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Garoufalia Z, Gefen R, Emile SH, Zhou P, Silva-Alvarenga E, Wexner SD. Financial and Inpatient Burden of Adhesion-Related Small Bowel Obstruction: A Systematic Review of the Literature. Am Surg 2023; 89:2693-2700. [PMID: 36113044 DOI: 10.1177/00031348221126952] [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: 07/28/2023]
Abstract
BACKGROUND Postoperative adhesions may occur after >90% of laparotomies and is the most common cause of small bowel obstruction (SBO). Despite the high incidence, there is a lack of data related to financial implications of adhesion-related SBO (ASBO). This systematic literature review of in-hospital costs for treatment of ASBO searched PubMed, Scopus and Google Scholar databases according to PRISMA guidelines. Exclusion criteria were reviews, editorials, clinical vignettes, studies of patients <18 years of age, studies with no English full text and studies assessing adhesiolysis for causes other than SBO or that used extrapolations with economic models. Main outcome measures were financial costs per patient and national costs. RESULTS Seven studies, published between 1999 and 2016, incorporating a total of 39 573 patients, were identified. Four were undertaken in European countries, one in the USA, 1 in New Zealand and 1 in Nigeria. Overall national costs regarding treatment of patients with ASBO ranged between $3.468 million and $1.77 billion. Median overall cost in the medical management group was $2371.5 ($1814-$2568) vs $12370 ($4914-$25321) in the surgical group. Median length of stay was 4 (3-7) days for patients conservatively treated and 11.5 (8-16.3) days for patients who underwent surgery. Median length of stay of operated patients on was almost triple that of patients conservatively managed. CONCLUSIONS Given the major financial implications of ASBO, further initiatives are needed to avoid operations for SBO when clinically appropriate and minimize delays taking patients with high suspicion of complete SBO to the operating room.
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Affiliation(s)
- Zoe Garoufalia
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Rachel Gefen
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Sameh Hany Emile
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Peige Zhou
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | | | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Auzhanov D, Aimagambetov M, Omarov N. Complex assessment of immunosuppression effects in prevention and treatment of adhesive disease, an experiment. J Med Life 2022; 15:762-767. [PMID: 35928349 PMCID: PMC9321496 DOI: 10.25122/jml-2021-0371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/04/2022] [Indexed: 11/19/2022] Open
Abstract
The cause of all small bowel obstruction in 60-75% of cases is adhesive development. The first and main method for adhesion prevention is undoubtedly the surgical technique, but the prevention of adhesive development is still actual. We aimed to study macroscopic and microscopic peculiarities of the intestine, peritoneum, and scars of the anterolateral abdominal wall. Also, immunological blood changes were observed in rats with the experimental created adhesive disease on the background of azathioprine introduction. The experiment was conducted on 40 rats divided into 2 subgroups: 20 animals as an experimental group (EG1) and 20 as a control group (CG1). Animals from EG received azathioprine (Moshimerampreparaty named by N.A. Semashko, Russia) in a dosage of 1 mg/100g of weight once a day for the first 3 days (starting from the day of surgery). The control group did not receive any drugs. All 40 rats survived the postoperative period. Rats were removed from the experiment on the 7th day after the operation. There were significant statistical differences in most indicators between the experimental and control groups. Phagocytic index (PI) was reduced by 4.55 due to the natural reaction of the rat organism to the surgery. Indicators of EG were a slight decrease in leukocytes and lymphocytes by 0.3 and 0.9, respectively, a moderate decrease in T-lymphocytes by no more than 2.0, and a decrease in phagocytic activity by 5.8. Immunosuppression with azathioprine significantly reduced the frequency and severity of the adhesive process of the abdominal cavity. Used in the recommended dose does not significantly inhibit important indicators of immunity and does not affect wound healing processes.
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Affiliation(s)
- Dauren Auzhanov
- Department of Hospital Surgery, Non-Commercial Joint-Stock Company Semey Medical University, Semey, Kazakhstan,Corresponding Author: Dauren Auzhanov, Department of Hospital Surgery, Non-Commercial Joint-Stock Company Semey Medical University, Semey, Kazakhstan. E-mail:
| | - Meirbek Aimagambetov
- Department of Hospital Surgery, Non-Commercial Joint-Stock Company Semey Medical University, Semey, Kazakhstan
| | - Nazarbek Omarov
- Department of Hospital Surgery, Non-Commercial Joint-Stock Company Semey Medical University, Semey, Kazakhstan
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Ikemoto Y, Nagai S, Tejima K, Saito J. Post-surgical Intrauterine Adhesions After Hysteroscopic Myomectomy Using the Myoma Pseudocapsule Preservation Technique Evaluated bv Second-look Hysteroscopy: A Retrospective Comparative Study. J Minim Invasive Gynecol 2022; 29:998-1002. [PMID: 35568332 DOI: 10.1016/j.jmig.2022.05.004] [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: 01/07/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE To analyze the frequency and risk factors of post-surgical intrauterine adhesions (IUA) using second-look hysteroscopy (SLH) in patients undergoing hysteroscopic myomectomy carried out by the myoma pseudocapsule preservation technique for submucosal myoma. DESIGN Retrospective cohort study. SETTING University hospital from January 2017 to December 2019. PATIENTS A total of 124 patients underwent hysteroscopic myomectomy and SLH. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Surgical duration, intraoperative blood loss, number of enucleated myomas, volume of specimen, post-surgical IUA evaluated by SLH. Post-surgical IUA were found in 5/124 cases (4.0%) at SLH. There were no cases of intrauterine adhesion formation in cases in which a single myomas was resected (0/83 cases, 0%), all cases were multiple myomas (5/41 cases, 12.2%), and significantly occurred more frequently in cases of multiple myoma (p = 0.003). Univariate analyses showed that the IUA group contained a significantly larger number of enucleated uterine myoma (p < 0.001), required a longer operation (p = 0.003), displayed an increased volume of intraoperative bleeding (p = 0.007), and the heavier the specimen, the greater the number of patients that had inserted an IUD than the group that did not display post-surgical IUA. Multivariate logistic regression analysis of the risk factors of post-surgical IUA showed that the number of enucleated myomas was strongly associated with IUA (odds ratio 1.45,95% confidence interval 1.06-1.97). CONCLUSION The frequency of post-surgical IUA after hysteroscopic myomectomy was high in cases of multiple myoma and may be a risk factor. SLH should be actively pursued in cases where the patient desires to bear children, and informed consent should be attained before carrying out surgery.
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Affiliation(s)
- Yuko Ikemoto
- Department of Obstetrics and Gynecology, Juntendo Tokyo Koto Geriatric Medical Center, Juntendo University Faculty of Medicine, Tokyo, Japan.
| | - Saki Nagai
- Department of Obstetrics and Gynecology, Juntendo Tokyo Koto Geriatric Medical Center, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kaoru Tejima
- Department of Obstetrics and Gynecology, Juntendo Tokyo Koto Geriatric Medical Center, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Juichiro Saito
- Department of Obstetrics and Gynecology, Juntendo Tokyo Koto Geriatric Medical Center, Juntendo University Faculty of Medicine, Tokyo, Japan
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Glauser G, Winter E, Caplan IF, Goodrich S, McClintock SD, Srinivas SK, Malhotra NR. Composite Score for Outcome Prediction in Gynecologic Surgery Patients. J Healthc Qual 2021; 43:163-173. [PMID: 32134807 DOI: 10.1097/jhq.0000000000000254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The LACE+ index is a well-studied metric that compacts patient data in an effort to assess readmission risk. PURPOSE Assess the capacity of LACE+ scores for predicting short-term undesirable outcomes in an entire single-center population of patients undergoing gynecologic surgery. IMPORTANCE AND RELEVANCE TO HEALTHCARE QUALITY Proactive identification of high-risk patients, with tools such as the LACE+ index, may serve as the first step toward appropriately engaging resources for reducing readmissions. METHODS This study was a retrospective analysis that used coarsened exact matching. All gynecologic surgery cases over 2 years within a single health system (n = 12,225) were included for analysis. Outcomes of interest were unplanned readmission, emergency room (ER) evaluation, and return to surgery. Composite LACE+ scores were separated into quartiles and matched. For outcome comparison, matched patients were assessed by LACE+ quartile, using Q4 as the reference group. RESULTS Increasing LACE+ score reflected a higher rate of readmission (p = .003, p = .001) and visits to the ER at 30 postoperative days (p < .001). CONCLUSION The data presented here suggest that LACE+ index is a viable metric for patient outcome prediction following gynecologic surgery.
