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Chen J, Tang X, Wang Z, Perez A, Yao B, Huang K, Zhang Y, King MW. Techniques for navigating postsurgical adhesions: Insights into mechanisms and future directions. Bioeng Transl Med 2023; 8:e10565. [PMID: 38023705 PMCID: PMC10658569 DOI: 10.1002/btm2.10565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 12/01/2023] Open
Abstract
Postsurgical adhesions are a common complication of surgical procedures that can lead to postoperative pain, bowel obstruction, infertility, as well as complications with future procedures. Several agents have been developed to prevent adhesion formation, such as barriers, anti-inflammatory and fibrinolytic agents. The Food and Drug Administration (FDA) has approved the use of physical barrier agents, but they have been associated with conflicting clinical studies and controversy in the clinical utilization of anti-adhesion barriers. In this review, we summarize the human anatomy of the peritoneum, the pathophysiology of adhesion formation, the current prevention agents, as well as the current research progress on adhesion prevention. The early cellular events starting with injured mesothelial cells and incorporating macrophage response have recently been found to be associated with adhesion formation. This may provide the key component for developing future adhesion prevention methods. The current use of physical barriers to separate tissues, such as Seprafilm®, composed of hyaluronic acid and carboxymethylcellulose, can only reduce the risk of adhesion formation at the end stage. Other anti-inflammatory or fibrinolytic agents for preventing adhesions have only been studied within the context of current research models, which is limited by the lack of in-vitro model systems as well as in-depth study of in-vivo models to evaluate the efficiency of anti-adhesion agents. In addition, we explore emerging therapies, such as gene therapy and stem cell-based approaches, that may offer new strategies for preventing adhesion formation. In conclusion, anti-adhesion agents represent a promising approach for reducing the burden of adhesion-related complications in surgical patients. Further research is needed to optimize their use and develop new therapies for this challenging clinical problem.
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Affiliation(s)
- Jiahui Chen
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Xiaoqi Tang
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Ziyu Wang
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Arielle Perez
- UNC School of Medicine Department of SurgeryUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Benjamin Yao
- Montefiore Medical Center Department of Obstetrics & Gynecology & Women's Health ServicesMontefiore Medical CenterBronxNew YorkUSA
| | - Ke Huang
- Joint Department of Biomedical EngineeringNorth Carolina State University & University of North Carolina at Chapel HillRaleighNorth CarolinaUSA
- Department of Molecular Biomedical SciencesNorth Carolina State UniversityRaleighNorth CarolinaUnited States
| | - Yang Zhang
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Martin W. King
- Department of Textile Engineering, Chemistry and ScienceNorth Carolina State UniversityRaleighNorth CarolinaUSA
- College of Textiles, Donghua UniversityShanghaiSongjiangChina
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Wada Y, Takahashi H, Matsui H, Yasunaga H, Fujiwara H, Sasabuchi Y. Adhesion barriers and intraperitoneal or uterine infections after cesarean section: A retrospective cohort study. Surgery 2022; 172:1722-1727. [PMID: 36210187 DOI: 10.1016/j.surg.2022.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/29/2022] [Accepted: 08/24/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraperitoneal adhesion is a common complication of cesarean section, and adhesion barriers are often used to prevent postoperative adhesion. However, the association between the use of adhesion barriers and infections after cesarean section remains unknown. This study aimed to evaluate the association. METHODS Using the administrative claims database of a single prefecture in Japan, we identified all patients who underwent cesarean section from June 2014 to February 2019. A multivariable logistic regression model fitted with a generalized estimating equation was used to compare the postoperative outcomes between patients who received intraperitoneal adhesion barriers during cesarean section and those who did not. The primary outcome was intraperitoneal or uterine infections within 3 months after cesarean section, including intraperitoneal abscess, pelvic inflammatory disease, peritonitis, uterine wound infection, endometritis, and adnexitis. RESULTS A total of 1,392 patients with 1,498 cesarean section cases were reviewed. Adhesion barriers were used in 1,153/1,498 (77.0%) cases. One hundred and fourteen (9.9%) intraperitoneal or uterine infections occurred in the group with and 15 (4.3%) in the group without adhesion barriers. The proportion of intraperitoneal or uterine infections was significantly higher in the group with than in the group without adhesion barriers (9.9% and 4.3%, respectively; adjusted odds ratio = 2.59; 95% confidence interval, 1.40-4.77; P = .002). CONCLUSION The use of adhesion barriers was associated with an increase in intraperitoneal or uterine infections after cesarean section.
