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Siebert T, Moersdorf G, Colberg T. Laparoscopic application of sodium hyaluronate-carboxymethylcellulose barrier in abdominopelvic surgery: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Systematic Review Protocols-compliant systematic review and meta-analysis. Surgery 2024; 175:1358-1367. [PMID: 38429164 DOI: 10.1016/j.surg.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND We aimed to evaluate the incidence of postoperative adhesion formation and adhesion-related consequences (eg, bowel obstruction) after placement of a sodium hyaluronate-carboxymethylcellulose adhesion barrier after laparoscopic abdominopelvic surgery. METHODS In this systematic review and meta-analysis, we searched the Medical Literature Analysis and Retrieval System Online and Embase via Ovid, Cochrane Central Register of Controlled Trials, ScienceDirect, BIOSIS Previews, Cumulative Index to Nursing and Allied Health Literature, and Clinical Trial Registries. A manual search (eg, Google Scholar and professional association websites) was also conducted to supplement the electronic database results. Two reviewers independently identified relevant studies based on inclusion and exclusion criteria and extracted data. RESULTS A total of 28 studies were included in the systematic qualitative review. Three of the 28 studies included had comparable outcome measures, interventions, and control groups, allowing the pooling of study data. A total of 938 patients (490 patients in the sodium hyaluronate-carboxymethylcellulose barrier group and 448 in the no adhesion barrier group) from these 3 studies were included in the meta-analyses, which found the incidence of bowel obstruction was significantly lower (65% risk reduction) in the sodium hyaluronate-carboxymethylcellulose barrier group compared with the control group (relative risk = 0.35; 95% confidence interval, 0.19-0.63; P = .005) with extremely low heterogeneity between studies (I2 = 0; P = .41). The placement of sodium hyaluronate-carboxymethylcellulose barrier laparoscopically did not create new safety signals nor did it increase the incidence of adverse events. CONCLUSION Our meta-analysis found that laparoscopic application of a sodium hyaluronate-carboxymethylcellulose barrier in abdominopelvic surgery reduces the risk of bowel obstruction where applied during the early postoperative phase.
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Affiliation(s)
- Terri Siebert
- Medical Affairs, Baxter Healthcare Corporation, Deerfield, IL.
| | | | - Torben Colberg
- Medical Affairs, Baxter Healthcare Corporation, Deerfield, IL
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2
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Song BR, Park IS, Park DY, Kim YJ, Kim MS, Lee KB, Park SR, Choi BH, Min BH. Anti-adhesive effect of chondrocyte-derived extracellular matrix surface-modified with poly-L-lysine (PLL). J Tissue Eng Regen Med 2021; 16:279-289. [PMID: 34788485 DOI: 10.1002/term.3263] [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: 07/05/2021] [Revised: 10/25/2021] [Accepted: 11/03/2021] [Indexed: 12/08/2022]
Abstract
After an injury, soft tissue structures in the body undergo a natural healing process through specific phases of healing. Adhesions occur as abnormal attachments between tissues and organs through the formation of blood vessels and/or fibrinous adhesions during the regenerative repair process. In this study, we developed an adhesion-preventing membrane with an improved physical protection function by modifying the surface of chondrocyte-derived extracellular matrices (CECM) with anti-adhesion function. We attempted to change the negative charge of the CECM surface to neutral using poly-L-lysine (PLL) and investigated whether it blocked fibroblast adhesion to it and showed an improved anti-adhesion effect in animal models of tissue adhesion. The surface of the membrane was modified with PLL coating (PLL 10), which neutralized the surface charge. We confirmed that the surface characteristics except for the potential difference were maintained after the modification and tested cell attachment in vitro. Adhesion inhibition was identified in a peritoneal adhesion animal model at 1 week and in a subcutaneous adhesion model for 4 weeks. N-CECM suppressed fibroblast and endothelial cell adhesion in vitro and inhibited abdominal adhesions in vivo. The CECM appeared to actively inhibit the infiltration of endothelial cells into the injured site, thereby suppressing adhesion formation, which differed from conventional adhesion barriers in the mode of action. Furthermore, the N-CECM remained intact without degradation for more than four weeks in vivo and exerted anti-adhesion effects for a long time. This study demonstrated that PLL10 surface modification rendered a neutral charge to the polymer on the extracellular matrix surface, thereby inhibiting cell and tissue adhesion. Furthermore, this study suggests a means to modify extracellular matrix surfaces to meet the specific requirements of the target tissue in preventing post-surgical adhesions. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Bo Ram Song
- Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea.,Department of Molecular Science & Technology, Ajou University, Suwon, Republic of Korea
| | - In Su Park
- Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea
| | - Do Young Park
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Young Jick Kim
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Moon Suk Kim
- Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea
| | - Kyi Beom Lee
- Department of Pathology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - So Ra Park
- Department of Physiology, College of Medicine, Inha University, Incheon, Republic of Korea
| | - Byung Hyune Choi
- Department of Biomedical Sciences, College of Medicine, Inha University, Incheon, Republic of Korea
| | - Byoung-Hyun Min
- Cell Therapy Center, Ajou University Medical Center, Suwon, Republic of Korea.,Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea.,Department of Molecular Science & Technology, Ajou University, Suwon, Republic of Korea
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Taokaew S, Alghunaim A, Newby BMZ. Zosteric Acid, a Bioactive Component in Eelgrass Zostera marina, Reduced Collagen I Expression in a Repaired Mouse Fibroblast Scratch. Nat Prod Commun 2019. [DOI: 10.1177/1934578x19850713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Zosteric acid (ZA), a bioactive component in Zostera marina eelgrass, was applied to assess closure of normal mouse fibroblast scratch and collagen I expression. The cytotoxicity of ZA on the fibroblast at different ZA concentrations was evaluated. ZA showed low toxicity with ~80% of cell viability at a concentration of ~1600 ppm. A single scratch (~1500 μm) was made on a layer of fibroblast, and collagen expression was determined after 72 hours when the scratch fully closed for both ZA-treated and untreated samples. Compared to control, the ZA-treated cells were slightly less dense and randomly oriented in the closure region and had lower actin and vinculin expressions. The total collagen expressions were comparable to the control, whereas collagen I expression of the mouse fibroblast treated with 1600 ppm of ZA was significantly lower than untreated fibroblasts.
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Affiliation(s)
- Siriporn Taokaew
- Department of Chemical and Biomolecular Engineering, The University of Akron, OH, USA
- Department of Materials Science and Technology, School of Engineering, Nagaoka University of Technology, Kamitomioka, Niigata, Japan
| | - Abdullah Alghunaim
- Department of Chemical and Biomolecular Engineering, The University of Akron, OH, USA
| | - Bi-min Zhang Newby
- Department of Chemical and Biomolecular Engineering, The University of Akron, OH, USA
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Development of novel biocompatible thermosensitive anti-adhesive agents using human-derived acellular dermal matrix. PLoS One 2019; 14:e0212583. [PMID: 30794612 PMCID: PMC6386309 DOI: 10.1371/journal.pone.0212583] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/05/2019] [Indexed: 11/19/2022] Open
Abstract
Postoperative adhesion is a natural phenomenon that occurs in damaged tissue cells. Several anti-adhesion agents are currently used, but there is no leading-edge product with excellent adhesion-preventive effects. The purpose of this study was to develop ideal anti-adhesive agents using human-derived acellular dermal matrix (ADM). We developed 5 new biocompatible thermosensitive anti-adhesion barriers (AABs) using micronized human-derived ADM, hyaluronic acid, and temperature-sensitive and biocompatible synthesized polymers. The biocompatibility, anti-adhesion effect, and biodegradability of these AABs were compared with those of commercial thermosensitive anti-adhesion agents. No cytotoxic effects were observed in vitro and in vivo. Animal testing of adhesion resistance confirmed that the adhesion area, strength, and grade of AAB03 were statistically superior to those of the control group. Factors related to adhesion formation, such as lymphocytes, macrophages, microvessels, and collagen fiber density, were observed using specific staining methods; the results confirmed that AAB03 group exhibited significantly lower macrophage counts, microvessel density, and collagen fiber density than the control groups. Furthermore, AAB03 was completely absorbed by 6 weeks. Thus, AAB03 has the potential to be used as a high-performance anti-adhesion agent.