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Detz DJ, Podrat JL, Muniz Castro JC, Lee YK, Zheng F, Purnell S, Pei KY. Small bowel obstruction. Curr Probl Surg 2020; 58:100893. [PMID: 34130796 DOI: 10.1016/j.cpsurg.2020.100893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | - Yoon K Lee
- Houston Methodist Hospital, Houston, Texas
| | - Feibi Zheng
- Weill Cornell Medicine, Houston Methodist Hospital, Houston, Texas
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Santamaria X, Isaacson K, Simón C. Asherman's Syndrome: it may not be all our fault. Hum Reprod 2020; 33:1374-1380. [PMID: 31986212 DOI: 10.1093/humrep/dey232] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/04/2018] [Accepted: 06/08/2018] [Indexed: 01/24/2023] Open
Abstract
Asherman's Syndrome (AS) is an acquired condition defined by the presence of intrauterine adhesions (IUA) that cause symptoms such as menstrual abnormalities, pelvic pain, infertility, recurrent miscarriage, abnormal placentation and attendant psychological distress. Classically, AS is considered an iatrogenic disease triggered by trauma to the pregnant uterus. Different factors can cause the destruction of the endometrium, thus affecting the endometrial stem cell niche and creating IUAs. Curettage of the pregnant uterus appears to be the most common source of this destruction. Nevertheless, some AS cases have been associated with congenital uterine abnormalities and infections, and there are some idiopathic cases without any prior surgical procedures, suggesting a putative constitutional predisposition to IUA. Factors reported to cause AS share an underlying inflammatory mechanism leading to defective endometrial healing and vascularization. Interestingly, distinct genetic profiles have been observed in the endometrium of AS patients. These data suggest that AS might not just be an iatrogenic complication, but also the result of a genetic predisposition. Elucidating the possible physiopathological processes that contribute to AS will help to identify patients at risk for this condition, providing an opportunity for prevention.
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Affiliation(s)
| | - Keith Isaacson
- Department of Obstetrics and Gynecology and Reproductive Endocrinology, Harvard Medical School, Boston, MA, USA
| | - Carlos Simón
- Igenomix Academy, Valencia, Spain
- Department of Obstetrics and Gynecology. Stanford University, Stanford, CA, USA
- Department of Obstetrics and Gynecology. Baylor College of Medicine, Houston, TX, USA
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Ahmad G, Kim K, Thompson M, Agarwal P, O'Flynn H, Hindocha A, Watson A. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2020; 3:CD000475. [PMID: 32199406 PMCID: PMC7085418 DOI: 10.1002/14651858.cd000475.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pelvic adhesions can form secondary to inflammation, endometriosis, or surgical trauma. Strategies to reduce pelvic adhesion formation include placing barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene, and fibrin or collagen sheets between pelvic structures. OBJECTIVES To evaluate the effects of barrier agents used during pelvic surgery on rates of pain, live birth, and postoperative adhesions in women of reproductive age. SEARCH METHODS We searched the following databases in August 2019: the Cochrane Gynaecology and Fertility (CGF) Specialised Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), Epistemonikos, and trial registries. We searched reference lists of relevant papers, conference proceedings, and grey literature sources. We contacted pharmaceutical companies for information and handsearched relevant journals and conference abstracts. SELECTION CRITERIA Randomised controlled trials (RCTs) on the use of barrier agents compared with other barrier agents, placebo, or no treatment for prevention of adhesions in women undergoing gynaecological surgery. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for eligibility and risk of bias and extracted data. We calculated odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) using a fixed-effect model. We assessed the overall quality of the evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods. MAIN RESULTS We included 19 RCTs (1316 women). Seven RCTs randomised women; the remainder randomised pelvic organs. Laparoscopy (eight RCTs) and laparotomy (11 RCTs) were the primary surgical techniques. Indications for surgery included myomectomy (seven RCTs), ovarian surgery (five RCTs), pelvic adhesions (five RCTs), endometriosis (one RCT), and mixed gynaecological surgery (one RCT). The sole indication for surgery in three of the RCTs was infertility. Thirteen RCTs reported commercial funding; the rest did not state their source of funding. No studies reported our primary outcomes of pelvic pain and live birth rate. Oxidised regenerated cellulose versus no treatment at laparoscopy or laparotomy (13 RCTs) At second-look laparoscopy, we are uncertain whether oxidised regenerated cellulose at laparoscopy reduced the incidence of de novo adhesions (OR 0.50, 95% CI 0.30 to 0.83, 3 RCTs, 360 participants; I² = 75%; very low-quality evidence) or of re-formed adhesions (OR 0.17, 95% CI 0.07 to 0.41, 3 RCTs, 100 participants; I² = 36%; very low-quality evidence). At second-look laparoscopy, we are uncertain whether oxidised regenerated cellulose affected the incidence of de novo adhesions after laparotomy (OR 0.72, 95% CI 0.42 to 1.25, 1 RCT, 271 participants; very low-quality evidence). However, the incidence of re-formed adhesions may have been reduced in the intervention group (OR 0.38, 95% CI 0.27 to 0.55, 6 RCTs, 554 participants; I² = 41%; low-quality evidence). No studies reported results on pelvic pain, live birth rate, adhesion score, or clinical pregnancy rate. Expanded polytetrafluoroethylene versus oxidised regenerated cellulose at gynaecological surgery (two RCTs) We are uncertain whether expanded polytetrafluoroethylene reduced the incidence of de novo adhesions at second-look laparoscopy (OR 0.93, 95% CI 0.26 to 3.41, 38 participants; very low-quality evidence). We are also uncertain whether expanded polytetrafluoroethylene resulted in a lower adhesion score (out of 11) (MD -3.79, 95% CI -5.12 to -2.46, 62 participants; very low-quality evidence) or a lower risk of re-formed adhesions (OR 0.13, 95% CI 0.02 to 0.80, 23 participants; very low-quality evidence) when compared with oxidised regenerated cellulose. No studies reported results regarding pelvic pain, live birth rate, or clinical pregnancy rate. Collagen membrane with polyethylene glycol and glycerol versus no treatment at gynaecological surgery (one RCT) Evidence suggests that collagen membrane with polyethylene glycol and glycerol may reduce the incidence of adhesions at second-look laparoscopy (OR 0.04, 95% CI 0.00 to 0.77, 47 participants; low-quality evidence). We are uncertain whether collagen membrane with polyethylene glycol and glycerol improved clinical pregnancy rate (OR 5.69, 95% CI 1.38 to 23.48, 39 participants; very low-quality evidence). One study reported adhesion scores but reported them as median scores rather than mean scores (median score 0.8 in the treatment group vs median score 1.2 in the control group) and therefore could not be included in the meta-analysis. The reported P value was 0.230, and no evidence suggests a difference between treatment and control groups. No studies reported results regarding pelvic pain or live birth rate. In total, 15 of the 19 RCTs included in this review reported adverse events. No events directly attributed to adhesion agents were reported. AUTHORS' CONCLUSIONS We found no evidence on the effects of barrier agents used during pelvic surgery on pelvic pain or live birth rate in women of reproductive age because no trial reported these outcomes. It is difficult to draw credible conclusions due to lack of evidence and the low quality of included studies. Given this caveat, low-quality evidence suggests that collagen membrane with polyethylene glycol plus glycerol may be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. Low-quality evidence also shows that oxidised regenerated cellulose may reduce the incidence of re-formation of adhesions when compared with no treatment at laparotomy. It is not possible to draw conclusions on the relative effectiveness of these interventions due to lack of evidence. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. Common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.
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Affiliation(s)
- Gaity Ahmad
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Kyungmin Kim
- Pennine Acute Hospitals NHS TrustManchesterUKM8 5RB
| | | | | | - Helena O'Flynn
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Akshay Hindocha
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Andrew Watson
- Tameside & Glossop Acute Services NHS TrustDepartment of Obstetrics and GynaecologyFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
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Lang J, Ma D, Xiang Y, Hua K, Liu K, Pan L, Wang P, Yao S, Zhao F, Cheng W, Cui M, Guo H, Guo R, Hong L, Li P, Liu M, Meng Y, Wang H, Wang J, Wang W, Wu M, Yang X, Zhang J. Chinese expert consensus on the prevention of abdominal pelvic adhesions after gynecological tumor surgeries. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:79. [PMID: 32175372 DOI: 10.21037/atm.2020.02.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Adhesion is a postoperative complication that has plagued gynecologists for many years, as 60-90% of gynecological patients develop adhesions after abdominopelvic surgeries. Abdominopelvic adhesions could lead to chronic pelvic pain, infertility, intestinal obstruction, and complicated reoperations. Adhesions might also increase the risk of postoperative chemoradiotherapy failure and endanger patients' lives, especially after surgeries for gynecological malignant tumors. The aim of this consensus was to review the pathogenesis and clinical consequences of adhesions and to summarize various surgical procedures and preventive measures that can reduce the occurrence of adhesions after gynecological tumor surgeries based on a discussion among well-known domestic gynecology specialists.
