of the 114 patients received closure of enterostomy, during which occurrence and severity of intra-abdominal adhesions were visually assessed by a blinded assessor.Incidence of adhesion appears to be lower in patients received sodium hyaluronate gel or chitosan but differences did not reach a significant level (SHG group vs CH group vs CON group: 62.1% vs 62.1% vs 82.8%, P = 0.15). Compared with the CON group, severity of postoperative adhesion was significantly decreased in the SHG and CH group (SHG group vs CH group vs CON group: 31.0% vs 27.6% vs 62.1%; P = 0.01). There was no significant difference in the occurrence of postoperative complications and other safety outcomes among the 3 groups.Sodium hyaluronate gel or chitosan smeared around the limbs of a defunctioning enterostomy was safe and effective in the prevention of postoperative peristomal adhesions.

Regulation of synthesis and roles of hyaluronan in peritoneal dialysis

Hyaluronan (HA) is a ubiquitous extracellular matrix glycosaminoglycan composed of repeated disaccharide units of alternating D-glucuronic acid and D-N-acetylglucosamine residues linked via alternating β-1,4 and β-1,3 glycosidic bonds. HA is synthesized in humans by HA synthase (HAS) enzymes 1, 2, and 3, which are encoded by the corresponding HAS genes. Previous in vitro studies have shown characteristic changes in HAS expression and increased HA synthesis in response to wounding and proinflammatory cytokines in human peritoneal mesothelial cells. In addition, in vivo models and human peritoneal biopsy samples have provided evidence of changes in HA metabolism in the fibrosis that at present accompanies peritoneal dialysis treatment. This review discusses these published observations and how they might contribute to improvement in peritoneal dialysis.

Small bowel obstruction due to an unconjugated ursodeoxycholic acid enterolith following living donor liver transplantation: Report of a case

We report an unusual case of small bowel obstruction due to an ursodeoxycholic acid (UDCA) enterolith that occurred 7 years after liver transplantation. A 70-year-old man had undergone multiple operations, including a living donor liver transplantation (LDLT) and hepaticojejunostomy. Four years after the LDLT, cholestasis developed, for which oral UDCA was administrated. Seven years after the LDLT, he was admitted to our hospital because of pneumonia; intestinal obstruction occurred following its resolution. A radiographic contrast study and computed tomographic scan indicated a movable mass as the cause of the ileus, suggesting a giant stone. We were unable to observe or remove the stone by double balloon enteroscopy owing to the presence of severe adhesion; thus, we surgically removed the mass. The patient's postoperative course was uneventful. He was discharged 20 days after the operation. An infrared spectrophotometric analysis revealed that the stone was a true enterolith, primarily composed of unconjugated UDCA. An ileus caused by a true enterolith is a rare clinical complication of LDLT. Nevertheless, it must be considered in the differential diagnosis of intestinal obstructions in liver transplant recipients with Roux-en-Y hepaticojejunostomies and/or bowel stasis.

Efficacy and Safety of Ultrapure Alginate-Based Anti-Adhesion Gel in Experimental Peritonitis

BACKGROUND

Intra-abdominal infection may lead to adhesion and abscess formation. An adhesion barrier can reduce these complications but also aggravate intra-peritoneal infection, causing the opposite effects. The fear of infection propagation has limited clinical adhesion barrier use in a contaminated or infected abdomen. This study evaluated both adhesion and abscess reduction and infection propagation of a new ultrapure alginate-based anti-adhesive barrier gel in a rat peritonitis model.

METHODS

In 64 male Wistar rats, bacterial peritonitis was induced via intra-abdominal injection of a mixture of sterile feces, 10(5) colony-forming units (CFU) of Escherichia coli, and 10(4) CFU of Bacteroides fragilis. Surgical debridement and peritoneal lavage were performed 1 h after inoculation. Animals were randomly allocated in equal numbers to a control group or an alginate gel group. Animals were sacrificed on day five post-operatively. Death and the presence and size of intra-abdominal abscesses were noted, and adhesions were scored. All outcomes were compared in the two groups.

RESULTS

Seventeen rats (27%) died prematurely without any difference between the groups. Of the surviving rats in the alginate gel group, 88% developed abscesses vs. 100% of the control group. There was no significant difference in the abscess scores or incidence rates of adhesion formation between the groups. The adhesion scores were lower for the alginate gel group compared with control animals (p=0.04).

