Role of hypoestrogenism or sex steroid antagonism in adhesion formation after myometrial surgery in primates**Prize Paper, The Society of Reproductive Surgeons; presented at the 50th Annual Meeting of The American Fertility Society, San Antonio, Texas, November 5 to 10, 1994

Update on antiadhesion barriers and therapeutics in gynecological surgery

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Genetic and Epidemiological Similarities, and Differences Between Postoperative Intraperitoneal Adhesion Development and Other Benign Fibro-proliferative Disorders

Intraperitoneal adhesions complicate over half of abdominal-pelvic surgeries with immediate, short, and long-term sequelae of major healthcare concern. The pathogenesis of adhesion development is similar to the pathogenesis of wound healing in all tissues, which if unchecked result in production of fibrotic conditions. Given the similarities, we explore the published literature to highlight the similarities in the pathogenesis of intra-abdominal adhesion development (IPAD) and other fibrotic diseases such as keloids, endometriosis, uterine fibroids, bronchopulmonary dysplasia, and pulmonary, intraperitoneal, and retroperitoneal fibrosis. Following a literature search using PubMed database for all relevant English language articles up to November 2020, we reviewed relevant articles addressing the genetic and epidemiological similarities and differences in the pathogenesis and pathobiology of fibrotic diseases. We found genetic and epidemiological similarities and differences between the pathobiology of postoperative IPAD and other diseases that involve altered fibroblast-derived cells. We also found several genes and single nucleotide polymorphisms that are up- or downregulated and whose products directly or indirectly increase the propensity for postoperative adhesion development and other fibrotic diseases. An understanding of the similarities in pathophysiology of adhesion development and other fibrotic diseases contributes to a greater understanding of IPAD and these disease processes. At a very fundamental level, blocking changes in the expression or function of genes necessary for the transformation of normal to altered fibroblasts may curtail adhesion formation and other fibrotic disease since this is a prerequisite for their development. Similarly, applying measures to induce apoptosis of altered fibroblast may do the same; however, apoptosis should be at a desired level to simultaneously ameliorate development of fibrotic diseases while allowing for normal healing. Scientists may use such information to develop pharmacologic interventions for those most at risk for developing these fibrotic conditions.

NEOURETEROCYSTOSTOMY AND URETHRAL STENT PLACEMENT IN A BLACK-HANDED SPIDER MONKEY (ATELES GEOFFROYI)

A 27-y-old female black-handed spider monkey (Ateles geoffroyi) was evaluated 13 d after an ovariohysterectomy because of abdominal distension, anorexia, and absent urination. The animal was diagnosed with a uroabdomen and urethral obstruction from computed tomographic findings and fluid creatinine levels. During exploratory laparotomy, a defect in the right ureter was confirmed as the source of the uroabdomen. Utilizing intraoperative fluoroscopy, a urethral obstruction with an irregular luminal filling defect was evident. A self-expanding nitinol urethral stent was placed, and a ureteral transposition was performed. Two months after the procedure, the animal developed dysuria, a urinary tract infection, recurrent bladder distension and a partial urethral obstruction. Treatment with prazosin 1 mg/kg PO q12h improved urination. Reobstruction of the urethra occurred 17 mo postsurgery, and the animal was euthanatized. On postmortem examination, the animal had ingrowth into the stent with proliferative granulation tissue, detrusor muscle degeneration, pelvic adhesions, cystitis, pyelonephritis, and hydronephrosis.

Modified Adenovirus Reduces De Novo Peritoneal Adhesions in Rats and Limits Off-Target Transfection. Role of EZH2 in Adhesion Formation

AIM OF THE STUDY

Adenovector encoding tissue plasminogen activator (tPA) was shown to reduce experimental peritoneal adhesion. We investigated the targeting potential of our modified adenovector, its ability to reduce adhesions and the epigenetic role of histone methyltransferase EZH2 in adhesion formation.

MATERIALS AND METHODS

Control lacZ, nonmodified tPA or modified tPA vectors were instilled in the peritoneal cavity after injury in de novo adhesions or after lysis of adhesions in recurrent adhesions. Adhesion severity was scored and adhesions and liver tissues were examined for adenovirus E4 gene and tPA mRNA expression. Levels of tPA, plasminogen activator inhibitor-1 (PAI-1), transforming growth factor-β1 (TGF-β1), and EZH2 expression were measured.