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Affiliation(s)
- Yoshimitsu Wada
- Data Science Center, Jichi Medical University, Tochigi, Japan; Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan.
| | - Hiroki Matsui
- Data Science Center, Jichi Medical University, Tochigi, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| | - Hideo Yasunaga
- Data Science Center, Jichi Medical University, Tochigi, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| | - Hiroyuki Fujiwara
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan
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Strangulated small bowel obstruction caused by isolated obturator nerve and pelvic vessels after pelvic lymphadenectomy in gynecologic surgery: two case reports. Surg Case Rep 2022; 8:104. [PMID: 35644816 PMCID: PMC9148868 DOI: 10.1186/s40792-022-01459-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/24/2022] [Indexed: 01/06/2023] Open
Abstract
Abstract
Background
Although small bowel obstruction (SBO) is a major complication occurring after abdominal surgery, few reports have described strangulated SBO after pelvic lymphadenectomy (PL). This report describes two cases of strangulated SBO caused by a skeletonized obturator nerve and pelvic vessels after laparoscopic PL during gynecologic surgery.
Case presentation
Case 1: A 57-year-old woman with endometrial cancer underwent a laparoscopic semi-radical total hysterectomy with PL. Nine months after the operation, she visited our emergency room complaining about subacute pain spreading in the right groin, right buttock, and dorsal part of the right thigh. She had no abdominal pain. Although her symptoms were not typical, computed tomography (CT) revealed strangulated SBO in the right pelvis. Laparoscopic surgery revealed that the small bowel was ischemic. Then we converted to open surgery. We transected the right obturator nerve and umbilical artery, which constructed an internal hernia orifice in the right pelvis, followed by resection of the ischemic small bowel. Fortunately, during 6-month follow-up, she showed only slight difficulty in walking as a postoperative complication. Case 2: A 62-year-old woman with cervical cancer underwent laparoscopic radical hysterectomy with PL. Six months after the operation, she visited our hospital emergently because of sudden onset of abdominal pain and vomiting. CT showed strangulated SBO. Urgent laparoscopic surgery exhibited the incarcerated small bowel at the right pelvis. Consequently, we converted to open surgery. The terminal ileum was detained into the space constructed by the right umbilical artery. We cut the umbilical artery and performed ileocecal resection. After the surgery, she was discharged with no complication or sequela.
Conclusion
When examining a patient after PL who complains of severe pain or symptoms, one should consider the possibility of PL-related SBO, even if the pain is apparently atypical for SBO.
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Erenberg M, Rotem R, Segal D, Yohay Z, Idan I, Yohay D, Weintraub AY. Adhesion barriers and topical hemostatic agents are risk factors for post-cesarean section infections. Surgery 2021; 170:1120-1124. [PMID: 33933281 DOI: 10.1016/j.surg.2021.03.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cesarean sections are the most common surgery worldwide, and post-cesarean section infections and hemorrhage are a major cause for morbidity and mortality. In recent years, many surgeons use adhesion barriers as well as hemostatic agents during primary and repeated cesarean section. The data regarding the safety of these agents is relatively limited. The objective of this study was to investigate whether the use of adhesion barriers and topical hemostatic agents pose a risk for post-cesarean section infections. METHOD A case-control study composed of women who were admitted to the Soroka University Medical Center between the years 2012 and 2016 was conducted. The study group was composed of women admitted owing to post-cesarean section infections (cases) and those who underwent cesarean sections without post-cesarean section infection (control subjects). Matching was done according to date and surgery setting (elective versus emergency). A univariate analysis was followed by a multiple regression model in order to examine the association between adhesion barriers/hemostatic agents and post-cesarean section infections. RESULTS During the study period, 113 patients developed postoperative infection (cases); 71.7% were diagnosed with surgical site infection, 7.1% with endometritis, and 21.2% with other infections. These were compared with 226 control subjects. In the univariate analysis, the use of adhesion barriers/hemostatic agents were found to be associated with post-cesarean section infection. Using a multivariable analysis controlling for previous cesarean section, skin closer technique, preterm delivery, and duration of surgery >60 minutes, the use of adhesion barriers as well as hemostatic agents was found to be independently associated with post-cesarean section infection (adjusted odds ratio = 2.11, 95% confidence interval = 1.17-3.84; adjusted odds ratio = 2.29, 95% confidence interval = 1.37-3.8, respectively) CONCLUSION: Adhesion barriers and hemostatic agents were found to be independently associated with post-cesarean section infections. Further larger studies are needed to reinforce our findings. The use of these materials should be carefully considered, and their cost-effectiveness re-examined.