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Affiliation(s)
- Jinghe Lang
- Department of Genecology and Obstetrics, Beijing Union Medical College Hospital, Beijing 100140, China
| | - Ding Ma
- Department of Genecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yang Xiang
- Department of Genecology and Obstetrics, Beijing Union Medical College Hospital, Beijing 100140, China
| | - Keqin Hua
- Department of Genecology and Obstetrics, Fudan University Affiliated Obstetrics and Gynecology Hospital, Shanghai 200032, China
| | - Kaijiang Liu
- Department of Genecology and Obstetrics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China
| | - Lingya Pan
- Department of Genecology and Obstetrics, Beijing Union Medical College Hospital, Beijing 100140, China
| | - Ping Wang
- Department of Genecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China
| | - Shuzhong Yao
- Department of Genecology and Obstetrics, The First Affiliated Hospital of Zhongshan University, Guangzhou 510080, China
| | - Fujie Zhao
- Department of Genecology and Obstetrics, Shengjing Hospital Affiliated with China Medical University, Shenyang 110004, China
| | - Wenjun Cheng
- Department of Genecology and Obstetrics, Jiangsu Provincial People's Hospital, Nanjing 210036, China
| | - Manhua Cui
- Department of Genecology and Obstetrics, Second Hospital of Jilin University, Changchun 130042, China
| | - Hongyan Guo
- Department of Genecology and Obstetrics, Third Hospital of Peking University, Beijing 100191, China
| | - Ruixia Guo
- Department of Genecology and Obstetrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Li Hong
- Department of Genecology and Obstetrics, Wuhan University People's Hospital, Wuhan 430060, China
| | - Peiling Li
- Department of Genecology and Obstetrics, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Mubiao Liu
- Department of Genecology and Obstetrics, Guangdong Provincial People's Hospital, Guangzhou 510080, China
| | - Yuanguang Meng
- Department of Genecology and Obstetrics, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Hui Wang
- Department of Genecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jianliu Wang
- Department of Genecology and Obstetrics, Peking University People's Hospital, Beijing 100044, China
| | - Wuliang Wang
- Department of Genecology and Obstetrics, The Second Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China
| | - Ming Wu
- Department of Genecology and Obstetrics, Beijing Union Medical College Hospital, Beijing 100140, China
| | - Xingsheng Yang
- Department of Genecology and Obstetrics, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Jun Zhang
- Department of Genecology and Obstetrics, Beijing Anzhen Hospital, Capital Medical University, Beijing 100011, China
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Kondo H, Hirano Y, Ishii T, Hara K, Obara N, Wang L, Asari M, Kato T, Yamaguchi S. Intestinal endometriosis treated by laparoscopic surgery: case series of 5 patients. Surg Case Rep 2020; 6:49. [PMID: 32157569 PMCID: PMC7064691 DOI: 10.1186/s40792-020-00811-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background Intestinal endometriosis is rare and most frequently involves the rectum and sigmoid colon. Case presentation Here, we report a case series of 5 patients who underwent laparoscopic resection for intestinal endometriosis. None of the patients developed postoperative complications, and all were discharged at 5–8 days after surgery. The diagnosis of intestinal endometriosis is difficult to obtain before surgery. Only 2 of 5 patients were diagnosed preoperatively. Among 1 of the 2 patients, the symptoms at the time of menstruation were obvious. In patients with submucosal tumors, the preoperative diagnosis can be difficult. Additional imaging examinations at the time of menstruation might be useful for obtaining a diagnosis. D2 dissections were performed for 3 patients, because malignancy could not be ruled out as a preoperative diagnosis. The surgical findings of 1 patient did not appear to be endometriosis. Surgery for intestinal endometriosis usually encounters advanced pelvic adhesions and fibrosis. For patients undergoing sigmoidectomy, the mean operative time was 152 min and mean blood loss was 10 mL. For patients undergoing rectal resection, the mean operative time was 282 min and mean blood loss was 17 mL. Two cases had severe pelvic adhesions, and the residual rectum could not be straightened. Therefore, side-to-side anastomosis was performed. For intestinal endometriosis surgery, flexible planning for the anastomosis method used for residual intestine should be undertaken. Conclusion Laparoscopic surgery for intestinal endometriosis was safe but technically difficult, because of fibrosis and adhesions. An accurate diagnosis should be attempted based on the clinical symptoms, imaging findings, and intraoperative findings. The method used for anastomosis should be decided on a case-by-case basis.
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Affiliation(s)
- Hiroka Kondo
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan.
| | - Yasumitsu Hirano
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Toshimasa Ishii
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Kiyoka Hara
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Nao Obara
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Liming Wang
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Masahiro Asari
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Takuya Kato
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shigeki Yamaguchi
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
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10
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Kan O, Gorkem U, Alkilic A, Cetin M. Efficacy of striae gravidarum extension and localization on predicting intraperitoneal adhesion risk. J Obstet Gynaecol Res 2019; 45:2358-2363. [PMID: 31531933 DOI: 10.1111/jog.14125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the diagnostic value of striae gravidarum (SG) presence and localization in predicting the intraperitoneal adhesion (IPA) risk in pregnant women with a history of at least one previous cesarean delivery (CD). METHODS A total of 100 pregnant women with repeated CD were included in this prospective observational study. Patients were divided into three groups according to severity of SG with Davey scoring system. Intraoperative adhesion severity and extension were evaluated by using Nair classification system. Moreover, operation duration and neonatal outcomes were analyzed. RESULTS Demographic features were comparable between the groups. Adhesion scores were significantly higher in mild and severe SG groups (for mild SG: 1.93 ± 0.99, for severe SG: 2.81 ± 0.88 and for no SG: 1.4 ± 0.57; P < 0.001). Analysis revealed a positive correlation between IPA and severity of SG (P < 0.001). There was a correlation between increased striae density and adhesion severity especially in the right and left upper quadrants of the abdomen (for right quadrant: r = 0.515, P < 0.001; for left quadrant: r = 0.359, P = 0.005). CONCLUSION Our results suggest that preoperative evaluation of SG severity and extend particularly in upper quadrants is a feasible option to predict IPA risk in patients with repeated CD.
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Affiliation(s)
- Ozgur Kan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hitit University, Corum, Turkey
| | - Umit Gorkem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hitit University, Corum, Turkey
| | - Aysegul Alkilic
- Department of Obstetrics and Gynecology, Faculty of Medicine, TOBB University, Ankara, Turkey
| | - Mustafa Cetin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hitit University, Corum, Turkey
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Qi P, Zheng YG, Ohta S, Kokudo N, Hasegawa K, Ito T. In Situ Fabrication of Double-Layered Hydrogels via Spray Processes to Prevent Postoperative Peritoneal Adhesion. ACS Biomater Sci Eng 2019; 5:4790-4798. [DOI: 10.1021/acsbiomaterials.9b00791] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | | | | | - Norihiro Kokudo
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
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Tsauo J, Song HY, Choi EY, Kim DK, Kim KY, Park JH, Kim MT, Yoon SH, Lim YJ. EW-7197, an oral transforming growth factor β type I receptor kinase inhibitor, for preventing peritoneal adhesion formation in a rat model. Surgery 2018; 164:1100-1108. [DOI: 10.1016/j.surg.2018.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 06/25/2018] [Accepted: 07/06/2018] [Indexed: 02/06/2023]
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13
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The systemic effect and the absorption rate of aerosolized intra-peritoneal heparin with or without hyaluronic acid in the prevention of postoperative abdominal adhesions. Surg Endosc 2018; 33:2517-2520. [DOI: 10.1007/s00464-018-6540-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 10/15/2018] [Indexed: 11/26/2022]
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14
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Preventing postoperative tissue adhesion using injectable carboxymethyl cellulose-pullulan hydrogels. Int J Biol Macromol 2017; 105:886-893. [DOI: 10.1016/j.ijbiomac.2017.07.103] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/10/2017] [Accepted: 07/17/2017] [Indexed: 11/20/2022]
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Nayyar N, Lakhwani P, Goel A, Pande PK, Kumar K. Management of Borderline Ovarian Tumors-Still a Gray Zone. Indian J Surg Oncol 2017; 8:607-614. [PMID: 29203995 DOI: 10.1007/s13193-017-0697-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/14/2017] [Indexed: 11/30/2022] Open
Abstract
Borderline ovarian tumors (BOTs) are a heterogeneous group of non-invasive epithelial ovarian tumors that occur at a younger age, present in early stage, frequently associated with infertility but are easily curable. Although they may have symptomatic long-term recurrences, they have an excellent prognosis in spite of peritoneal spread. Among the epithelial tumors of the ovary, BOTs fall in the spectrum lying between cystadenomas (benign) and cystadenocarcinomas (malignant). Their oncological behavior is more aggressive than benign ovarian tumors but relatively less than that of malignant ovarian tumors. Since the age group affected is usually young females, preservation of fertility is an important aspect of treatment protocol. Although the management of these tumors has been extensively discussed, it still remains a controversial gray zone. In this review, epidemiology, pathogenesis, histologic subtypes, various surgical approaches, follow-up, and management of recurrence have been discussed. Choosing the best treatment still poses a challenge for the treating oncosurgeon.