RESULTS

E4 transcripts were detected in adhesions of nonmodified and modified and in livers of nonmodified but not in livers of modified de novo adhesions. Both nonmodified (p = 0.021) and modified vectors (p = 0.036) reduced the severity of de novo adhesions compared to lacZ vector. Levels of tPA in nonmodified (p = 0.021) and modified adhesions (p = 0.001) were elevated while PAI-1 (p = 0.013 and p = 0.001, respectively) and TGF-β1 levels (p = 0.002 and p = 0.016, respectively) were reduced compared with lacZ group. All vectors were not expressed in recurrent adhesions and severity score were not different among groups. EZH2 levels were elevated in de novo nontreated (p = 0.001) and was further increased in recurrent (p = 0.001) nontreated adhesions compared with noninjured peritoneum.

CONCLUSION

Modified adenovirus successfully targeted de novo adhesions but not liver tissues and reduced the severity of de novo adhesions. EZH2 is involved in the development and progression of peritoneal adhesions.

Initiation of GnRH agonist treatment on 3-5 days postoperatively in endometriosis patients: a randomized controlled trial

Seventy patients with stage III or IV endometriosis were randomly assigned to 2 groups after conservative surgery. Group O (n = 35) received 3 cycles of a 28-day gonadotropin-releasing hormone agonist (GnRH-a) treatment (goserelin, 3.6 mg) starting 3-5 days postoperatively. Group M (n = 35) received the same treatment starting on days 1-5 of menstruation. Groups were further subdivided according to add-back treatment. Pre- and posttreated levels of estradiol (E2 ), follicle stimulating hormone (FSH), and luteinizing hormone (LH) and visual analog scale (VAS), Kupperman menopausal index (KMI), and bone mineral density (BMD) scores were recorded. The incidence of uterine bleeding was assessed. In both groups, serum levels of E2 , FSH, and LH and VAS scores decreased significantly after treatment. Spotting was the most frequent bleeding pattern. During cycle 1, the bleeding time in group M was much longer that than that in group O (P =.001), and the bleeding rate in group M was significantly higher than that in group O (P =.024, RR = 1.185). In patients with stage III or IV endometriosis, the efficacy of GnRH-a initiated 3-5 days postoperatively was equivalent to that of GnRH-a initiated on days 1-5 of menstruation. Female patients who initiated GnRH-a treatment 3-5 days postoperatively experienced less uterine bleeding during the first cycle of treatment.

The aromatase inhibitor letrozole reduces adhesion formation after intraperitoneal surgery in a rat uterine horn model

OBJECTIVE

To investigate, in an experimental animal study, the effects of letrozole and tamoxifen in the reduction of adhesion formation following abdominopelvic surgery.

STUDY DESIGN

Thirty female Wistar albino rats were included and divided into three groups. One group received 500 μg/d tamoxifen and a second group received 1 mg/kg/d letrozole through an enteric tube. A third group did not receive any drugs and served as the control group. On the fifth day, a laparotomy was performed and the right uterine horn was injured by monopolar cautery. The left uterine horn was incised with a scalpel and sutured. The preventive therapy protocols were continued for 7 days after surgery. On the 14th day after first surgery the animals were sacrificed, and the intraperitoneal macroscopic adhesion formation and microscopic adhesion features were evaluated. The Kruskal-Wallis test was used to compare the scores of the macroscopic adhesion scores and histologic features among the three groups, followed by a post hoc Mann-Whitney test. The total histological score was analyzed with a one-way ANOVA, followed by post hoc Bonferroni correction tests. p values ≤0.05 were considered statistically significant. The level of significance was set at p≤0.016 for the post hoc tests.

RESULTS

The letrozole and tamoxifen groups had significantly lower adhesion scores for the right uterine horn than the control group (p=0.005 and p=0.013, respectively). For the left horn, however, only the letrozole group had a lower macroscopic adhesion score than the controls (p=0.011). The total histological score was significantly lower in the letrozole group than in the control group (p=0.014), but no differences were found between the tamoxifen group and the control group (p=0.954). Inflammation, fibroblastic activity, collagen formation and vascular proliferation were significantly lower in the letrozole group compared with the control group (p<0.05). The foreign body reactions were similar among the three groups (p>0.05). Tamoxifen administration did not result in any significant effects on the histological scores (p>0.05).