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Oh SH, Kang JG, Lee JH. Co-micellized Pluronic mixture with thermo-sensitivity and residence stability as an injectable tissue adhesion barrier hydrogel. J Biomed Mater Res B Appl Biomater 2016; 106:172-182. [DOI: 10.1002/jbm.b.33824] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/20/2016] [Accepted: 11/16/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Se Heang Oh
- Department of Nanobiomedical Science; Dankook University; Cheonan 31116 Republic of Korea
| | - Jun Goo Kang
- Department of Advanced Materials; Hannam University; Daejeon 34054 Republic of Korea
| | - Jin Ho Lee
- Department of Advanced Materials; Hannam University; Daejeon 34054 Republic of Korea
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Kim M, Hwang Y, Tae G. The enhanced anti-tissue adhesive effect of injectable pluronic-HA hydrogel by poly(γ-glutamic acid). Int J Biol Macromol 2016; 93:1603-1611. [DOI: 10.1016/j.ijbiomac.2016.02.064] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
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7
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Baeva LF, Sarkar Das S, Hitchins VM. Bacterial endotoxin detection in hyaluronic acid-based medical devices. J Biomed Mater Res B Appl Biomater 2016; 105:1210-1215. [DOI: 10.1002/jbm.b.33659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 02/19/2016] [Accepted: 03/10/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Larissa F. Baeva
- Division of Biology, Chemistry, and Materials Science, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health; US Food and Drug Administration; Silver Spring Maryland 20993
| | - Srilekha Sarkar Das
- Division of Biology, Chemistry, and Materials Science, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health; US Food and Drug Administration; Silver Spring Maryland 20993
| | - Victoria M. Hitchins
- Division of Biology, Chemistry, and Materials Science, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health; US Food and Drug Administration; Silver Spring Maryland 20993
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9
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Thermosensitive methyl cellulose-based injectable hydrogels for post-operation anti-adhesion. Carbohydr Polym 2014; 101:171-8. [DOI: 10.1016/j.carbpol.2013.09.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 08/14/2013] [Accepted: 09/02/2013] [Indexed: 01/15/2023]
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Yamaoka T, Njatawidjaja E, Kasai A, Agudelo CA, Ehashi T, Kakinoki S, Kato S, Mahara A. Elastic/adhesive double-layered PLA-PEG multiblock copolymer membranes for postoperative adhesion prevention. Polym Degrad Stab 2013. [DOI: 10.1016/j.polymdegradstab.2013.08.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sprayable powder of hyaluronate embedded in mildly cross-linked alginate as a post-surgical tissue adhesion barrier. Macromol Res 2013. [DOI: 10.1007/s13233-013-1163-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Na SY, Oh SH, Song KS, Lee JH. Hyaluronic acid/mildly crosslinked alginate hydrogel as an injectable tissue adhesion barrier. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2012; 23:2303-13. [PMID: 22661246 DOI: 10.1007/s10856-012-4689-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 05/21/2012] [Indexed: 05/25/2023]
Abstract
Although hyaluronic acid (HA) has been conventionally utilized as a tissue adhesion barrier material, its rapid clearance in the body still remains as a big challenge in the clinical practice. In this study, we prepared a hydrogel of HA embedded in mildly crosslinked alginate (HA/mcALG hydrogel), which is injectable, easily covers injured tissues, and remains stably at the applied site during wound healing (by muco-adhesive HA embedded in the network structure of the mcALG hydrogel). The HA/mcALG hydrogel was highly effective for the prevention of peritoneal tissue adhesion compared to HA and mcALG hydrogels, and did not lead to any abnormal tissue responses during wound healing. The HA/mcALG hydrogel can be a good candidate as an injectable tissue adhesion barrier for clinical applications.