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Affiliation(s)
- Nidhi Nayyar
- Department of Surgical Oncology, BLK Cancer Centre, BLK Super Speciality Hospital, New Delhi, India
| | - Prerna Lakhwani
- Department of Surgical Oncology, BLK Cancer Centre, BLK Super Speciality Hospital, New Delhi, India
| | - Ashish Goel
- Department of Surgical Oncology, BLK Cancer Centre, BLK Super Speciality Hospital, New Delhi, India
| | - Pankaj Kr Pande
- Department of Surgical Oncology, BLK Cancer Centre, BLK Super Speciality Hospital, New Delhi, India
| | - Kapil Kumar
- Department of Surgical Oncology, BLK Cancer Centre, BLK Super Speciality Hospital, New Delhi, India
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Hesselman S, Högberg U, Råssjö EB, Schytt E, Löfgren M, Jonsson M. Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study. BJOG 2017; 125:597-603. [PMID: 28444984 DOI: 10.1111/1471-0528.14708] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the association between abdominal adhesions at the time of gynaecologic surgery and a history of caesarean delivery, and to investigate obstetric factors contributing to adhesion formation after caesarean section (CS). DESIGN Longitudinal population-based register study. SETTING Sweden. POPULATION Women undergoing benign hysterectomy and/or adnexal surgery in Sweden, 2000-2014, with a previous delivery during 1973-2013 (n = 15 479). METHODS Information about abdominal adhesions during gynaecological surgery, prior medical history, pregnancies and deliveries were retrieved from Swedish National Health and Quality registers. MAIN OUTCOME MEASURES Adhesions. RESULTS In women with previous CS, adhesions were present in 37%, compared with 10% of women with no previous CS [odds ratio (OR): 5.18, 95% confidence interval (CI): 4.70-5.71]. Adhesions increased with the number of caesarean sections: 32% after one CS; 42% after two CS and 59% after three or more CS (P < 0.001). Regardless of the number of CS, factors at CS such as age ≥35 years (aOR: 1.28, 95% CI: 1.05-1.55), body mass index (BMI) ≥30 [adjusted OR (aOR): 1.91, 95% CI: 1.49-2.45] and postpartum infection (aOR: 1.55, 95% CI: 1.05-2.30) increased the risk of adhesions. CONCLUSIONS Presence of adhesions in abdominal gynaecological surgery is associated with women's personal history of caesarean delivery. The number of caesarean sections was the important predictor of adhesions; advanced age, obesity and postpartum infection further increased the incidence. TWEETABLE ABSTRACT Repeat caesarean, age, obesity and infection increased the risk of pelvic adhesions after caesarean section.
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Affiliation(s)
- S Hesselman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Centre for Clinical Research Dalarna, Falun, Sweden
| | - U Högberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - E-B Råssjö
- Centre for Clinical Research Dalarna, Falun, Sweden
| | - E Schytt
- Centre for Clinical Research Dalarna, Falun, Sweden
| | - M Löfgren
- Department of Obstetrics & Gynaecology, Umeå University Hospital, Umeå, Sweden
| | - M Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Zhang Y, Liu Q, Yang N, Zhang X. Hyaluronic acid and oxidized regenerated cellulose prevent adhesion reformation after adhesiolysis in rat models. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:3501-3507. [PMID: 27822014 PMCID: PMC5087760 DOI: 10.2147/dddt.s103824] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Postsurgical adhesion formation is the most common complication in abdominal and pelvic surgery. Adhesiolysis is the most commonly applied treatment for adhesion formation but is often followed by adhesion reformation. Therefore, an efficient strategy should be adopted to solve these problems. This study aimed to explore whether hyaluronic acid and oxidized regenerated cellulose (ORC) could prevent adhesion formation and reformation. Thirty female Sprague Dawley rats were randomly divided into three groups (n=10 each) and subjected to different treatments during the first and second surgery. The control group was treated with isotonic sodium chloride, the ORC group was treated with ORC (1.5×1 cm), and the medical sodium hyaluronate (MSH) group was treated with 1% MSH (0.5 mL). At 2 weeks after the first surgery, adhesion scores in the MSH group (1.90±0.99) and the ORC group (1.40±0.97) were significantly lower than those in the control group (3.00±0.82) (P=0.005). Similarly, 2 weeks after the second surgery, adhesion scores in the MSH group (2.00±0.82) and the ORC group (1.50±1.27) were significantly lower than those in the control group (3.50±0.53) (P=0.001). In addition, body weights in the MSH group and the ORC group did not change significantly, whereas the control group showed a consistent decrease in body weight during the experiment. Histological examination revealed that inflammatory infiltration was involved in both adhesion formation and reformation. In conclusion, hyaluronic acid and ORC were both efficient in reducing adhesion formation and reformation in the rat model.
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Affiliation(s)
- Yan Zhang
- Department of Gynecology, Kunshan Hospital Affiliated to Jiangsu University, Kunshan, Jiangsu, People's Republic of China
| | - Qin Liu
- Department of Gynecology, Kunshan Hospital Affiliated to Jiangsu University, Kunshan, Jiangsu, People's Republic of China
| | - Ning Yang
- Department of Gynecology, Kunshan Hospital Affiliated to Jiangsu University, Kunshan, Jiangsu, People's Republic of China
| | - Xuegang Zhang
- Department of Gynecology, Kunshan Hospital Affiliated to Jiangsu University, Kunshan, Jiangsu, People's Republic of China
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Fertility preservation in women with borderline ovarian tumours. Cancer Treat Rev 2016; 49:13-24. [DOI: 10.1016/j.ctrv.2016.06.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 12/15/2022]
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Beyene RT, Kavalukas SL, Barbul A. Intra-abdominal adhesions: Anatomy, physiology, pathophysiology, and treatment. Curr Probl Surg 2015; 52:271-319. [PMID: 26258583 DOI: 10.1067/j.cpsurg.2015.05.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/12/2015] [Indexed: 12/18/2022]
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Ahmad G, O'Flynn H, Hindocha A, Watson A. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2015; 2015:CD000475. [PMID: 25924805 PMCID: PMC7043269 DOI: 10.1002/14651858.cd000475.pub3] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pelvic adhesions can form as a result of inflammation, endometriosis or surgical trauma. During pelvic surgery, strategies to reduce pelvic adhesion formation include placing barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene or fibrin sheets between the pelvic structures. OBJECTIVES To evaluate the effects of barrier agents used during pelvic surgery on rates of pain, live birth and postoperative adhesions in women of reproductive age. SEARCH METHODS We searched the following databases in February 2015: the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL) and trial registries. We handsearched relevant journals, conference proceedings and grey literature sources and we contacted pharmaceutical companies for information. SELECTION CRITERIA Randomised controlled trials (RCTs) of the use of barrier agents compared with other barrier agents, placebo or no treatment for the prevention of adhesions in women undergoing gynaecological surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and risk of bias and extracted the data. We calculated odds ratios (ORs) or mean differences (MD) with 95% confidence intervals (CIs) using a fixed effect model. The overall quality of the evidence was assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods. MAIN RESULTS Eighteen RCTs (1262 women) were included. Six RCTs randomised women; the remainder randomised pelvic organs. Laparoscopy (eight RCTs) and laparotomy (10 RCTs) were the primary surgical techniques. Indications for surgery included myomectomy (six RCTs), ovarian surgery (five RCTs), pelvic adhesions (five RCTs), endometriosis (one RCT) and mixed (one RCT). The sole indication for surgery in three of the RCTs was infertility. Twelve RCTs reported commercial funding; the rest did not state their source of funding.No studies reported either of our primary outcomes of pelvic pain and live birth. Oxidised regenerated cellulose (Interceed) versus no treatment at laparoscopy or laparotomy (13 RCTs)At second-look laparoscopy oxidised regenerated cellulose at laparoscopy was associated with reduced incidence of de novo adhesions (OR 0.50, 95% CI 0.30 to 0.83, three RCTs, 360 participants, I(2) = 75%, very low-quality evidence) and of re-formed adhesions (OR 0.17, 95% CI 0.07 to 0.41, three RCTs, 100 participants, I(2) = 36%, low quality evidence).At second-look laparoscopy no evidence was found of any difference between the groups in the incidence of de novo adhesions after laparotomy (OR 0.72, 95% CI 0.42 to 1.25, one RCT, 271 participants, I(2) = 41%, low-quality evidence). However, the incidence of re-formed adhesions was lower in the intervention group (OR 0.38, 95% CI 0.27 to 0.55, six RCTs, 554 participants, moderate-quality evidence). Expanded polytetrafluoroethylene (Gore-Tex) versus no treatment at gynaecological surgery (one RCT) The evidence suggested that at second-look laparoscopy expanded polytetrafluoroethylene was associated with a reduction in new adhesion formation (OR 0.17, 95% CI 0.03 to 0.94, one RCT, 42 participants, low-quality evidence). Expanded polytetrafluoroethylene (Gore-Tex) versus oxidised regenerated cellulose (Interceed) at gynaecological surgery (two RCTs)One RCT found no difference between the groups at second-look laparoscopy in the incidence of de novo adhesions (OR 0.93, 95% CI 0.26 to 3.41, 38 participants, very low-quality evidence). A second RCT suggested that the expanded polytetrafluoroethylene group had a lower adhesion score (out of 11) (MD -3.79, 95% CI -5.12 to -2.46, 62 participants, very low-quality evidence) and a lower risk of re-formed adhesions (OR 0.13, 95% CI 0.02 to 0.80, 23 participants, very low-quality evidence). This last finding was sensitive to choice of effect estimate and no longer suggested a difference between the groups when a risk ratio was calculated (RR 0.36, 95% CI 0.13 to 1.01). Sodium hyaluronate and carboxymethylcellulose (Seprafilm) versus no treatment at gynaecological surgery (one RCT)Sodium hyaluronate and carboxymethylcellulose was associated with a lower adhesion score (out of 4) at second-look laparoscopy (MD 0.49, 95% CI 0.53 to 0.45, one RCT, 127 participants, moderate-quality evidence). Fibrin sheet versus no treatment at laparoscopic myomectomy (one RCT)There was no evidence of a difference between the groups in the incidence of de novo adhesions at second-look laparoscopy (OR 1.20, 95% CI 0.42 to 3.41, one RCT, 62 participants) or in adhesion score (out of 4) (MD 0.14, 95% CI -0.67 to 0.39, one RCT, 48 participants, low-quality evidence).Fourteen of the 18 RCTs reported adverse events. No events directly attributed to adhesion agents were reported. AUTHORS' CONCLUSIONS We found no evidence on the effects of barrier agents used during pelvic surgery on either pain or fertility outcomes in women of reproductive age.Low quality evidence suggests that oxidised regenerated cellulose (Interceed), expanded polytetrafluoroethylene (Gore-Tex) and sodium hyaluronate with carboxymethylcellulose (Seprafilm) may all be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. There is no conclusive evidence on the relative effectiveness of these interventions. There is no evidence to suggest that fibrin sheet is more effective than no treatment. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. The most common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.