CONCLUSION

Letrozole resulted in a significant decrease in postoperative macroscopic adhesion formation and the total histological scores, but tamoxifen did not demonstrate a similar effect on the histological scores.

Gender of the patient may influence perioperative and long-term complications after restorative proctocolectomy

AIM

Gender-related differences in preoperative characteristics and early and long-term outcome for patients undergoing ileal pouch anal anastomosis (IPAA) have not previously been well studied.

METHOD

All male and female patients undergoing IPAA at a single centre between 1983 and 2008 were compared for perioperative variables and long-term outcome. Statistical tests were used as appropriate. A multivariate analysis was performed to evaluate the effects of gender on pouch failure.

RESULTS

Female patients (n=1495) were younger than male patients (n=1912) (P<0.001). Surgery type and pouch configuration were similar, although male gender was associated with a higher use of ileostomy (P<0.001) and a higher incidence of 30-day anastomotic separation (P=0.001). During a median follow up of 9.9 (female) and 9.3 (male) years, female patients were more likely to develop bowel obstruction (20.8 vs 16.7%, P=0.02) and pouch-related fistula (10.9 vs 7.6%, P=0.001). Women had a higher number of daily bowel movements than men (P=0.001), and more frequently had urgency (P=0.001), daily seepage (P=0.01) and pad use (P<0.001). A higher percentage of female patients reported dietary (P<0.001) and work (P=0.022) restrictions and lower mental component of the Short-Form 36 quality of life score (P=0.018). On multivariate analysis of perioperative variables, female gender was associated with pouch failure (P=0.05).

CONCLUSION

The gender of the patient seems to be associated with specific differences in preoperative variables and postoperative outcomes for patients undergoing IPAA.

Pelvic adhesion and gonadotropin-releasing hormone analogue: effects of triptorelin acetate depot on coagulation and fibrinolytic activities

The study investigated the impact of gonadotropin-releasing hormone analogue (GnRH-a) on coagulation and fibrinolytic activities and its effectiveness in the prevention of pelvic adhesion after myomectomy. Thirty-two infertile women underwent myomectomy followed by adhesion evaluation surgery with a second-look laparoscopy. Before myomectomy, 15 women were treated with triptorelin acetate for 3 months and 17 received no treatment. Plasminogen activator inhibitor (PAI), thrombin activatable fibrinolysis inhibitor (TAFI), protein C (PC), plasminogen, α2-antiplasmin were determined by enzyme-linked immunosorbent assays and the activity of coagulation factors V and VIII by coagulometric methods. Patients treated with GnRH-a showed significant decrease in PAI, TAFI, factors V, and VIII (P < .05) and increased PC (P < .05), but no significant change in plasminogen and α2-antiplasmin levels compared with control group. The incidence, extent, and severity of adhesions were significantly lower in GnRH-a-treated patients compared with control group (P < .05), suggesting a possible critical role of the GnRH-a therapy in preventing postoperative adhesion development.

Quality Management Issues in the Assisted Reproduction Laboratory

In the United States, the Clinical Laboratory Improvement Act (CLIA) of 1988 describes requirements and guidelines for implementing a quality control/quality assurance (QC/QA) program for moderate and high complexity laboratories. These requirements and guidelines apply to Assisted Reproductive Technology (ART) laboratories as well. The general topic of QC and QA as it pertains to in vitro fertilization (IVF) and embryo transfer (ET) is extensively reviewed. This review summarizes many of the QC and QA events that contribute to the advancement of knowledge in this biotechnological field. These events include control of the culture environment inside and outside of the incubator, as well as factors that affect culture media. This review also discusses, in considerable detail, the QC and the QA that pertain to equipment used within the laboratory and how to control for potential contaminants, which reside within the laboratory. This review provides evidence to indicate the need for laboratory personnel to monitor quality improvement issues on a continuous basis. Personnel must be willing to change as improvements in technology occur in order to meet the ever-evolving demands of a more difficult patient population. Suggestions for meeting these demands are offered.

The effect of estradiol on the expression of estrogen, progesterone, androgen, and prolactin receptors in human peritoneal fibroblasts

PURPOSE

To assess the ability of fibroblasts isolated from normal peritoneum and adhesion tissues to express various hormone receptors when cultured with exogenous estradiol.