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Affiliation(s)
- Seung Yeon Na
- Department of Advanced Materials, Hannam University, 461-6 Jeonmin Dong, Yuseong Gu, Daejeon, 305-811, Republic of Korea
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Abstract
Surgical sealants form gel when applied to tissues. Currently, fibrin sealant has been successfully used in many surgical fields, but it has several disadvantages, including possible virus transmission, low adhesive strength, and high cost. In this study, gelatin and glutaraldehyde (GA) solutions were chosen to demonstrate the effectiveness of cross-linked gelatin gel as sealant and barrier, both of which have long been used in medical applications. It was found that the gelatin gel prepared from 26 wt% gelatin and 1 wt% GA solutions exhibited bonding strength almost three times higher than that of fibrin glue. The bonding strength increased with the increasing gelatin and GA concentrations. When a needle hole on PTFE vascular grafts was sealed with the gelatin gel, the water-resistant pressure significantly increased upon rubbing and was twice higher than that of fibrin glue. The cytotoxicity of gelatin gel was found to be much lower than that of albumin glue prepared at the same composition as commercially available BioGlue®. The gelatin gel was found to be also effective as barrier to prevent adhesion in a rat cecum abrasion model.
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Affiliation(s)
- S Suzuki
- Biomedical Engineering, Graduate School of Medicine, Nara Medical University, Nara 634-8521, Japan
| | - Y Ikada
- Biomedical Engineering, Graduate School of Medicine, Nara Medical University, Nara 634-8521, Japan
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14
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Park JK, Yeom J, Hahn SK, Hwang EJ, Shin JS, Cho IH, Bhang SH, Kim BS. Anti-coagulating hydroxyethyl starch blended with hyaluronic acid as a novel post-surgical adhesion barrier. Macromol Res 2010. [DOI: 10.1007/s13233-010-1103-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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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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Saber A. Effect of honey versus intergel in intraperitoneal adhesion prevention and colonic anastomotic healing: A randomized controlled study in rats. Int J Surg 2010; 8:121-7. [DOI: 10.1016/j.ijsu.2009.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 10/18/2009] [Accepted: 11/17/2009] [Indexed: 10/20/2022]
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Tepetes K, Asprodini EK, Christodoulidis G, Spyridakis M, Kouvaras E, Hatzitheofilou K. Prevention of postoperative adhesion formation by individual and combined administration of 4 per cent icodextrin and dimetindene maleate. Br J Surg 2009; 96:1476-83. [PMID: 19918860 DOI: 10.1002/bjs.6746] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND To date, no single method has been successful in eliminating peritoneal adhesion formation after major abdominal surgery. This study evaluated the individual and possible synergistic effect of a local intraperitoneal barrier, 4 per cent icodextrin, and an intravenously administered antihistamine drug, dimetindene maleate, in the prevention of adhesion development following surgical trauma. METHODS De novo experimental adhesions were induced by standardized trauma of the peritoneum and large bowel in 120 New Zealand White rabbits. The animals were randomized into four groups receiving intraperitoneal saline, intraperitoneal 4 per cent icodextrin (60 ml), intravenous dimetindene maleate (0.1 mg/kg) and 4 per cent icodextrin-dimetindene in combination (n = 30 per group). Ten days later, adhesion scores and incidence were assessed by two independent surgeons. and surface area by computer-aided planimetry. RESULTS Treatment with either icodextrin or dimetindene maleate significantly reduced adhesion scores and increased the incidence of adhesion-free animals in an equipotent manner. The effect of combined treatment on severity, incidence and surface area of adhesions was more pronounced than that of each drug administered separately. CONCLUSION Combined administration of 4 per cent icodextrin and dimetindene maleate may be used safely and efficaciously to prevent surgically induced adhesions.
