Prevention of de-novo adhesion formation after laparoscopic myomectomy: a randomized trial to evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier

MR imaging for preoperative characterization of pelvic adhesions: role in diagnosis and surgical planning

Pelvic adhesions are nonanatomic connections between organs and normal peritoneal surfaces that develop secondary to a maladaptive inflammatory response to tissue insults. Comprised of fibrous tissue, adhesions can result in the distortion of operative dissection planes, which can complicate the establishment of abdominal access in patients undergoing surgery, prolong the length of surgery, and increase the risk of injury to bowel and other structures if involved by extensive adhesive disease. This can adversely impact patient outcomes by increasing the risk of surgical complications including bleeding, infection, and prolonging postoperative length of stay. Literature on the characterization of adhesions with imaging is limited and a systematic framework for evaluating adhesive disease on cross-sectional imaging of the pelvis does not currently exist. In this review, we discuss the MR imaging features of pelvic adhesions, highlighting unique teaching cases in which surgical exploration was significantly complicated by the presence of adhesive disease. We will also review the correlation between MR imaging and intraoperative findings in these cases. A proposed standardized framework for the detection and characterization of adhesions on pelvic MRI will be reviewed with multiple imaging examples. Identification and characterization of pelvic adhesive disease on preoperative imaging provides radiologists with an opportunity to inform the referring clinician of their presence, potentially improving outcomes and the quality of patient care.

Prevention of peritoneal adhesions after gynecological surgery: a systematic review

IMPORTANCE

The formation of adhesions after gynecological surgery not only has detrimental impacts on those affected, including pain, obstruction, and infertility, but also imposes a high economic burden on healthcare systems worldwide.

OBJECTIVE

The aim of this review was to evaluate the adhesion prevention potential of all currently available adhesion barriers for gynecological surgery.

EVIDENCE ACQUISITION

We systematically searched MEDLINE and CENTRAL databases for randomized controlled trials (RCTs) on the use of adhesion barriers as compared with peritoneal irrigation or no treatment in gynecological surgery. Only RCTs with second-look surgery to evaluate adhesions in the pelvic/abdominal (but not intrauterine) cavity were included.

RESULTS

We included 45 RCTs with a total of 4,120 patients examining a total of 10 unique types of barriers in second-look gynecological surgery. While RCTs on oxidized regenerated cellulose (significant improvement in 6 of 14 trials), polyethylene glycol with/without other agents (4/10), hyaluronic acid and hyaluronate + carboxymethylcellulose (7/10), icodextrin (1/3), dextran (0/3), fibrin-containing agents (1/2), expanded polytetrafluoroethylene (1/1), N,O-carboxymethylchitosan (0/1), and modified starch (1/1) overall showed inconsistent findings, results for expanded polytetrafluoroethylene, hyaluronic acid, and modified starch yielded the greatest improvements regarding adhesion reduction at 75%, 0-67%, and 85%, respectively.

CONCLUSIONS AND RELEVANCE

Best results for adhesion prevention were reported after applying Gore-Tex Surgical Membrane, hyaluronic acid, and 4DryField®. As Gore-Tex Surgical Membrane is nonabsorbable, it is associated with a greater risk of new adhesion formation due to second-look surgery to remove the product. 4DryField® yielded the greatest improvement in adhesion score compared to all other barrier agents (85%). For better comparability, future studies should use standardized scores and put more emphasis on patient-reported outcome measures, such as pain and infertility.

Clinical Outcomes after the Use of Antiadhesive Agents in Laparoscopic Reproductive Surgery

INTRODUCTION

Intra-abdominal adhesions are abnormal fibrous attachments between tissues and organs that can be congenital or acquired. Adhesion formation is a critical postoperative complication that may lead to bowel obstruction, chronic abdominal pain, and infertility. Physical barrier agents separate opposing peritoneal surfaces in the critical 5-day period of remesotheliazation. These agents are subdivided into solid or liquid/gel. Liquid agents seem easier to use in laparoscopic procedures than solid agents.

METHODS

The search for suitable articles published in English was carried out using the following databases: MEDLINE, Embase, Global Health, the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register (ClinicalTrial.gov). Only studies reporting data about the impact of the use of an antiadhesive agent on adhesion formation after a primary gynecologic laparoscopic surgery were considered eligible.

RESULTS

Twenty-two papers that met the inclusion criteria were included in this systematic review.

CONCLUSIONS

Surgeons should consider applying antiadhesive agents after gynecologic surgery to help reduce adhesion formation and its adverse effects. However, further studies are still needed to confirm their impact on reproductive outcome and to implement clear guidelines on their per-operative application.