METHODS

Primary cultures of fibroblasts from normal human peritoneum and adhesion tissue were treated with zero (control), 10(-10), 10(-8), and 10(-6) M concentrations of 17beta-estradiol. We performed real time reverse transcriptase polymerase chain reaction to determine mRNA levels of estradiol-alpha receptor (ER-alpha) and estradiol-beta receptor (ER-beta), progesterone receptor (P-R), androgen receptor (A-R), and prolactin receptor (PRL-R) in the two types of fibroblast cultures.

RESULTS

In the control groups, P-R and A-R were higher in normal than in adhesion fibroblasts. In adhesion cells, ER-alpha were higher at 10(-8) estradiol; ER-beta were higher at 10(-6) M estradiol; P-R remained constant; A-R showed a higher expression at 10(-10) and 10(-8) M estradiol; and PRL-R showed an exponential increase at 10(-10) M estradiol.

CONCLUSIONS

The inflammatory-like changes manifested by adhesion fibroblasts enhance the anabolic hormones receptor expression (ER-alpha, ER-beta, PRL, and A-R), when exposed to estradiol.

Gonadotropin-releasing hormone agonist pretreatment did not decrease postoperative adhesion formation after abdominal myomectomy in a randomized control trial

OBJECTIVE

To determine if 3 months of preoperative gonadotropin-releasing hormone agonist (GnRH-a) treatment decreases postoperative uterine adhesions after open abdominal surgery for the removal of uterine fibroids.

DESIGN

Prospective, randomized, clinical study.

SETTING

A tertiary care medical center.

PATIENT(S)

Women of reproductive age with symptomatic uterine fibroids not amenable to hysteroscopic removal.

INTERVENTION(S)

Twenty patients underwent an initial abdominal myomectomy followed by a second-look laparoscopy for evaluating uterine adhesions after random allocation to groups receiving either GnRH analog or placebo for 3 months before the initial surgery.

MAIN OUTCOME MEASURE(S)

Adhesion formation between treatment groups and by incision number and aggregate length.

RESULT(S)

Presurgical GnRH-a treatment did not decrease adhesion formation compared with placebo. For every additional centimeter of incision length, the total adhesion area over the uterine serosal surface increased by 0.55 cm(2). The number of myomas removed and the number of incisions were positively correlated with total adhesion area.

CONCLUSION(S)

Preoperative treatment with GnRH-a for 3 months before open abdominal myomectomy did not decrease postoperative uterine adhesions. Following the standards of good surgical technique, adhesions are minimized with fewer and smaller incisions.

Effect of small bowel obstruction on functional outcome and quality of life in patients with ileal pouch-anal anastomosis: 10-year follow-up study

BACKGROUND AND AIM

Postoperative abdominal adhesion formation is a troublesome clinical problem and a common cause of intestinal obstruction, chronic pain and infertility. The aim of this study was to evaluate the effect of small bowel obstruction (SBO) on functional outcome and quality of life (QOL) in patients who experienced ileal pouch-anal anastomosis (IPAA).

METHODS

A total of 2418 patients who had undergone IPAA were categorized into three groups: group 1 comprised patients who had no SBO episodes until the last follow-up; group 2 comprised patients who had one or more SBO episodes treated medically; and group 3 comprised patients who had one or more SBO episodes, at least one of which was treated surgically. Functional outcomes and QOL scores for patients in each group were evaluated at 1, 3, 5 and 10 years of follow-up using multivariate analysis.

RESULTS

We found that patients who had SBO episodes which were treated medically were more likely to have a higher number of total bowel movements in a day in the first year of follow-up compared to patients without postoperative SBO (P = 0.03), and more seepage during the day at 10 years follow-up compared to patients with no SBO episodes or surgically treated SBO episodes (P = 0.01). The Cleveland Global Quality of Life (CGQL) scores were comparable between the three groups at 1, 3, 5 and 10 years of follow-up.

CONCLUSION

Medical management of SBO is associated with an increase in two symptoms, but QOL is comparable with surgical management.

Impact of aromatase inhibitors on adhesion formation in a rat model

OBJECTIVE

To investigate the antiadhesion potential of tamoxifen and anastrozole in a rat uterine horn model.

DESIGN

Experimental animal study.

SETTING

University animal laboratory.

ANIMAL(S)

Forty-five female Wistar albino rats.

INTERVENTION(S)

We examined the effects of tamoxifen and anastrozole to reduce the extent and severity of postoperative adhesions in a rat uterine horn model: the control group received no therapy while the second and third groups received 500 mug/day tamoxifen and 0.2 mg/kg/day anastrazole, respectively, through an enteric tube, starting 5 days before surgery. These protocols were continued for 14 days after the surgery until the rats were killed.