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Affiliation(s)
- K Tepetes
- Department of General Surgery, Larissa University Hospital, Larissa, Greece.
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Wei CZ, Hou CL, Gu QS, Jiang LX, Zhu B, Sheng AL. A thermosensitive chitosan-based hydrogel barrier for post-operative adhesions' prevention. Biomaterials 2009; 30:5534-40. [DOI: 10.1016/j.biomaterials.2009.05.084] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 05/19/2009] [Indexed: 11/25/2022]
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Zawaneh PN, Putnam D. Materials in Surgery: A Review of Biomaterials in Postsurgical Tissue Adhesion and Seroma Prevention. TISSUE ENGINEERING PART B-REVIEWS 2008; 14:377-91. [DOI: 10.1089/ten.teb.2008.0226] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Peter N. Zawaneh
- School of Chemical and Biomolecular Engineering, Cornell University, Ithaca, New York
| | - David Putnam
- School of Chemical and Biomolecular Engineering, Cornell University, Ithaca, New York
- Department of Biomedical Engineering, Cornell University, Ithaca, New York
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Adhesions are common and costly after open pouch surgery. J Gastrointest Surg 2008; 12:1239-45. [PMID: 18278539 DOI: 10.1007/s11605-008-0481-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Accepted: 01/16/2008] [Indexed: 01/31/2023]
Abstract
PURPOSE Open ileal pouch surgery leads to high rates of adhesive small-bowel obstruction (SBO). A laparoscopic approach may reduce these complications. We aimed to review the incidence of adhesive SBO-related complications after open pouch surgery and to model the potential financial impact of a laparoscopic approach purely as an adhesion prevention strategy. MATERIALS AND METHODS We reviewed cases of open ileal pouch patients kept on a database and examined annually. Case notes were studied for episodes of adhesive SBO requiring admission or reoperation. Similar parameters were studied in a small series undergoing laparoscopic pouch surgery. The financial burden of the open access complications was estimated and potential financial impact of a laparoscopic approach modeled. RESULTS Two hundred seventy-six patients were followed up after open surgery (median, 6.3; range, 0.2-20.1 years). There were 76 (28%) readmissions (median length of stay, 7.4 days) in 53 patients (19%) and 28 (10%) reoperations (43% within 1 year). Laparoscopic patients required less adhesiolysis at second-stage surgery (0% vs 36%, p < 0.0001) and had less SBO episodes within 12 months of surgery (0% vs 14%, p < 0.0001) than open patients. Modeling a laparoscopic approach cost $1,450 and saved $3,282, thus netting $1,832 per pouch constructed. CONCLUSION Open ileal pouch surgery results in significant cumulative long-term access-related complications, particularly adhesions. These impose a large medical burden on patients and financial burden on health-care systems, all of which may be recouped by a laparoscopic approach, despite higher theater costs.
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Yeo Y, Kohane DS. Polymers in the prevention of peritoneal adhesions. Eur J Pharm Biopharm 2007; 68:57-66. [PMID: 17881201 PMCID: PMC2228410 DOI: 10.1016/j.ejpb.2007.03.027] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Revised: 03/22/2007] [Accepted: 03/22/2007] [Indexed: 11/20/2022]
Abstract
Peritoneal adhesions are serious complications of surgery, and can result in pain, infertility, and potentially lethal bowel obstruction. Pharmacotherapy and barrier devices have reduced adhesion formation to varying degrees in preclinical studies or clinical trials; however, complete prevention of adhesions remains to be accomplished. We and others have hypothesized that the limitations of the two approaches could be overcome by combining their strengths in the context of controlled drug delivery. Here we review the role of polymeric systems in the prevention of peritoneal adhesions, with an emphasis on our recent work in developing and applying polymeric drug delivery systems such as nano- or microparticles, hydrogels, and hybrid systems for peritoneal use.