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Affiliation(s)
- Miriam Erenberg
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Reut Rotem
- Obstetric and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University Medical School of Jerusalem, Israel
| | - David Segal
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Zehava Yohay
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Inbal Idan
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - David Yohay
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Adi Y Weintraub
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Picaud L, Thibault B, Mery E, Ouali M, Martinez A, Delord JP, Couderc B, Ferron G. Evaluation of the effects of hyaluronic acid-carboxymethyl cellulose barrier on ovarian tumor progression. J Ovarian Res 2014; 7:40. [PMID: 24739440 PMCID: PMC3996858 DOI: 10.1186/1757-2215-7-40] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/25/2014] [Indexed: 12/04/2022] Open
Abstract
Background Hyaluronic acid is a prognostic factor in ovarian cancers. It is also a component of Hyaluronic Acid-Carboxymethyl Cellulose (HA-CMC) barrier, an anti-adhesion membrane widely used during abdominal surgeries in particular for ovarian carcinosis. 70% of patients who undergo ovarian surgery will relapse due to the persistence of cancer cells. This study’s objective was to determine the oncological risk from use of this material, in the presence of residual disease, despite the benefit gained by it decreasing post-surgical adhesions in order to provide an unambiguous assessment of its appropriateness for use in ovarian surgical management. Methods We assessed the effects of HA-CMC barrier on the in vitro proliferation of human ovarian tumor cell lines (OVCAR-3, IGROV-1 and SKOV-3). We next evaluated, in vivo in nude mice, the capacity of this biomaterial to regulate the tumor progression of subcutaneous and intraperitoneal models of ovarian tumor xenografts. Results We showed that HA-CMC barrier does not increase in vitro proliferation of ovarian cancer cell lines compared to control. In vivo, HA-CMC barrier presence with subcutaneous xenografts induced neither an increase in tumor volume nor cell proliferation (Ki67 and mitotic index). With the exception of an increased murine carcinosis score in peritoneum, the presence of HA-CMC barrier with intraperitoneal xenografts modified neither macro nor microscopic tumor growth. Finally, protein analysis of survival (Akt), proliferation (ERK) and adhesion (FAK) pathways highlighted no activation on the xenografts imputable to HA-CMC barrier. Conclusions For the most part, our results support the lack of tumor progression activation due to HA-CMC barrier. We conclude that the benefits gained from using HA-CMC barrier membrane during ovarian cancer surgeries seem to outweigh the potential oncological risks.