MAIN OUTCOME MEASURE(S)

Adhesions were scored according to their extent and severity, and specimens were also evaluated and scored histologically according to the following features: inflammation, fibroblastic activities, foreign body reaction, collagen formation, and vascular proliferation.

RESULT(S)

Anastrozole had the lowest mean adhesion scores, and these scores were significantly different from those of the controls. However, there were no statistically significant differences between control and tamoxifen groups and between tamoxifen and anastrozole groups. Histologic scores were lowest in the anastrozole group, which were statistically different from those of the tamoxifen and anastrozole groups, whereas scores of the control group were not statistically different from those of the tamoxifen group.

CONCLUSION(S)

Anastrazole decreased postsurgical adhesion scores by both visual scores and histologic analyses in a rat model. Further experimental and clinical trials are required to confirm these results.

Laparoscopic myomectomy for symptomatic uterine myomas

OBJECTIVE

To evaluate the safety, efficacy, and techniques of laparoscopic myomectomy as treatment for symptomatic uterine myomas.

DESIGN

Medline literature review and cross-reference of published data.

RESULTS

Results from randomized trials and clinical series have shown that laparoscopic myomectomy provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than abdominal myomectomy when performed by skilled surgeons. Improvements in surgical instruments and techniques allows for safe removal and multilayer myometrial repair of multiple large intramural myomas. Randomized trials support the use of absorbable adhesion barriers to reduce adhesions, but there is no apparent benefit of presurgical use of GnRH agonists. Pregnancy outcomes have been good, and the risk of uterine rupture is very low when the myometrium is repaired appropriately.

CONCLUSION(S)

Advances in surgical instruments and techniques are expanding the role of laparoscopic myomectomy in well-selected individuals. Meticulous repair of the myometrium is essential for women considering pregnancy after laparoscopic myomectomy to minimize the risk of uterine rupture. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy, hysterectomy, and uterine artery embolization for some women.

Preoperative leuprolide acetate combined with Interceed optimally reduces uterine adhesions and fibrosis in a rabbit model,

OBJECTIVE

To determine the optimal approach to prevent adhesions comparing leuprolide acetate (GnRH-a), Interceed (oxidized regenerated cellulose; Johnson & Johnson Medical, Inc., New Brunswick, NJ), and a combination of leuprolide with Interceed in a rabbit uterine horn adhesion model.

DESIGN

Prospective, randomized, blinded study.

SETTING

Certified animal care facility.

ANIMAL(S)

Twenty-eight sexually mature, female New Zealand White rabbits.

INTERVENTION(S)

Animals were prospectively randomized (by number generator) to receive GnRH-a or saline. After 6 weeks, standard surgical manipulations were performed at three sites in each uterine horn by [1]. suture, [2]. unipolar cautery, and [3]. superficial abrasion. Interceed was applied over one randomly assigned uterine horn only. Six weeks after surgery, uterine adhesions were assessed visually, and tissue fibrosis was assessed by histology.

MAIN OUTCOME MEASURE(S)

Presence or absence of adhesions and microscopic tissue fibrosis.

RESULT(S)

Gonadotropin-releasing hormone agonist significantly decreased adhesions, whereas Interceed alone did not reduce adhesions. However, GnRH agonist plus Interceed was the most effective measure to reduce tissue fibrosis.

CONCLUSION(S)

Preoperative GnRH-a is more effective than Interceed in preventing surgical adhesions in the rabbit uterine horn. However, preoperative GnRH-a plus Interceed may provide optimal results in this animal model, because microscopic tissue fibrosis is minimized with this combination.

Hormone-independent ovarian influence on adhesion development

OBJECTIVE

To determine which ovarian sex steroid(s), when removed from an intact organism, reduce(s) postoperative adhesion development.

DESIGN

Randomized, prospective, blinded study.

SETTING

University vivarium.

PATIENT(S)

One hundred twenty sexually mature female Sprague-Dawley rats, 226-250 g.

INTERVENTION(S)

Day 0, sham ovariectomy or bilateral ovariectomy, accompanied by continuous-release sex steroid replacement of either no steroids (control), 17beta-E(2), natural P (P4), or combined E(2)/P4. Day 7, standardized cecal abrasion; day 14, necropsy with assessment of adhesion presence or absence.