Laparoscopic myomectomy complications: META analysis on RCTs and review of large cohort studies

Complications of myomectomy are generally rare and highly dependent on the surgeons' skills and selection of patients. Haemorrhage, direct injury, post-operative pain and fever present as intra and peri-operative complications, while adhesions are considered late complications. 21 RCTs and 15 meta-analyses have been conducted to date, with the last comprehensive meta-analysis being published in 2009. The main disadvantage of the previous meta-analysis included incomplete selection of studies, inclusion of studies with small sample sizes, and major heterogeneity of methods used between studies. The aim of this meta-analysis comparing laparoscopic myomectomy (LMy) to open conservative myomectomy is to provide an updated review of the type, frequency and severity of complications. These results can direct teaching efforts and guidelines and give updated advice to gynaecologists. A literature search was conducted on PubMed and Google scholar for RCTs on this topic. 276 studies were identified and 19 RCTs ultimately met the criteria for inclusion in the meta-analysis and subsequent heterogeneity assessment. The results showed that laparoscopic myomectomy has a more favourable outcome with regards to several complications when compared with laparotomy. Laparoscopic myomectomy is significantly associated with lower Hg drop (WMD = -0.48, 95% CI [-0.89, -0.07], p = 0.02179); lower incidence of post-operative fever (RR = 0.43, 95% CI [0.29, 0.64], p < 0.001); lower levels of pain at 48Hrs post-op (WMD = -0.88, 95% CI [-1.63, -0.014], p = 0.02020) and decreased analgesia requests (RR = 0.49, 95% CI [0.37, 0.64], p < 0.0001). Prophylaxis use was associated with less adhesions (RR = 0.064, 95% CI [0.44, 0.92], p = 0.01), although not enough data was available to draw conclusions regarding specific prophylactic agents. No differences were found between LMy and laparotomy for blood loss (WMD = -13.6494, 95% CI [-44.48, 17.18], p = 0.38553) or pain at 24Hrs post-op (WMD = -0.19, 95% CI [-0.55, 0.18], p = 0.32136). These findings support previously published meta-analyses. Given the right indications of the surgery and training of the surgeon, LMy seems to be most preferable to laparotomy in achieving a better clinical result with fewer complications.

Myomectomy in infertile women: More harm than good?

Adhesion formation following gynecological surgery remains a challenge. The adoption of minimally invasive surgical approaches, such as conventional or robotic-assisted laparoscopy combined with meticulous microsurgical principles and the application of adhesion-reducing substances, is able to reduce the risk of de novo adhesion formation but do not eliminate it entirely. Myomectomy is the most adhesiogenic surgical procedure and postoperative adhesions can have a significant impact on the ability to conceive. Therefore, when surgery is performed as infertility treatment, attention should be paid to whether the benefits outweigh the risks. Among several factors, the size and the location of fibroids are the most accountable factors in terms of adhesion development and post surgical infertility; therefore, the search for effective strategies against adhesion formation in this setting is of paramount importance. The purpose of this review is to evaluate the incidence and factors of adhesion formation and the best preventive measures current available.

Barrier materials for prevention of surgical adhesions: systematic review

BACKGROUND

Postoperative surgical adhesions constitute a major health burden internationally. A wide range of materials have been evaluated, but despite constructive efforts and the obvious necessity, there remains no specific barrier widely utilized to prevent postoperative adhesion formation. The aim of this study was to highlight and characterize materials used for prevention of postoperative surgical adhesions in both animal and human studies.

METHODS

A systematic review was performed of all original research articles presenting data related to the prevention of postoperative adhesions using a barrier agent. All available observational studies and randomized trials using animal models or human participants were included, with no restrictions related to type of surgery. PubMed and Embase databases were searched using key terms from inception to August 2019. Standardized data collection forms were used to extract details for each study and assess desirable characteristics of each barrier and success in animal and/or human studies.

RESULTS

A total of 185 articles were identified for inclusion in the review, with a total of 67 unique adhesion barrier agents (37 natural and 30 synthetic materials). Desirable barrier characteristics of an ideal barrier were identified on review of the literature. Ten barriers achieved the primary outcome of reducing the incidence of postoperative adhesions in animal studies followed with positive outputs in human participants. A further 48 materials had successful results from animal studies, but with no human study performed to date.

DISCUSSION

Multiple barriers showed promise in animal studies, with several progressing to success, and fulfilment of desirable qualities, in human trials. No barrier is currently utilized commonly worldwide, but potential barriers have been identified to reduce the burden of postoperative adhesions and associated sequelae.

Prevention of Post-Operative Adhesions: A Comprehensive Review of Present and Emerging Strategies

Post-operative adhesions affect patients undergoing all types of surgeries. They are associated with serious complications, including higher risk of morbidity and mortality. Given increased hospitalization, longer operative times, and longer length of hospital stay, post-surgical adhesions also pose a great financial burden. Although our knowledge of some of the underlying mechanisms driving adhesion formation has significantly improved over the past two decades, literature has yet to fully explain the pathogenesis and etiology of post-surgical adhesions. As a result, finding an ideal preventative strategy and leveraging appropriate tissue engineering strategies has proven to be difficult. Different products have been developed and enjoyed various levels of success along the translational tissue engineering research spectrum, but their clinical translation has been limited. Herein, we comprehensively review the agents and products that have been developed to mitigate post-operative adhesion formation. We also assess emerging strategies that aid in facilitating precision and personalized medicine to improve outcomes for patients and our healthcare system.