CONCLUSION

Ultrapure alginate gel reduces adhesion severity but not abscesses. The gel seemed to be safe, not aggravating intra-peritoneal infection in this abdominal infection model.

Tranexamic acid and hyaluronate/carboxymethylcellulose create cell injury

Background and Objectives:

Postoperative pelvic adhesions are associated with chronic pelvic pain, dyspareunia, and infertility. The aim of this study was to evaluate the adhesion prevention effects of tranexamic acid (TA) and hyaluronate/carboxymethylcellulose (HA/CMC) barrier in the rat uterine horn models on the basis of macroscopic and microscopic adhesion scores and histopathological as well as biochemical parameters of inflammation.

Methods:

Twenty-one Wistar rats were randomly divided into 3 groups. Ten lesions were created on the antimesenteric surface of both uterine horns by bipolar cautery. Three milliliters of 0.9% sodium chloride solution were administered in the control group. A single layer of 2 × 2 cm HA/CMC was plated in group 2. Two milliliters of TA was applied in the last group. All rats were sacrificed at postoperative day 21.

Results:

No significant difference was found among the control group, the HA/CMC group, and the TA group in terms of macro-adhesion score (P = .206) and microadhesion score (P = .056). No significant difference was found among the 3 groups in terms of inflammation score (P = .815) and inflammatory cell activity (P = .835). Malondialdehyde levels were significantly lower in the control group than in the TA group and HA/CMC group (P = .028). Superoxide dismutase and glutathione S-transferase activities were found to be higher in the control group than in the TA group (P = .005) and HA/CMC group (P = .009).

Conclusions:

TA and HA/CMC had no efficacy in preventing macroscopic or microscopic adhesion formation and decreasing inflammatory cell activity or inflammation score in our rat models. TA and HA/CMC increased the levels of free radicals and reduced the activities of superoxide dismutase and glutathione S-transferase enzymes, which act to reduce tissue injury.

Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature

BACKGROUND

Postoperative intra-abdominal adhesions after GI surgery constitute a major burden for health care provision globally, causing chronic abdominal symptoms and necessitating repeated surgical intervention.

OBJECTIVE

This systematic review examines safety and efficacy data for current anti-adhesion strategies after GI surgery.

DATA SOURCES

PubMed, Medline, and Embase databases were searched for randomized control trials and nonrandomized clinical studies of anti-adhesion products from January 1980 to October 2013.

STUDY SELECTION

A list of predefined search terms was combined with the Cochrane Highly Sensitive Search Strategy to identify studies.

INTERVENTION

The use of an anti-adhesion strategy was investigated.

MAIN OUTCOME MEASURES

The primary outcome was the safety profile of anti-adhesion products. Secondary outcomes included the analysis of the reduction in the incidence, extent, and severity of adhesions; incidence of bowel obstruction; quality-of-life data; and oncological outcomes.

RESULTS

In total, 24 articles were included in the qualitative analysis: 17 randomized controlled trials and 7 nonrandomized studies, reporting on 5 anti-adhesion products. Data suggest that anti-adhesive products may be used safely; however, hyaluronic acid-based products should not be placed in contact with an anastomosis. The most studied product, a hyaluronic acid/carboxymethylcellulose membrane, reduces the incidence, extent, and severity of adhesions but without strong evidence of prevention of bowel obstruction.

LIMITATIONS

The size and quality of available studies varied greatly, reflected by the Jadad and MINORS scores. The majority of studies reported the use of a single product, hyaluronic acid/carboxymethylcellulose membrane.

CONCLUSIONS

Limiting adhesion formation after GI surgery is feasible. More evidence is needed regarding the efficacy in reducing chronic abdominal symptoms, repeated operative intervention, and improving quality of life.

Hypothermia decreases postoperative intra-abdominal adhesion formation

BACKGROUND

Hypothermia may decrease postoperative intra-abdominal adhesion. We sought to determine the most suitable temperature for hypothermia for decreasing postoperative adhesion formation.

METHODS

One hundred and twenty male BALB/c mice weighing 25 to 30 g were randomized into 5 groups: adhesion model with infusion of cold saline at (I) 15°C; (II) 10°C; or (III) 4°C; (IV) adhesion model without infusion of saline; and (V) sham operation without infusion of saline. Adhesion scores, incidence of adhesion, and serum cytokine levels were measured at postoperative days 1, 3, 7, and 14.