MAIN OUTCOME MEASURE(S)

Adhesion formation.

RESULT(S)

Three rats died because of anesthesia or surgical complications, and 117 rats reached necropsy. The ovary-intact (sham) rats adhesion incidence was 60.9%; ovariectomized control rats, 20.8%; E(2), 28.6%; P4, 33.3%; and combined E(2)/P4, 24.0%. Despite differing sex steroid replacement, two-tailed chi(2) testing with correction for multiple comparisons showed no statistical difference in adhesion incidence among the four ovariectomy groups. A statistically significant lower adhesion incidence was noted between the ovary-intact sham cohort and the collective ovariectomy groups and between the sham and ovariectomized control cohorts.

CONCLUSION(S)

Ovarian presence or absence at the time of surgical wounding, and not the 17beta-E(2) or P milieu, modulates adhesion development. This implicates other ovarian factor(s) in postoperative adhesion development.

Comparison of the reduction of postoperative adhesions by two barriers, one solution, and two pharmacologic agents in the rat uterine model

OBJECTIVE

To evaluate the effects of two barriers, one solution, and two pharmacologic agents, in single or in combined use, for preventing postsurgical adhesion formation in the rat model.

DESIGN

A randomized, prospective study to evaluate the ability of leuprolide acetate, oxidized regenerated cellulose, medroxyprogesterone acetate, sodium hyaluronate, sodium hyaluronate/carboxymethyl cellulose, in single or in combined use, for preventing adhesion formation in a rat model.

ANIMAL(S)

Wistar female rats.

SETTING

University animal laboratory.

INTERVENTION(S)

Intramuscular injection of pharmacologic agents before surgery and intraperitoneal application of barriers and solution at the end of surgery.

MAIN OUTCOME MEASURE(S)

Two weeks after surgery, a second laparotomy was performed and the extent of adhesion formation was determined.

RESULT(S)

All the treatment groups had fewer, less severe adhesions when compared with controls. The combination of medroxyprogesterone acetate and oxidized regenerated cellulose did enhance the adhesion-reducing capacity of oxidized regenerated cellulose. The performance of sodium hyaluronate solution for adhesion prevention was statistically significant, when compared with oxidized regenerated cellulose alone, or sodium hyaluronate used with carboxymethyl cellulose film.

CONCLUSION(S)

Pharmacologic agents, barriers, or solutions result in significant reduction of postsurgical adhesions. The sodium hyaluronate solution alone and medroxyprogesterone acetate treatment alone had the least adhesion prevention scores. However, neither monotherapy nor combined therapy proved to be significantly more beneficial.

Effects of leuprolide acetate on adhesion formation and wound healing in the rat model

STUDY OBJECTIVE

To assess the effects of a hypoestrogenic state on adhesion formation and reformation and on wound healing in the rat model.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SUBJECTS

Forty-eight female Sprague-Dawley rats.

INTERVENTIONS

Rats were injected with gonadotropin-hormone releasing hormone (GnRH) agonist and control rats with normal saline. Two weeks later (day zero) laparotomy was performed to create adhesions and a full-thickness wound on the flank. On day 14 the adhesions were scored and liberated. The rats were sacrificed on day 28 and adhesion reformation was evaluated. The wound surface area was measured serially until complete closure.

MEASUREMENTS AND MAIN RESULTS

Mean adhesion scores on day 14 after adhesion formation were not significantly different between GnRH agonist and control groups. Preadhesiolysis and postadhesiolysis scores were not significantly different. There was no significant difference in size of wounds between groups on days zero, 7, or 14.

CONCLUSION

Administration of a GnRH agonist does not seem to influence postoperative adhesion formation or wound healing in the rat model. (J Am Assoc Gynecol Laparosc 8(1):124-128, 2001)

Surgical management of adhesions, endometriosis, and tubal pathology in the woman with infertility

There are many considerations in the surgical treatment of patients with infertility. Of prime importance is the baseline condition of the tubes and skill of the surgeon. With further advances in the understanding of the process of fertilization and implantation, it is anticipated that the use of surgical methods and application of new technologies will continue to improve fecundity for patients with infertility.

The effect of medroxyprogesterone acetate and heparin in the prevention of postsurgical adhesion formation in the rat uterine model

OBJECTIVE

To evaluate the effects of depot medroxyprogesterone acetate and heparin in preventing postsurgical adhesion formation in the rat model.