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Affiliation(s)
- Yoon Yeo
- Department of Chemical Engineering, 77 Massachusetts Avenue, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Daniel S Kohane
- Department of Chemical Engineering, 77 Massachusetts Avenue, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Laboratory for Biomaterials and Drug Delivery, Bartlett Extension 413, Division of Pediatric Intensive Care, Massachusetts General Hospital, 55 Fruit St. Boston, MA 02114, USA
- * To whom correspondence should be addressed: Phone: (617) 724-4380 FAX: (617) 724-4391
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Cooper K, Young J, Wadsworth S, Cui H, diZerega GS, Rodgers KE. Reduction of post-surgical adhesion formation with tranilast. J Surg Res 2007; 141:153-61. [PMID: 17560610 DOI: 10.1016/j.jss.2006.05.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 05/05/2006] [Accepted: 05/10/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preclinical studies using the rabbit sidewall and double uterine horn models were used to assess time and dose response of tranilast delivered via subcutaneous pump, p.o., or as an intraperitoneal bolus in viscoelastic gels as well as an intraperitoneal biodegradable poly(p-dioxanone) fiber in reducing adhesions compared to vehicle controls. MATERIALS AND METHODS New Zealand white rabbits underwent laparotomy followed by: 1) uterine horn abrasion and peripheral devascularization or 2) cecal abrasion and sidewall deperitonealization. Tranilast treatment using various vehicles and dosages was compared to vehicle alone versus no treatment. Animals were euthanized after 7 to 21 days. Adhesion formation was assessed by two independent observers. RESULTS There were reductions in adhesion formation when drug was delivered topically, but oral drug alone was not effective. When tranilast was given preoperatively, oral drug added to the adhesion reduction of intraperitoneal administered drug. Tranilast in a viscoelastic carrier as well as in a biodegradable fiber was effective at reducing adhesions in the double uterine horn model. The slow release of tranilast from a biodegradable rod produced overall the best results. There were no safety issues. CONCLUSION Tranilast was effective in reducing adhesions when given in a variety of vehicles in different rabbit models of adhesion formation. Overall, the sustained intraperitoneal delivery of tranilast from biodegradable fibers was the most suitable for clinical testing.
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Affiliation(s)
- Kevin Cooper
- Center for Biomaterials & Advanced Technologies, Medical Devices Group, A division of Ethicon, A Johnson & Johnson Company, Somerville, New Jersey, USA
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Yeo Y, Ito T, Bellas E, Highley CB, Marini R, Kohane DS. In Situ Cross-linkable Hyaluronan Hydrogels Containing Polymeric Nanoparticles for Preventing Postsurgical Adhesions. Ann Surg 2007; 245:819-24. [PMID: 17457177 PMCID: PMC1877063 DOI: 10.1097/01.sla.0000251519.49405.55] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a combined barrier method and drug delivery system ("hybrid system") for preventing postoperative peritoneal adhesions, which could combine the biocompatibility and ease of application of in situ cross-linkable hydrogels with the controlled release features of polymeric nanoparticles. METHODS Poly(lactic-co-glycolic acid) nanoparticles were dispersed in aldehyde- and hydrazide-modified hyaluronic acids (HA), then combined via a double-barreled syringe. The material was subjected to mechanical testing and was assayed for in vitro cytotoxicity to murine mesothelial cells. Subsequently, it was tested for biocompatibility by intraperitoneal injection in mice. The hybrid's effectiveness in preventing postsurgical adhesions was assessed using a rabbit sidewall defect-cecum abrasion model, where it was applied to both injured surfaces. RESULTS The in situ hybrid gel system formed a flexible and durable hydrogel in less than 10 seconds. It had low in vitro cytotoxicity. In the mouse, the cross-linked HA maintained the polymeric nanoparticles in the peritoneum for 1 week, which we had previously shown would have cleared in less than 2 days, and no animals developed adhesions. Notably, the hybrid gel, even in the absence of encapsulated drug, was highly effective in preventing peritoneal adhesions in the rabbit model employed. Animals treated with the hybrid (n = 8) had no adhesions in 62.5% of cases, and none had adhesions that could only be separated by sharp dissection. In contrast, only 4.2% of untreated animals (n = 24) had no adhesions, and 58.3% developed adhesions requiring sharp dissection. CONCLUSIONS The hybrid cross-linked HA-nanoparticle system described here appears to be a biocompatible and highly effective adhesion barrier, which could also deliver antiadhesion drugs.