RESULTS

Adhesion scores among groups I, II, and III did not differ significantly. Interleukin-6 was significantly decreased in groups I, II, and III, compared to the levels in groups IV and V (P < .05). Tumor necrosis factor-α levels in groups I and II were significantly decreased compared to those in groups III, IV, and V (P < .05).

CONCLUSION

We suggest that 15°C is the appropriate temperature for induction of hypothermia to decrease postoperative intra-abdominal adhesion formation.

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Background

In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy.

Recommendations

In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.

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

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

Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.

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

Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.

Utilization and safety of sodium hyaluronate-carboxymethylcellulose adhesion barrier

BACKGROUND

Little is known about the use and toxicity of antiadhesion substances such as sodium hyaluronate-carboxymethylcellulose.

OBJECTIVE

We analyzed the patterns of use and safety of sodium hyaluronate-carboxymethylcellulose in patients undergoing colectomy and gynecologic surgery.

DESIGN

This is a retrospective cohort study.

SETTING

This study covered hospitals nationwide.

PATIENTS

All patients in the Premier Perspective database who underwent colectomy or hysterectomy from 2000 to 2010 were included in the analyses.

MAIN OUTCOME MEASURE

Hyaluronate-carboxymethylcellulose use was determined by billing codes. For the primary outcome, we used hierarchical mixed-effects logistic regression models to determine the factors associated with the use of hyaluronate-carboxymethylcellulose, whereas a propensity score-matched analysis was used to secondarily assess the association between hyaluronate-carboxymethylcellulose use and toxicity (abscess, bowel and wound complications, peritonitis).

RESULTS

We identified 382,355 patients who underwent hysterectomy and 267,368 who underwent colectomy. For hysterectomy, hyaluronate-carboxymethylcellulose use was 5.0% overall, increasing from 1.1% in 2000 to 9.8% in 2010. Hyaluronate-carboxymethylcellulose was used in 8.1% of those who underwent colectomy and increased from 6.2% in 2000 to 12.4% in 2010. The year of diagnosis and procedure volume of the attending surgeon were the strongest predictors of hyaluronate-carboxymethylcellulose use. After matching and risk adjustment, hyaluronate-carboxymethylcellulose use was not associated with abscess formation (1.5% vs 1.5%) (relative risk = 0.97; 95% CI, 0.84-1.12) in those who underwent hysterectomy. A patient receiving hyaluronate-carboxymethylcellulose had a 13% increased risk of abscess (17.4% vs 15.0%) (relative risk = 1.13; 95% CI, 1.08-1.17) after colectomy.

LIMITATIONS

This was an observational study.

CONCLUSION

Hyaluronate-carboxymethylcellulose use has increased over the past decade for colectomy and hysterectomy. Although there is no association between hyaluronate-carboxymethylcellulose use and abscess following hysterectomy, hyaluronate-carboxymethylcellulose use was associated with a small increased risk of abscess after colectomy.

Adhesions after abdominal surgery: a systematic review of the incidence, distribution and severity

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.

Postoperative Complications Leading to Death after Coagulum Pyelolithotomy in a Tetraplegic Patient: Can We Prevent Prolonged Ileus, Recurrent Intestinal Obstruction due to Adhesions Requiring Laparotomies, Chest Infection Warranting Tracheostomy, and Mechanical Ventilation?

A 22-year-old male sustained C-6 tetraplegia in 1992. In 1993, intravenous pyelography revealed normal kidneys. Suprapubic cystostomy was performed. He underwent open cystolithotomy in 2004 and 2008. In 2009, computed tomography revealed bilateral renal calculi. Coagulum pyelolithotomy of left kidney was performed. Pleura and peritoneum were opened. Peritoneum could not be closed. Following surgery, he developed pulmonary atelectasis; he required tracheostomy and mechanical ventilation. He did not tolerate nasogastric feeding. CT of abdomen revealed bilateral renal calculi and features of proximal small bowel obstruction. Laparotomy revealed small bowel obstruction due to dense inflammatory adhesions involving multiple small bowel loops which protruded through the defect in sigmoid mesocolon and fixed posteriorly over the area of previous intervention. All adhesions were divided. The wide defect in mesocolon was not closed. In 2010, this patient again developed vomiting and distension of abdomen. Laparotomy revealed multiple adhesions. He developed chest infection and required ventilatory support again. He developed pressure sores and depression. Later abdominal symptoms recurred. This patient's general condition deteriorated and he expired in 2011. Conclusion. Risk of postoperative complications could have been reduced if minimally invasive surgery had been performed instead of open surgery to remove stones from left kidney. Suprapubic cystostomy predisposed to repeated occurrence of stones in urinary bladder and kidneys. Spinal cord physicians should try to establish intermittent catheterisation regime in tetraplegic patients.