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Affiliation(s)
- Gaity Ahmad
- Pennine Acute NHS TrustObstetrics & GynaecologyManchesterUK
| | - Helena O'Flynn
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyDelaunays RoadCrumpsallManchesterUKM8 5RB
| | - Akshay Hindocha
- Pennine Acute Hospitals NHS TrustDelaunays RoadCrumpsallManchesterUKM8 5RB
| | - Andrew Watson
- Tameside General HospitalTameside & Glossop Acute Services NHS TrustFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
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An injured tissue affects the opposite intact peritoneum during postoperative adhesion formation. Sci Rep 2015; 5:7668. [PMID: 25566876 PMCID: PMC4286739 DOI: 10.1038/srep07668] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 12/03/2014] [Indexed: 01/17/2023] Open
Abstract
The pathophysiology of adhesion formation needs to be clarified to reduce the adhesion-related morbidity. The epithelial characteristics of the peritoneum suggest a protective role against adhesion formation, yet how the peritoneum is involved in adhesion formation is not well characterized. We microscopically observed an experimental model of adhesion formation to investigate the effects of an injured tissue on the opposite intact peritoneum. Adhesions were induced between injured and intact hepatic lobes, and the intact peritoneum opposite to the injured tissue was examined for 8 days. The opposite intact peritoneum was denuded of mesothelial cells for 6 hours, and the remnant mesothelial cells changed morphologically for 24 hours. The detachment of mesothelial cells allowed fibrin to attach to the basement membrane of the opposite peritoneum, connecting the two lobes. Moreover, macrophages and myofibroblasts accumulated between the two lobes, and angiogenesis occurred from the opposite intact lobe to the injured lobe. These observations indicate that an injured tissue deprives the opposite intact peritoneum of its epithelial structure and causes fibrous adhesions to the opposite intact tissue. This study implies a possible role of mesothelial cells for barrier function against adhesion formation, that is, keeping mesothelial cells intact might lead to its prophylaxis.
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22
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Hindocha A, Beere L, Dias S, Watson A, Ahmad G. Adhesion prevention agents for gynaecological surgery: an overview of Cochrane reviews. Cochrane Database Syst Rev 2015; 1:CD011254. [PMID: 25561409 PMCID: PMC6544806 DOI: 10.1002/14651858.cd011254.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intraperitoneal adhesions are associated with considerable co-morbidity and have large financial and public health repercussions. They have secondary effects that include chronic pelvic pain, dyspareunia, subfertility and bowel obstruction. In women with adhesions, subsequent surgery is more difficult, often takes longer, and is associated with a higher complication rate (Broek 2013). The significant burden of adhesions has led to the development of several anti-adhesion agents, although there is disagreement as to their relative effectiveness. OBJECTIVES To summarise evidence derived from Cochrane systematic reviews on the clinical safety and effectiveness of solid agents, gel agents, liquid agents and pharmacological agents, used as adjuvants to prevent formation of adhesions after gynaecological pelvic surgery. METHODS The Cochrane Database of Systematic Reviews was searched using the keyword 'adhesion' up to August 2014. The Cochrane information management system was also searched for any titles or protocols of reviews in progress. Two review authors independently extracted information from the reviews, with disagreements being resolved by a third review author. The quality of the included reviews was described in a narrative manner, and the AMSTAR tool was used to formally assess each review included in this overview. The quality of evidence provided in the original reviews was described using GRADE methods. MAIN RESULTS We included two reviews, one with 18 studies comparing solid agents (oxidised regenerated cellulose expanded polytetrafluoroethylene, sodium hyaluronate and carboxymethylcellulose, and fibrin sheets) with control or with each other. The other review included 29 studies which compared liquid agents (4% icodextrin, 32% dextran, crystalloids), gel agents (carboxymethylcellulose and polyethylene oxide, polyethylene glycol gels, hyaluronic acid based gel, 0.5% ferric hyaluronate gel, sodium hyaluronate spray) and pharmacological agents (gonadotrophin-releasing hormone agonist, reteplase plasminogen activator, N,O-carboxymethyl chitosan, steroid agents, intraperitoneal noxytioline, intraperitoneal heparin, systemic promethazine) with control or each other. Both reviews met all of the criteria of the AMSTAR assessment.The reviews included as outcomes both the primary outcomes of this overview (pelvic pain, pregnancy, live birth rate and quality of life (QoL)) and our secondary outcomes (adverse effects, presence or absence of adhesions at second-look laparoscopy (SLL) and adhesion score). However, neither of the reviews identified any primary studies of solid, gel or pharmacological agents that reported any of our primary outcomes. The only studies in either review that reported any of our primary outcomes were studies comparing liquid agents versus control (saline or Hartmann's solution), which reported pelvic pain (two studies), live birth (two studies) and pregnancy (three studies).An external source of funding was stated for 25 of the 47 studies across both reviews; in 24 of these studies the funding was commercial. Solid agents (18 studies)None of our primary outcomes were reported. Adverse events were reported as an outcome by only 9 of the 18 studies. These reported no adverse events. Liquid agents (nine studies)There was no evidence of a difference between liquid agents and control (saline or Hartmann's solution) with respect to pelvic pain (odds ratio (OR) 0.65, 95% confidence interval (CI) 0.37 to 1.14, 1 study, n = 286, moderate quality evidence), pregnancy rate (OR 0.64, 95% CI 0.36 to 1.14, 3 studies, n = 310, moderate quality evidence) or live birth rate (OR 0.67, 95% CI 0.29 to 1.58, 2 studies, n = 208, moderate quality evidence). No studies of liquid agents reported QoL. Adverse events were not reported as an outcome by any of the nine studies. Gel agents (seven studies)None of our primary outcomes were reported. Adverse events were not reported as an outcome by any of the seven studies. Pharmacological agents (seven studies)None of our primary outcomes were reported. Adverse events were reported as an outcome by only one of the seven primary studies. This study reported no evidence of difference in ectopic pregnancy rates between intraperitoneal noxytioline and no treatment (OR 4.91, 95% CI 0.45 to 53.27, 1 study, n = 33, low quality evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to allow us to draw any conclusions about the effectiveness and safety of anti-adhesion agents in gynaecological surgery, due to the lack of data on pelvic pain, fertility outcomes, quality of life or safety. A substantial proportion of research in this field has been funded by private companies that manufacture these agents, and further high powered, independent trials will be needed before definitive conclusions can be made.