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Affiliation(s)
- Yoon Yeo
- Department of Chemical Engineering and Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
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diZerega GS, Cortese S, Rodgers KE, Block KM, Falcone SJ, Juarez TG, Berg R. A modern biomaterial for adhesion prevention. J Biomed Mater Res B Appl Biomater 2007; 81:239-50. [PMID: 16969823 DOI: 10.1002/jbm.b.30659] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A biomaterial composed of carboxymethylcellulose, poly(ethylene oxide), and calcium can be prepared in a variety of ways to reduce fibrin deposition and adhesion formation. This biomaterial platform can be formulated into a flowable gel with tissue adherence appropriate for use in minimally invasive surgery. The device remains at the site of placement even in gravitationally dependent areas. A peridural formulation was shown in preclinical studies to be safe and effective in reducing adhesions to dura following spinal surgery. A peritoneal formulation used on pelvic organs following peritoneal cavity surgery was also shown to be safe and effective. A clinical feasibility study showed that patients with severe back pain and lower extremity weakness treated with the peridural formulation, applied over their nerve roots following laminectomy or laminotomy, experienced significantly reduced symptoms when compared with surgery-only controls. The peritoneal formulation was shown in two multicenter feasibility studies of women undergoing pelvic surgery to significantly reduce adhesion formation when compared with surgery-only controls. Confirmation of the feasibility studies awaits results from pivotal clinical trials. These formulations were safe, effective, and easy to use. This biomaterial provided a benefit to patients undergoing surgery where postsurgical adhesion formation is a concern.
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Affiliation(s)
- Gere S diZerega
- Department of Obstetrics and Gynecology, Livingston Reproductive Biology Laboratories, Keck-USC School of Medicine, Los Angeles, California, USA.
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Yeo Y, Burdick JA, Highley CB, Marini R, Langer R, Kohane DS. Peritoneal application of chitosan and UV-cross-linkable chitosan. J Biomed Mater Res A 2006; 78:668-75. [PMID: 16739173 DOI: 10.1002/jbm.a.30740] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The suitability of chitosan and UV-cross-linkable chitosan for intraperitoneal use, for example as a barrier device for preventing peritoneal adhesions or for drug delivery, was examined. In vitro experiments using two major cell types present in the peritoneal cavity (mesothelial cells and peritoneal macrophages) revealed neither attractive interactions between cross-linked chitosan gels and the cells nor a proliferative effect. However, the same UV-cross-linked chitosan applied in the peritoneal cavity of rabbits caused a granulomatous reaction with adhesion formation within two weeks in all animals, which persisted up to 4 weeks after exposure. Unmodified chitosan also caused adhesions, while UV irradiation did not. UV-cross-linkable chitosan induced significant elevations in MIP-2 and TNF-alpha from peritoneal macrophages, suggesting that soluble mediators could play a role in inducing adhesion formation. These results reinforce the view that the predictive value of in vitro cytotoxicity assays in matters of biocompatibility may not be sufficient, and suggest that other assays such as cytokine levels may be of value in predicting outcomes in situations involving multiple cell types (i.e. in vivo).