Peritoneofascial suture method for facilitating loop ileostomy mobilization

BACKGROUND

Ileostomy closure is a minor procedure and is performed through a small peristomal incision. However, a hard adhesion increases the technical difficulty. A peritoneofascial suture (PFS) will reduce the adhesion layers of the abdominal wall. This study was performed to evaluate whether the PFS method may decrease the extent of adhesions between the bowel and the abdominal wall opening and facilitate ileostomy mobilization.

METHODS

Forty-two patients (24 males and 18 females) with a mean age of 57 years (range = 31-80 years) and who were undergoing ileostomy closure were enrolled. The PFS group and the conventional group had 18 and 24 patients, respectively. The intraoperative findings such as degree of adhesion, mobilization time, and associated bowel injury were analyzed.

RESULTS

The thickness of the abdominal wall and the rectus abdominis was similar in both groups. The overall operation time was shorter in the PFS group than in the conventional group (50.9 vs. 80.4 min, respectively, p = 0.001). The ileostomy mobilization time was also shorter in the PFS group than in the conventional group (18.9 vs. 44.7 min, respectively, p < 0.001). The procedure was technically easier in the PFS group more frequently than in the conventional group (77.8 % vs. 31.6 %, respectively, p = 0.013). Bowel injury during mobilization was more common in the conventional group than in the PFS group (50.0 % vs. 16.7 %, respectively, p = 0.053).

CONCLUSIONS

The peritoneofascial suture method is a simple procedure, and it may facilitate ileostomy mobilization by decreasing adhesion layers. To confirm the technical advantage of this method a randomized study will be needed.

Pathogenesis and clinical and economic consequences of postoperative ileus

Postoperative ileus is a preventable disease with surprising economic consequences. Understanding the triad of dysmotility in conjunction with an enhanced recovery program improves patient outcome, decreases length of stay in hospital, and lowers the cost. Alvimopan and other investigational promotility medications can help attain these goals. Surgeons should avoid labeling all postoperative abdominal distention as ileus, which not only prevents timely diagnosis and treatment of early postoperative small bowel obstruction or acute colonic pseudo-obstruction but also increases patient morbidity and mortality.

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

INTRODUCTION

Post-operative adhesions after gastrointestinal surgery are responsible for significant morbidity and constitute an important public health problem. The aim of this study was to review the surgical literature to determine the incidence, consequences and the variety of possible countermeasures to prevent adhesion formation.

METHODS

A systematic review of English and French language surgical literature published between 1995 and 2009 was performed using the keywords "adhesion" and "surgery".

RESULTS

Peritoneal adhesions are reported as the cause of 32% of acute intestinal obstruction and 65-75% of all small bowel obstructions. It is estimated that peritoneal adhesions develop after 93-100% of upper abdominal laparotomies and after 67-93% of lower abdominal laparotomies. Nevertheless, only 15-18% of these adhesions require surgical re-intervention. The need for re-intervention for adhesion-related complications varies depending on the initial type of surgery, the postoperative course and the type of incision. The laparoscopic approach appears to decrease the risk of adhesion formation by 45% and the need for adhesion-related re-intervention to 0.8% after appendectomy and to 2.5% after colorectal surgery. At the present time, only one product consisting of hyaluronic acid applied to a layer of carboxymethylcellulose (Seprafilm(®)) has been shown to significantly reduce the incidence of postoperative adhesion formation; but this product is also associated with a significant increase in the incidence of anastomotic leakage when the membrane is applied in direct contact with the anastomosis. The use of this product has not been shown to decrease the risk of re-intervention for bowel obstruction.

CONCLUSIONS

The prevention of postoperative adhesions is an important public health goal, particularly in light of the frequency of this complication. The routine use of anti-adhesion products is not recommended given the lack of studies with a high level of evidence concerning their efficacy and safety of use.