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Affiliation(s)
- Akshay Hindocha
- Pennine Acute Hospitals NHS TrustDelaunays RoadCrumpsallManchesterUKM8 5RB
| | - Lawrence Beere
- Pennine Acute Hospitals NHS TrustDelaunays RoadCrumpsallManchesterUKM8 5RB
| | - Sofia Dias
- University of BristolSchool of Social and Community MedicineCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | - Andrew Watson
- Tameside General HospitalTameside & Glossop Acute Services NHS TrustFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
| | - Gaity Ahmad
- Pennine Acute NHS TrustObstetrics & GynaecologyManchesterUK
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Brochhausen C, Schmitt VH, Planck CNE, Rajab TK, Hollemann D, Tapprich C, Krämer B, Wallwiener C, Hierlemann H, Zehbe R, Planck H, Kirkpatrick CJ. Current strategies and future perspectives for intraperitoneal adhesion prevention. J Gastrointest Surg 2012; 16:1256-74. [PMID: 22297658 DOI: 10.1007/s11605-011-1819-9] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 12/28/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The formation of peritoneal adhesions still is a relevant clinical problem after abdominal surgery. Until today, the most important clinical strategies for adhesion prevention are accurate surgical technique and the physical separation of traumatized serosal areas. Despite a variety of barriers which are available in clinical use, the optimal material has not yet been found. DISCUSSION Mesothelial cells play a crucial physiological role in friction less gliding of the serosa and the maintenance of anantiadhesive surface. The formation of postoperative adhesions results from a cascade of events and is regulated by various cellular and humoral factors. Therefore, optimization or functionalization of barrier materials by developments interacting with this cascade on a structural or pharmacological level could give an innovative input for future strategies in peritoneal adhesion prevention. For this purpose, the proper understanding of the formal pathogenesis of adhesion formation is essential. Based on the physiology of the serosa and the pathophysiology of adhesion formation, the available barriers in current clinical practice as well as new innovations are discussed in the present review.
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Affiliation(s)
- Christoph Brochhausen
- REPAIR-lab, Institute of Pathology, University Medical Centre, Johannes Gutenberg-University, Langenbeckstraße 1,55101 Mainz, Germany.
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Uncoupling oxidative phosphorylation with 2,4-dinitrophenol promotes development of the adhesion phenotype. Fertil Steril 2012; 97:729-33. [DOI: 10.1016/j.fertnstert.2011.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 12/02/2011] [Accepted: 12/06/2011] [Indexed: 12/24/2022]
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Intrauterine Adhesions following Conservative Treatment of Uterine Fibroids. Obstet Gynecol Int 2011; 2012:853269. [PMID: 22190959 PMCID: PMC3236427 DOI: 10.1155/2012/853269] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 10/17/2011] [Indexed: 01/02/2023] Open
Abstract
Uterine fibroids are common in women of reproductive age and various conservative treatments are available. In order to achieve a successful conservative treatment of fibroids, functional integrity of the uterus is as important as tumor removal or symptoms relief. In this context, intrauterine adhesions must be recognized as a possible complication of conservative management of uterine fibroids, but diagnostic pitfalls might justify an underestimation of their incidence. Hysteroscopic myomectomy can cause adhesions as a result of surgical trauma to the endometrium. The average reported incidence is around 10% at second-look hysteroscopy, but it is higher in certain conditions, such as the case of multiple, apposing fibroids. Transmural myomectomies also have the potential for adhesion, especially when combined with uterine ischemia. Uterine arteries embolization also carries a risk of intracavitary adhesions. Prevention strategies including bipolar resection, barrier gel or postoperative estradiol, might be useful, but stronger evidence is needed. In view of current knowledge, we would recommend a prevention strategy based on a combination of surgical trauma minimization and identification of high-risk cases. Early hysteroscopic diagnosis and lysis possibly represents the best means of secondary prevention and treatment of postoperative intrauterine adhesions.
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Hull TL, Joyce MR, Geisler DP, Coffey JC. Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis. Br J Surg 2011; 99:270-5. [PMID: 22095139 DOI: 10.1002/bjs.7759] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Emerging evidence suggests that a laparoscopic approach to colorectal procedures generates fewer adhesions. Even though laparoscopic ileal pouch-anal anastomosis (IPAA) is a lengthy procedure, the prospect of fewer adhesions may justify this approach. The aim of this study was to assess abdominal and adnexal adhesion formation following laparoscopic versus open IPAA in patients with ulcerative colitis. METHODS A diagnostic laparoscopy was performed at time of ileostomy closure. All abdominal quadrants and the pelvis were video recorded systematically and graded offline. The incisional adhesion score (IAS; range 0-6) and total abdominal adhesion score (TAS; range 0-10) were calculated, based on the grade and extent of adhesions. Adnexal adhesions were classified by the American Fertility Society (AFS) adhesion score. RESULTS A total of 43 patients consented to participate, of whom 40 could be included in the study (laparoscopic 28, open 12). Median age was 38 (range 20-61) years. There was no difference in age, sex, body mass index, American Society of Anesthesiologists grade and time to ileostomy closure between groups. The IAS was significantly lower after laparoscopic IPAA than following an open procedure: median (range) 0 (0-5) versus 4 (2-6) respectively (P = 0·004). The TAS was also significantly lower in the laparoscopic group: 2 (0-6) versus 8 (2-10) (P = 0·002). Applying the AFS score, women undergoing laparoscopic IPAA had a significantly lower mean(s.d.) prognostic classification score than those in the open group: 5·2(3·7) versus 20·0(5·6) (P = 0·023). CONCLUSION Laparoscopic IPAA was associated with significantly fewer incisional, abdominal and adnexal adhesions in comparison with open IPAA.
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Affiliation(s)
- T L Hull
- Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avene/A30, Cleveland, Ohio 44195, USA.
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Brochhausen C, Schmitt VH, Rajab TK, Planck CNE, Krämer B, Wallwiener M, Hierlemann H, Kirkpatrick CJ. Intraperitoneal adhesions--an ongoing challenge between biomedical engineering and the life sciences. J Biomed Mater Res A 2011; 98:143-56. [PMID: 21548063 DOI: 10.1002/jbm.a.33083] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 01/12/2011] [Accepted: 01/20/2011] [Indexed: 01/29/2023]
Abstract
Peritoneal adhesions remain a relevant clinical problem despite the currently available prophylactic barrier materials. So far, the physical separation of traumatized serosa areas using barriers represents the most important clinical strategy for adhesion prevention. However, the optimal material has not yet been found. Further optimization or pharmacological functionalization of these barriers could give an innovative input for peritoneal adhesion prevention. Therefore, a more complete understanding of pathogenesis is required. On the basis of the pathophysiology of adhesion formation the main barriers currently in clinical practice as well as new innovations are discussed in the present review. Physiologically, mesothelial cells play a decisive role in providing a frictionless gliding surface on the serosa. Adhesion formation results from a cascade of events and is regulated by a variety of cellular and humoral factors. The main clinically applied strategy for adhesion prevention is based on the use of liquid or solid adhesion barriers to separate physically any denuded tissue. Both animal and human trials have not yet been able to identify the optimal barrier to prevent adhesion formation in a sustainable way. Therefore, further developments are required for effective prevention of postoperative adhesion formation. To reach this goal the combination of structural modification and pharmacological functionalization of barrier materials should be addressed. Achieving this aim requires the interaction between basic research, materials science and clinical expertise.
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Affiliation(s)
- Christoph Brochhausen
- REPAIR-Lab, Institute of Pathology, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.
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Efficacy of transient abdominal ovariopexy in patients with severe endometriosis. Eur J Obstet Gynecol Reprod Biol 2011; 155:183-7. [DOI: 10.1016/j.ejogrb.2010.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 10/19/2010] [Accepted: 11/23/2010] [Indexed: 11/22/2022]
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Daraï E, Lesieur B, Dubernard G, Rouzier R, Bazot M, Ballester M. Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery. Fertil Steril 2011; 95:1903-8. [PMID: 21392746 DOI: 10.1016/j.fertnstert.2011.02.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 01/20/2011] [Accepted: 02/11/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether the surgical route of colorectal resection for endometriosis is a determinant factor for fertility. DESIGN Prospective study. SETTING Tertiary-care university hospital. PATIENT(S) Fifty-two patients with endometriosis were randomly assigned to laparoscopic or open surgery. INTERVENTION(S) Laparoscopically assisted vs. open colorectal resection. MAIN OUTCOME MEASURE(S) Evaluation of fertility outcomes spontaneously and after assisted reproductive therapy. RESULT(S) The mean follow-up was 29 months. Among the 28 patients wishing to conceive, 11 (39.3%) became pregnant. Overall cumulative pregnancy rate at 52 months for these patients was 45.1%. For patients with or without infertility, the cumulative pregnancy rate was 37.6% and 55.6%, respectively, and the cumulative spontaneous pregnancy rate 13.3% and 36.5%, respectively. All the spontaneous pregnancies were observed in the laparoscopy group. CONCLUSION(S) This study demonstrates that spontaneous pregnancy is more frequent after laparoscopy compared with open surgery for colorectal endometriosis.