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Affiliation(s)
- Laetitia Picaud
- EA4553, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France ; Surgery Department, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France
| | - Benoît Thibault
- EA4553, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France
| | - Eliane Mery
- EA4553, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France
| | - Monia Ouali
- Biostatistic Unit, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France
| | - Alejandra Martinez
- Surgery Department, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France
| | - Jean-Pierre Delord
- EA4553, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France ; Université de Toulouse, Université Paul Sabatier, 118, Route de Narbonne, F-31062 Toulouse, France
| | - Bettina Couderc
- EA4553, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France ; Université de Toulouse, Université Paul Sabatier, 118, Route de Narbonne, F-31062 Toulouse, France
| | - Gwenael Ferron
- EA4553, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France ; Surgery Department, Institut Claudius Regaud, 20-24 rue du pont St Pierre, 31052 Toulouse, France
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Bae DS, Woo JW, Paek SH, Kwon H, Chai YJ, Kim SJ, Choi JY, Lee KE, Youn YK. Antiadhesive effect and safety of sodium hyaluronate-carboxymethyl cellulose membrane in thyroid surgery. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 85:199-204. [PMID: 24266009 PMCID: PMC3834017 DOI: 10.4174/jkss.2013.85.5.199] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 08/02/2013] [Accepted: 08/22/2013] [Indexed: 12/08/2022]
Abstract
Purpose A number of researchers have suggested the use of sodium hyaluronate carboxymethyl cellulose (HA-CMC) membrane for preventing postoperative adhesion. This study evaluated the antiadhesive effect and safety of HA-CMC membrane in thyroidectomy for papillary thyroid cancer. Methods One hundred sixty-two patients who underwent thyroidectomy were prospectively randomized. In the study group of 80 patients, the 7.5 cm × 13 cm HA-CMC membrane was applied to the operative field after thyroidectomy. The subjects were asked about complications including adhesive symptoms using an 8-item questionnaire at 2 weeks, 3 months, and 6 months after surgery. In addition, items on the appearance of neck wrinkles and scars were evaluated by a physician who had no information about the patient's allocation. Results There were no significant differences in complications such as swallowing difficulty, and wrinkles between study and control groups. Both groups presented significantly decreased scores over time in swallowing difficulty, and wrinkles. There were no complications regarding the HA-CMC membrane. Conclusion The antiadhesive effect of HA-CMC membrane in thyroid surgery is still uncertain, although it is biologically safe. Further investigation is needed to confirm the antiadhesive effect of HA-CMC membrane in thyroid surgery.
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Affiliation(s)
- Dong Sik Bae
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Abstract
BACKGROUND Little is known about the use and toxicity of antiadhesion substances such as sodium hyaluronate-carboxymethylcellulose. OBJECTIVE We analyzed the patterns of use and safety of sodium hyaluronate-carboxymethylcellulose in patients undergoing colectomy and gynecologic surgery. DESIGN This is a retrospective cohort study. SETTING This study covered hospitals nationwide. PATIENTS All patients in the Premier Perspective database who underwent colectomy or hysterectomy from 2000 to 2010 were included in the analyses. MAIN OUTCOME MEASURE Hyaluronate-carboxymethylcellulose use was determined by billing codes. For the primary outcome, we used hierarchical mixed-effects logistic regression models to determine the factors associated with the use of hyaluronate-carboxymethylcellulose, whereas a propensity score-matched analysis was used to secondarily assess the association between hyaluronate-carboxymethylcellulose use and toxicity (abscess, bowel and wound complications, peritonitis). RESULTS We identified 382,355 patients who underwent hysterectomy and 267,368 who underwent colectomy. For hysterectomy, hyaluronate-carboxymethylcellulose use was 5.0% overall, increasing from 1.1% in 2000 to 9.8% in 2010. Hyaluronate-carboxymethylcellulose was used in 8.1% of those who underwent colectomy and increased from 6.2% in 2000 to 12.4% in 2010. The year of diagnosis and procedure volume of the attending surgeon were the strongest predictors of hyaluronate-carboxymethylcellulose use. After matching and risk adjustment, hyaluronate-carboxymethylcellulose use was not associated with abscess formation (1.5% vs 1.5%) (relative risk = 0.97; 95% CI, 0.84-1.12) in those who underwent hysterectomy. A patient receiving hyaluronate-carboxymethylcellulose had a 13% increased risk of abscess (17.4% vs 15.0%) (relative risk = 1.13; 95% CI, 1.08-1.17) after colectomy. LIMITATIONS This was an observational study. CONCLUSION Hyaluronate-carboxymethylcellulose use has increased over the past decade for colectomy and hysterectomy. Although there is no association between hyaluronate-carboxymethylcellulose use and abscess following hysterectomy, hyaluronate-carboxymethylcellulose use was associated with a small increased risk of abscess after colectomy.
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