Prevention of peritoneal adhesions: a promising role for gene therapy

Adhesions are the most frequent complication of abdominopelvic surgery, yet the extent of the problem, and its serious consequences, has not been adequately recognized. Adhesions evolved as a life-saving mechanism to limit the spread of intraperitoneal inflammatory conditions. Three different pathophysiological mechanisms can independently trigger adhesion formation. Mesothelial cell injury and loss during operations, tissue hypoxia and inflammation each promotes adhesion formation separately, and potentiate the effect of each other. Studies have repeatedly demonstrated that interruption of a single pathway does not completely prevent adhesion formation. This review summarizes the pathogenesis of adhesion formation and the results of single gene therapy interventions. It explores the promising role of combinatorial gene therapy and vector modifications for the prevention of adhesion formation in order to stimulate new ideas and encourage rapid advancements in this field.

Strategies to minimize adhesion formation after surgery

No benefit was found for adhesion prevention with the addition of hyaluronate-carboxymethylcellulose.

Objectives:

To compare the potential for postoperative laparoscopic adhesion formation utilizing either monopolar cautery or ultrasonic energy and to determine whether there is added benefit with the addition of a suspension of hyaluronate/carboxymethylcellulose in saline versus saline alone.

Methods:

Injuries were induced in rabbits by using monopolar cautery on 1 uterine horn and adjacent sidewall and ultrasonic energy on the opposite. Hyaluronate/ carboxymethylcellulose or saline was added to every other animal. Autopsies were performed after 3 weeks. Clinical and pathologic scoring of adhesions was performed by blinded investigators.

Results:

A very significant difference occurred in pathologic adhesion scores favoring the ultrasonic scalpel when the animals were treated with saline. However, a borderline significant difference was found in pathologic scores favoring the ultrasonic scalpel compared to the monopolar cautery. There was no significant difference in clinical adhesion scores between the 2 modalities. No significant difference in either score was found with the addition of hyaluronate/carboxymethylcellulose or saline with either instrument.

Conclusion:

No benefit was found for adhesion prevention with hyaluronate/carboxymethylcellulose. Although no reduction was achieved in clinical adhesions, the ultrasonic scalpel resulted in fewer histologic signs of tissue inflammation in the early postoperative period, suggesting that further clinical adhesions might develop over time with cautery.

Impact of ileal pouch-anal anastomosis on female fertility: meta-analysis and systematic review

PURPOSE

The aim of this review is to determine the effect of ileal pouch-anal anastomosis (IPAA) on female fertility in ulcerative colitis (UC) and familial adenomatous polyposis (FAP), the mechanisms of this effect, strategies for prevention and management of infertility post-IPAA.

METHODS

This paper is a systematic literature review of all articles investigating IPAA and fertility from 1966 onwards that were found searching the Medline and Embase databases. Meta-analysis was performed on relevant studies.

RESULTS

Seventeen relevant studies were identified. Six studies were excluded (duplicate data, one; predominantly not IPAA patients, one; no control group, four). The control groups of the remaining 11 studies were too varied for comparison, and so the meta-analysis was limited to six studies that provided data on infertility both pre- and post-IPAA. Five of these involved predominantly UC patients and one FAP. Average infertility rates were 20% pre-IPAA and 63% post-IPAA. The relative risk of infertility after IPAA is 3.91 ([2.06, 7.44] 95% CI). The possibility of publication bias suggests that the risk may be lower. Any increased risk is probably due to tubal dysfunction secondary to adhesions. Various methods have been proposed to reduce pelvic adhesions, but there is no evidence they have any effect in preventing infertility. Infertility treatment post-IPAA is associated with good success rates.

CONCLUSIONS

Infertility is increased after IPAA in female patients in both UC and FAP. Both these disease processes affect patients during their reproductive years. This evidence emphasizes the need for careful consideration of fertility in the choice and timing of surgery.