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Affiliation(s)
- Emile Daraï
- Service de Gynécologie-Obstétrique, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, CancerEst, Université Pierre et Marie Curie, Paris, France.
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Tinelli A, Malvasi A, Guido M, Tsin DA, Hudelist G, Hurst B, Stark M, Mettler L. Adhesion formation after intracapsular myomectomy with or without adhesion barrier. Fertil Steril 2011; 95:1780-5. [PMID: 21256483 DOI: 10.1016/j.fertnstert.2010.12.049] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 11/19/2010] [Accepted: 12/22/2010] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To show the prevention of adhesion formation by placing an absorbable adhesion barrier after intracapsular myomectomy. DESIGN Prospective blinded observational study. SETTING University-affiliated Hospitals. PATIENT(S) Patients ≥ 18 years old with single or multiple uterine fibroids removed by laparoscopic or abdominal intracapsular myomectomy. INTERVENTION(S) A total of 694 women undergoing laparoscopic or abdominal myomectomy were randomized for placement of oxidized regenerated cellulose absorbable adhesion barrier to the uterine incision or for control subjects without barriers. The presence of adhesions was assessed in 546 patients who underwent subsequent surgery. MAIN OUTCOME MEASURE(S) The primary and secondary outcomes of the analysis were the presence and severity of adhesions for four groups: laparotomy with barrier, laparotomy without barrier, laparoscopy with barrier, and laparoscopy without barrier. RESULT(S) There was a higher rate of adhesions in laparotomy without barrier (28.1%) compared with laparoscopy with no barrier (22.6%), followed by laparotomy with barrier (22%) and laparoscopy with barrier (15.9%). Additionally, the type of adhesions were different, filmy and organized were predominant with an adhesion barrier, and cohesive adhesions were more common without an adhesion barrier. CONCLUSION(S) Oxidized regenerated cellulose reduces postsurgical adhesions. Cohesive adhesions reduction was noted in laparoscopy.
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Affiliation(s)
- Andrea Tinelli
- Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Lecce, Italy.
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Rizzo A, Spedicato M, Mutinati M, Minoia G, Angioni S, Jirillo F, Pantaleo M, Sciorsci RL. Peritoneal adhesions in human and veterinary medicine: from pathogenesis to therapy. A review. Immunopharmacol Immunotoxicol 2010; 32:481-94. [PMID: 20128633 DOI: 10.3109/08923970903524367] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Any peritoneal inflammatory process consequent to infections or surgical injuries may induce abdominal adhesion formation. Peritoneal adhesions are connective laciniae that develop among abdomino-pelvic organs that limit physiologic visceral motion. Consequently, fertility may be impaired, and intestinal obstruction and pelvic pain may develop, mainly in subjects that had undergone gynaecological surgery. This review illustrates the pathogenic steps of adhesiogenesis and the therapeutic scenario that evolved over the years to tackle the threat of peritoneal adhesions, both in domestic animals and in women.
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Affiliation(s)
- Annalisa Rizzo
- Department of Animal Production, Faculty of Veterinary Medicine, University of Bari, Bari, Italy
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Chapa HO, Sbarra MA. The Paucity of Information on Adhesions After Cesarean Delivery. J Gynecol Surg 2010. [DOI: 10.1089/gyn.2009.0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hector O. Chapa
- Women's Specialty Center, Department of Obstetrics/Gynecology Methodist Medical Center, Dallas, TX
| | - Michael A. Sbarra
- Hackensack University Medical Center, Hackenack, NJ, and University of Medicine and Dentistry in New Jersey at New Jersey Medical School, Newark, NJ
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Binnebösel M, Klink CD, Grommes J, Jansen M, Neumann UP, Junge K. Influence of small intestinal serosal defect closure on leakage rate and adhesion formation: a pilot study using rabbit models. Langenbecks Arch Surg 2010; 396:133-7. [DOI: 10.1007/s00423-010-0672-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 06/16/2010] [Indexed: 11/28/2022]
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Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility. Ann Surg 2010; 251:1018-23. [PMID: 20485146 DOI: 10.1097/sla.0b013e3181d9691d] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We report the first randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis focusing on perioperative complications, improvement in symptoms, quality of life, and fertility. SUMMARY OF BACKGROUND DATA Bowel endometriosis is one of the most severe forms of endometriosis. Although laparoscopically assisted surgery is a validated technique for colorectal cancer, there are serious concerns about its appropriateness for endometriosis in young women wishing to conceive because it is almost invariably a traumatic procedure. METHODS We conducted a noninferiority trial and randomly assigned 52 patients with colorectal endometriosis to undergo laparoscopically assisted or open colorectal resection. The median follow-up was 19 months. The primary end point was improvement in dyschesia. RESULTS Overall, a significant improvement in digestive symptoms (dyschesia P < 0.0001, diarrhea P < 0.01, and bowel pain and cramping P < 0.0001), gynecologic symptoms (dysmenorrhea P < 0.0001 and dyspareunia P < 0.0001), and general symptoms (back pain P = 0.001 and asthenia P = 0.0001) was observed. No difference in the symptom delta values and quality of life was noted between the groups. Median blood loss was lower in the laparoscopic group (P < 0.05). Total number of complications was higher in the open surgery group (P = 0.04), especially grade 3 (P = 0.03). Pregnancy rate was higher in the laparoscopic group (P = 0.006), and the cumulative pregnancy rate was 60%. CONCLUSION Our findings support that laparoscopy is a safe option for women requiring colorectal resection for endometriosis. Moreover, laparoscopy offers a higher pregnancy rate than open surgery with similar improvements in symptoms and in quality of life.
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Fucoidan film safely inhibits surgical adhesions in a rat model. J Surg Res 2010; 171:495-503. [PMID: 20638689 DOI: 10.1016/j.jss.2010.04.043] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Revised: 03/20/2010] [Accepted: 04/21/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the in vivo efficacy of 13 compounds and to further characterize the load limiting and potential toxicity of the most efficacious compound. The cascade of biochemical and molecular events that results in the formation of postsurgical adhesions provides numerous theoretical opportunities for prophylactic intervention. METHODS Candidate agents were loaded into sodium hyaluronate (HA) films and administered to male Sprague-Dawley rats using a cecal-sidewall model of surgical adhesions. An adhesion score was obtained for each rat based on the strength and extent of the adhesions. The most efficacious agent, fucoidan, was further evaluated in a load-limiting study with a concentration range of 0.0033 to 33% w/w per film. The potential toxicity of fucoidan was evaluated in a separate study by comparison of hematology findings, blood chemistry, urinalysis, and incision thickness from rats administered control films or 33% w/w fucoidan films 1 to 4 d prior to sacrifice. RESULTS Fucoidan loaded films reduced adhesion scores by approximately 90% compared with control films (P<0.05). A total of 50% to 100% of animals were adhesion free at fucoidan film loadings of 0.33% to 33% w/w compared with all control film animals having adhesions. No adverse effects were observed from 33% w/w fucoidan films equivalent to approximately 30 mg fucoidan/kg body weight. CONCLUSIONS Local administration of fucoidan film during rat cecal-sidewall surgery safely reduced adhesion scores by approximately 90% and resulted in 50% to 100% of animals being adhesion free.
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Yelian FD, Shavell VI, Diamond MP. Early demonstration of postoperative adhesions in a rodent model. Fertil Steril 2010; 93:2734-7. [DOI: 10.1016/j.fertnstert.2010.01.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 01/13/2010] [Accepted: 01/20/2010] [Indexed: 10/19/2022]
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Early postoperative small bowel obstruction after laparoscopic myomectomy. Fertil Steril 2010; 94:2329.e9-12. [PMID: 20416869 DOI: 10.1016/j.fertnstert.2010.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 03/05/2010] [Accepted: 03/10/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe an early small bowel obstruction after robotic-assisted laparoscopic myomectomy with the Davinci system. DESIGN Case report. SETTING Academic medical center. PATIENT(S) Two days after a robotic-assisted laparoscopic myomectomy, a 35-year-old nulligravid African-American woman developed a small bowel obstruction due to retained myoma fragments that had implanted on and subsequently kinked loops of the small bowel. INTERVENTION(S) The patient was managed conservatively for 4 days with bowel rest and IV hydration. Due to worsening clinical symptoms and supportive radiologic findings, exploratory laparotomy was performed to lyse adhesions and remove the implanted myoma pieces. MAIN OUTCOME MEASURE(S) Clinical resolution of small bowel obstruction symptoms. RESULT(S) No bowel resection was needed for this patient. CONCLUSION(S) Prompt recognition and operative treatment of the small bowel obstruction prevented the need for intestinal resection. To reduce the risk of ectopic implantation of myoma fragments, meticulous care should be taken to remove all remnants of morcellated tissue. Immediate postoperative complications, such as bowel obstruction, and long-term complications related to recurrent myomas may then be avoided.