METHODS

A hundred and five female Wistar rats were divided into 7 groups. Groups 1 and 2 were injected with intramuscular 15 mg medroxyprogesterone acetate 3 weeks before surgery and at the end of laparotomy. Groups 3 and 4 were given 15 mg medroxyprogesterone acetate by intramuscular injection, 3 weeks before surgery. An equal volume of intramuscular sterile saline was injected to control groups, 3 weeks before and at the end of surgery. Before abdominal closure, 2 ml of Ringer's lactate was instilled into the peritoneal cavity of all rats, except group 7. Groups 1, 4, and 5 were given 2 ml of intraperitoneal Ringer's lactate containing 500 U heparin/ml. A standardized surgical injury was performed in all rats. Two weeks after surgery, the adhesions were scored on a scale of 0 to 3 according to their thickness-tenacity and vascularity. Kruskall-Wallis and Mann-Whitney U statistical test were used.

RESULTS

The preoperative and postoperative administration of medroxyprogesterone acetate resulted in the least number of and the least severe adhesions, when compared with single dose medroxyprogesterone acetate treated rats and controls (p < 0.05). However, the combination of medroxyprogesterone acetate and intraperitoneal heparin did not enhance the adhesion reducing capacity of medroxyprogesterone acetate.

CONCLUSIONS

Concurrent preoperative and postoperative administration of medroxyprogesterone acetate results in the most significant reduction of postsurgical adhesions. The combination treatment of medroxyprogesterone acetate and heparin does not show any additional effect in the reduction of adhesion formation, when compared with medroxyprogesterone acetate treatment alone.

The comparison of gonadotropin-releasing hormone agonist therapy and intraperitoneal Ringer's lactate solution in prevention of postoperative adhesion formation in rat models

OBJECTIVE

To evaluate gonadotropin-releasing hormone agonists (GnRH-a) therapy and intraperitoneal Ringer's lactate solution (RL) for the prevention of postsurgical adhesion formation in rat models.

STUDY DESIGN

Forty rats were randomized into four groups: Group I was the control; in group II, RL was applied at the surgery; group III and IV received preoperative subcutaneous injections of the GNRH-a leuprolide acetate and only the diluent of the GNRH-a respectively. A standard lesion was created over the uterus of each rat. Adhesions were scored at relaparotomy 3 weeks later. Analysis of variance (Kruskal-Wallis) and Mann-Whitney U-tests were used for the statistical evaluation.

RESULTS

The average adhesion scores were 2.7+/-0.26, 1.4+/-0.27, 0.9+/-0.18, and 2.5+/-0.34 in groups I, II, III, and IV respectively. There were significant differences between the scores of groups I and II (P<0.01), groups I and III (P<0.001), groups II and IV (P<0.05), and groups III and IV (P<0.01); but not between the scores of groups II and III, and groups I and IV (P>0.05).

CONCLUSION

GNRH-a was successful in reducing postoperative adhesion formation but was not superior to intraperitoneal RL.

Pelvic adhesions contain sex steroid receptors and produce angiogenesis growth factors

OBJECTIVE

To evaluate female pelvic adhesion tissue for the presence of estrogen receptor (ER), progesterone receptor (PR), basic fibroblastic growth factor (basic-FGF), and vascular endothelial growth factor (VEGF).

DESIGN

Descriptive study.

SETTING

Patients at a tertiary medical center.

PATIENTS

Female reproductive age patients undergoing gynecologic surgery who were not receiving hormonal therapy.

INTERVENTIONS

Female reproductive tract peritoneal adhesion tissue was excised, frozen, and sent for immunohistologic evaluation.

MAIN OUTCOME MEASURE

Presence of ER, PR, basic-FGF, and VEGF in adhesion tissue.

RESULTS

Nineteen of 19 specimens were positive for PR; 16 of 19 specimens were positive for ER, which was present in a variety of the different cell types constituting adhesion. Vascular endothelial growth factor and basic-FGF were detected in endothelial cells of blood vessels supplying this tissue as well as in mesothelial cells.

CONCLUSION

Adhesion tissue contains ER, PR, and growth factors that may be important in the genesis of the permanent fibrovascular bands between pelvic organs. This supports the theoretical possibility of hormonal manipulation of these tissues to negatively influence postoperative pelvic adhesion formation.