An artificial tendon to connect the quadriceps muscle to the tibia

No permanent, reliable artificial tendon exists clinically. Our group developed the OrthoCoupler™ device as a versatile connector, fixed at one end to a muscle, and adaptable at the other end to inert implants such as prosthetic bones or to bone anchors. The objective of this study was to evaluate four configurations of the device to replace the extensor mechanism of the knee in goats. Within muscle, the four groups had: (A) needle-drawn uncoated bundles, (B) needle-drawn coated bundles, (C) barbed uncoated bundles, and (D) barbed coated bundles. The quadriceps tendon, patella, and patellar tendon were removed from the right hind limb in 24 goats. The four groups (n = 6 for each) were randomly assigned to connect the quadriceps muscle to the tibia (with a bone plate). Specimens were collected from each operated leg and contralateral unoperated controls both for mechanical testing and histology at 90 days post-surgery. In strength testing, maximum forces in the operated leg (vs. unoperated control) were 1,288 ± 123 N (vs. 1,387 ± 118 N) for group A, 1,323 ± 144 N (vs. 1,396 ± 779 N) for group B, 930 ± 125 N (vs. 1,337 ± 126 N) for group C, and 968 ± 109 N (vs. 1,528 ± 146 N) for group D (mean ± SEM). The strengths of the OrthoCoupler™ legs in the needled device groups were equivalent to unoperated controls (p = 0.6), while both barbed device groups had maximum forces significantly lower than their controls (p = 0.001). We believe this technology will yield improved procedures for clinical challenges in orthopaedic oncology, revision arthroplasty, tendon transfer, and tendon injury reconstruction.

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

Background

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

Methods

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

Recommendations

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

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

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

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

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

Prevention of postoperative peritoneal adhesions: a review of the literature

BACKGROUND

postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies.

METHODS

the National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions.

RESULTS

ileal pouch-anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopic techniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence).

CONCLUSIONS

postoperative adhesions are a significant health problem with major implications on quality of life and health care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions.

Case series of intra-abdominal adhesions induced by artificial ulceration after endoscopic submucosal dissection before additional laparoscopic gastrectomy

BACKGROUND

As endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) increases, increasing numbers of patients require additional gastrectomy with lymph node dissection after noncurative ESD. ESD may cause intra-abdominal adhesions, making additional laparoscopic gastrectomy technically difficult.

OBJECTIVE

To assess the relation of the presence of intra-abdominal adhesions and ESD treatment to allow safe laparoscopic gastrectomy.

DESIGN

Case series from a retrospective review of additional gastrectomy after noncurative ESD.

SETTING

Tertiary care center.

PATIENTS AND INTERVENTIONS

Eight of 333 patients receiving ESD at Oita University Faculty of Medicine from 1999 to 2008 underwent additional laparoscopic gastrectomy because of noncurative ESD.

MAIN OUTCOME MEASUREMENTS

Intra-abdominal adhesions were evaluated by using an adhesion scoring system (0-3 points) and clinicopathologic findings, including artificial ulcerations after ESD.

RESULTS

All patients successfully underwent laparoscopic gastrectomy within 1 to 2 months after ESD. Three patients with large artificial ulceration (>25 mm) after ESD treatment had severe intra-abdominal adhesions (adhesion score > or =2). These patients tended to have a large blood loss and long operation times during laparoscopic gastrectomy. Despite the 2-month interval from ESD to laparoscopic gastrectomy, ulcerations in these patients were at healing stage with inflammatory cells infiltrating the muscular deep layer.

LIMITATION

A retrospective study.

CONCLUSIONS

After ESD with large artificial ulceration (>25 mm), the presence of intra-abdominal adhesions complicating additional laparoscopic gastrectomy was often observed.

Laparoscopic use of a hyaluronic acid carboxycellulose membrane slurry in gynecological oncology

Described in this study is the use of a hyaluronic acid carboxycellulose slurry to prevent adhesions in complex gynecological cases.

Objectives:

We evaluated the use of a hyaluronic acid-carboxycellulose membrane (HAC) slurry in complex laparoscopies.

Materials and Methods:

A gel-like mixture of HAC was prepared and applied in 171 consecutive complex laparoscopies on a gynecologic oncology service. The HAC slurry was used to coat deperitonealized surfaces and surgical pedicals to prevent postoperative adhesions. The technique is described and the outcomes are prospectively evaluated for feasibility and safety.

Results:

There were no postoperative bowel obstructions, 1 pelvic hematoma in a patient on clopidogrel (Plavix) immediately prior to surgery, 8 postoperative ilea, and 1 bowel perforation. The bowel perforation occurred in a patient with extensive adhesiolysis and intraoperative bowel suturing.

Conclusion:

This report describes an easy approach to the laparoscopic application of HAC. Caution should be taken if HAC slurry is applied after significant bowel suturing because 1 of 9 patients with extensive adhesiolysis requiring suturing of the sigmoid colon developed sigmoid perforations.