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Imai A, Suzuki N. Topical non-barrier agents for postoperative adhesion prevention in animal models. Eur J Obstet Gynecol Reprod Biol 2010; 149:131-5. [DOI: 10.1016/j.ejogrb.2009.12.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 12/08/2009] [Accepted: 12/21/2009] [Indexed: 11/28/2022]
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Imai A, Takagi H, Matsunami K, Suzuki N. Non-barrier agents for postoperative adhesion prevention: clinical and preclinical aspects. Arch Gynecol Obstet 2010; 282:269-75. [DOI: 10.1007/s00404-010-1423-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Accepted: 03/01/2010] [Indexed: 11/24/2022]
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Blumenfeld YJ, Caughey AB, El-Sayed YY, Daniels K, Lyell DJ. Single- versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions. BJOG 2010; 117:690-4. [PMID: 20236104 DOI: 10.1111/j.1471-0528.2010.02529.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the association between single-layer (one running suture) and double-layer (second layer or imbricating suture) hysterotomy closure at primary caesarean delivery and subsequent adhesion formation. DESIGN A secondary analysis from a prospective cohort study of women undergoing first repeat caesarean section. SETTING Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA. POPULATION One hundred and twenty-seven pregnant women undergoing first repeat caesarean section. METHODS Patient records were reviewed to identify whether primary caesarean hysterotomies were closed with a single or double layer. Data were analysed by Fisher's exact tests and multivariable logistic regression. MAIN OUTCOME MEASURE Prevalence rate of pelvic and abdominal adhesions. RESULTS Of the 127 women, primary hysterotomy closure was single layer in 56 and double layer in 71. Single-layer hysterotomy closure was associated with bladder adhesions at the time of repeat caesarean (24% versus 7%, P = 0.01). Single-layer closure was associated in this study with a seven-fold increase in the odds of developing bladder adhesions (odds ratio, 6.96; 95% confidence interval, 1.72-28.1), regardless of other surgical techniques, previous labour, infection and age over 35 years. There was no association between single-layer closure and other pelvic or abdominal adhesions. CONCLUSIONS Primary single-layer hysterotomy closure may be associated with more frequent bladder adhesions during repeat caesarean deliveries. The severity and clinical implications of these adhesions should be assessed in large prospective trials.
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Affiliation(s)
- Y J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University, Stanford, CA 94305, USA.
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Hilgers TW. Near Adhesion-Free Reconstructive Pelvic Surgery: Three Distinct Phases of Progress Over 23 Years. J Gynecol Surg 2010. [DOI: 10.1089/gyn.2009.0031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas W. Hilgers
- Department of Obstetrics and Gynecology, Pope Paul VI Institute, Omaha, Nebraska
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Ahn HS, Lee HJ, Yoo MW, Jeong SH, Han TS, Kim WH, Song SC, Yang HK. Efficacy of an Injectable Thermosensitive Gel on Postoperative Adhesion in Rat Model. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2010. [DOI: 10.4174/jkss.2010.79.4.239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hye Seong Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Moon-Won Yoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Ho Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-Su Han
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Woo-Ho Kim
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Soo-Chang Song
- Division of Life Science, Korea Institute of Science and Technology, Seoul, Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Sbarra M, Boyd M, Dardarian TS. Complications due to adhesion formation following cesarean sections: a review of deliveries in three cases. Fertil Steril 2009; 92:394.e13-6. [PMID: 19482275 DOI: 10.1016/j.fertnstert.2009.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 02/26/2009] [Accepted: 03/09/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe complications due to adhesion formation following cesarean sections and methods to prevent adhesion formation. DESIGN Case reports. SETTING Labor and delivery suites in three hospitals. PATIENT(S) [1] A 32-year-old G2P1 undergoing a repeat cesarean section with severe adhesions and subsequent bladder injury and repair. [2] A 36-year-old G3P1 undergoing a vaginal birth after cesarean (VBAC) with partial uterine dehiscence, fetal distress, and dense pelvic adhesions. [3] A 38-year-old G4P2 undergoing repeat cesarean section with dense adhesions from the uterus to the anterior abdominal wall. INTERVENTION(S) Cesarean sections, lysis of adhesions, and cystotomy repair. RESULT(S) All three patients had significant complications and sequelae secondary to dense uterine adhesions from previous cesarean sections. CONCLUSION(S) Adhesion prevention measures should be routinely implemented to reduce adhesion formation after cesarean deliveries and thus decrease corresponding sequelae. Critical steps to decrease adhesion formation include practicing meticulous surgical techniques, gentle tissue handling, minimizing ischemia and desiccation, controlling hemostasis, avoiding powdered gloves, and achieving peritoneal closure. Based on available data, adhesion barriers are effective in preventing or reducing adhesions after gynecologic surgery and have also been effective following cesarean sections.
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Affiliation(s)
- Michael Sbarra
- Department of Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School
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Current World Literature. Curr Opin Obstet Gynecol 2009; 21:101-9. [DOI: 10.1097/gco.0b013e3283240745] [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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Reyftmann L, Dechanet C, Amar-Hoffet A, Flandrin A, Hédon B, Dechaud H. [Surgery for infertility]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2009; 38 Spec No 1-2:F35-F42. [PMID: 19268223 DOI: 10.1016/s0368-2315(09)70230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- L Reyftmann
- Service de gynécologie obstétrique et département de médecine et biologie de la reproduction, CHU A.-de-Villeneuve, Montpellier.
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A review of techniques for adhesion prevention after gynaecological surgery. Curr Opin Obstet Gynecol 2008; 20:345-52. [DOI: 10.1097/gco.0b013e3283073a6c] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rajab TK, Barre LJ. Adhesive-reducing agents. Fertil Steril 2008; 89:1846-7. [PMID: 18468604 DOI: 10.1016/j.fertnstert.2008.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ahmad G, Duffy JMN, Farquhar C, Vail A, Vandekerckhove P, Watson A, Wiseman D. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2008:CD000475. [PMID: 18425865 DOI: 10.1002/14651858.cd000475.pub2] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pelvic adhesion can form as a result of inflammation, endometriosis or surgical trauma. During pelvic surgery, strategies to reduce pelvic adhesion formation may include placing synthetic barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene or Fibrin sheets between the pelvic structures. OBJECTIVES To assess the effect of physical barriers used during pelvic surgery in women of reproductive age on pregnancy rates, pelvic pain, or postoperative adhesion reformation. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched September 2007) which is based on regular searches of MEDLINE, EMBASE, CINAHL, PsycINFO and CENTRAL, plus handsearching of 20 relevant journals and conference proceedings, and searches of several key grey literature sources. In addition, companies were contacted for unpublished trials. SELECTION CRITERIA Any randomised controlled trials (RCTs) comparing the use of physical barriers versus no treatment or other physical barriers in the prevention of adhesions in women undergoing gynaecological surgery. DATA COLLECTION AND ANALYSIS Review authors assessed trial eligibility and quality. MAIN RESULTS Sixteen RCTs were included. Five trials randomised patients while the remainder randomised pelvic organs. Laparoscopy (six trials) and laparotomy (10 trials) were the primary surgical techniques. Indications for surgery included myomectomy (five trials), ovarian surgery (five trials), pelvic adhesions (four trials), endometriosis (one trial), and mixed (one trial). Eleven trials assessed Interceed versus no treatment, two assessed Interceed versus Gore-Tex, one trial assessed Gore-Tex versus no treatment, and one trial assessed Seprafilm versus no treatment. A single trial assessed Fibrin sheet versus no treatment. No studies reported pregnancy or reduction in pain as outcomes. The use of Interceed was associated with reduced incidence of pelvic adhesion formation, both new formation and reformation following laparoscopic surgery or laparotomy. However, this result should be interpreted with caution. Gore-Tex was more effective than no barrier or Interceed in preventing adhesion formation. There was only limited evidence that Seprafilm was effective in preventing adhesion formation following myomectomy and no evidence to support Fibrin sheet. AUTHORS' CONCLUSIONS The absorbable adhesion barrier Interceed reduces the incidence of adhesion formation following laparoscopy and laparotomy, but there are insufficient data to support its use to improve pregnancy rates. Gore-Tex may be superior to Interceed in preventing adhesion formation but its usefulness is limited by the need for suturing and later removal. There was no evidence of effectiveness of Seprafilm and Fibrin sheet in preventing adhesion formation.
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Affiliation(s)
- G Ahmad
- Stepping Hill Hospital, Obstetric & Gynaecology, 30 Badger Road, Altrincham, Cheshire, UK, WA14 5UZ.
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Adhesion Reformation After Laparoscopic Adhesiolysis: Where, What Type, and in Whom They Are Most Likely to Recur. J Minim Invasive Gynecol 2008; 15:44-8. [DOI: 10.1016/j.jmig.2007.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 09/27/2007] [Accepted: 09/28/2007] [Indexed: 11/22/2022]
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