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Affiliation(s)
- Yoon Yeo
- Department of Chemical Engineering, 77 Massachusetts Avenue E25-342, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
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Yeo Y, Highley CB, Bellas E, Ito T, Marini R, Langer R, Kohane DS. In situ cross-linkable hyaluronic acid hydrogels prevent post-operative abdominal adhesions in a rabbit model. Biomaterials 2006; 27:4698-705. [PMID: 16750564 DOI: 10.1016/j.biomaterials.2006.04.043] [Citation(s) in RCA: 175] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Accepted: 04/28/2006] [Indexed: 11/23/2022]
Abstract
We studied the efficacy of an in situ cross-linked hyaluronic acid hydrogel (HAX) in preventing post-surgical peritoneal adhesions, using a rabbit sidewall defect-cecum abrasion model. Two cross-linkable precursors were prepared by modifying hyaluronic acid with adipic dihydrazide and aldehyde, respectively. The hydrogel precursors cross-linked to form a flexible hydrogel upon mixing. The hydrogel was biodegradable and provided a durable physical barrier, which was highly effective in reducing the formation of post-operative adhesions. Ten out of 12 animals in the untreated control group developed fibrous adhesions requiring sharp dissection, while only 2 out of 8 animals treated with HAX gels showed such adhesions, and those occurred in locations that were not covered by the hydrogel. We also studied means by which gel degradation time can be modulated by varying the precursor concentration and molecular weight.
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Affiliation(s)
- Yoon Yeo
- Department of Chemical Engineering, 77 Massachusetts Avenue, Massachusetts Institute of Technology, Cambridge, 02139, USA
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Young P, Johns A, Templeman C, Witz C, Webster B, Ferland R, Diamond MP, Block K, diZerega G. Reduction of postoperative adhesions after laparoscopic gynecological surgery with Oxiplex/AP Gel⁎ ⁎Oxiplex/AP Gel, FzioMed, Inc., San Luis Obispo, California.: a pilot study. Fertil Steril 2005; 84:1450-6. [PMID: 16275243 DOI: 10.1016/j.fertnstert.2005.04.055] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2004] [Revised: 04/20/2005] [Accepted: 04/20/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine whether Oxiplex/AP Gel (FzioMed, San Luis Obispo, CA) was safe and preliminarily effective in reducing postsurgical adhesions after adnexal surgery by laparoscopy. DESIGN Prospective, multicenter, double-blind, randomized, U.S. Food and Drug Administration-monitored feasibility study. SETTING University and private clinics. PATIENT(S) Patients undergoing laparoscopic surgery with pelvic adhesions, tubal occlusion, endometriosis, and/or dermoids were randomized to receive Oxiplex/AP Gel or no further treatment after surgery. INTERVENTION(S) A blinded, parallel-group design was conducted at six centers. Patients (aged 18-46 years) underwent laparoscopic surgery, with second-look surgery 6-10 weeks later. Surgeries were videotaped. Oxiplex/AP Gel was used to cover adnexa and adjacent tissue. MAIN OUTCOME MEASURE(S) Blinded reviews of videotapes were quantitated with the American Fertility Society adhesion score (AFS score). RESULT(S) In 18 treatment patients, surgery was performed on 29 adnexa. Application of Oxiplex/AP Gel required approximately 90 seconds. In 10 control patients, surgery was performed on 18 adnexa. The mean baseline AFS score for each group was 8.0. At second look, treated adnexa had the same score (8.1), whereas in control adnexa the score increased (from 8.0 to 11.6). Thirty-four percent of treated adnexa increased in adhesion score, in contrast to 67% of control adnexa. There were no device-related adverse events. CONCLUSION(S) In this pilot study, Oxiplex/AP Gel was safe, easy to use with laparoscopy, and produced a reduction in the increase of adnexal adhesion scores.
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Affiliation(s)
- Phil Young
- IGO Medical Group, San Diego, California, USA
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