Peritoneal Adhesions and their Prevention - Current Trends

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

Adhesion barriers in laparoscopic myomectomy: Evidence from randomized clinical trials

OBJECTIVE

To evaluate the effectiveness of different adhesion barriers in the prevention of de novo adhesion development after laparoscopic myomectomy.

METHODS

A systematic review was performed by searching seven electronic databases for all randomized clinical trials (RCTs) comparing the use of any absorbable adhesion barrier (i.e. intervention group) with either no treatment or placebo (i.e. control group) in the prevention of adhesion development after laparoscopic myomectomy.

RESULTS

Eight RCTs with a total of 748 participants (392 in the intervention group and 356 in the control group) were included. The assessed adhesion barrier methods were: oxidized regenerated cellulose (ORC) in two studies, auto-crosslinked hyaluronic acid (HA) gel in two studies, 4% icodextrin solution in one study, modified HA and carboxy-methylcellulose in one study, polyethylene glycol ester trilysine amine solution plus a borate buffer solution in one study, and polyethylene glycol amine plus dextran aldehyde polymers in another study.

CONCLUSION

Adhesion barrier methods showing the most promising results were: ORC, auto-crosslinked HA gel, and polyethylene glycol amine plus dextran aldehyde polymers.

Adhesions after Laparoscopic Myomectomy: Incidence, Risk Factors, Complications, and Prevention

Uterine fibroids or uterine myomas are one of the most common benign diseases of the uterus. Symptoms associated with myomas can make surgical removal of myomas necessary. Besides the traditional abdominal route, laparoscopic myomectomy (LM) has gained more acceptances over the last few decades, and it is anticipated that laparoscopy is associated with lower adhesion development. Therefore, we conducted this review to analyze the evidence on adhesions after LM. The PubMed database was searched using the search terms “myomectomy” alone and in combination with “adhesions,” “infertility OR fertility outcome,” and “laparoscopy” among articles published in English and German. Although the well-known advantages of laparoscopy, for example, less pain, less blood loss, or shorter hospital stay, myomectomy belongs to high-risk operations concerning adhesion formation, with at least every fifth patient developing postsurgical adhesions. In laparoscopic surgery, surgeons´ experience as well tissue trauma, due to desiccation and hypoxia, are the underlying mechanisms leading to adhesion formation. Incisions of the posterior uterus may be associated with a higher rate of adhesions compared to anterior or fundal incisions. Adhesions can be associated with severe complications such as small bowel obstruction, chronic pelvic pain, complications in further operations, or impaired fertility. Tissue trauma and the experience of the surgeon in laparoscopic surgery are most of the influencing factors for adhesion formation after myomectomy. Therefore, every surgeon should adopt strategies to reduce adhesion development in daily routine, especially when it conducted to preserve or restore fertility.

Safety of Use of a Sheet-Type Adhesion Barrier (Interceed®) During Liver Surgery

BACKGROUND

Adhesion barriers are increasingly used in hepatobiliary surgery. However, there has been no solid evidence yet in support of their safety.

METHODS

Incidences of global postoperative morbidities and major abdominal morbidities were compared between 101 consecutive patients who received a sheet-type adhesion barrier (Interceed^®) and 134 patients who did not receive any adhesion barriers during hepatectomy. Propensity score (PS) adjustment was used to account for potential bias to receive Interceed.

RESULTS

In the PS-adjusted population, the incidences of both global postoperative morbidities and major abdominal morbidities showed no significant difference between the Interceed group and the control group (17.9% vs. 17.6%; P = 0.948 and 7.8% vs. 9.1%; P = 0.813, respectively). Multivariate analysis showed that age + 10 years (odds ratio [OR], 1.70; 95% CI, 1.15-2.50; P = 0.007), estimated blood loss + 100 mL (OR, 1.05; 95% CI, 1.01-1.09, P = 0.009), and laparoscopic approach (OR, 0.10; 95% CI, 0.01-0.75; P = 0.026) were independent predictors for global postoperative morbidities and operation time + 1 h (OR, 1.56; 95% CI, 1.23-1.96; P < 0.001) was a risk factor for major abdominal morbidity, while no specific association between the use of Interceed and the risk of postoperative morbidity was observed.

CONCLUSIONS

Use of Interceed does not increase the risk of postoperative morbidities after hepatectomy.

Effectiveness of laparoscopic ultrasonography in laparoscopic myomectomy

INTRODUCTION

Laparoscopic myomectomy (LM) has become increasingly common in recent years because it minimizes invasiveness. However, myoma can recur after myomectomy. Therefore, we began using laparoscopic ultrasonography, which involves inserting a probe into the peritoneal cavity via a trocar and placing it in direct contact with the uterus. During surgery, this enables the detection of myomas as a small as 1 mm in diameter, which are often undetectable on MRI. Here, we report the effectiveness of laparoscopic ultrasonography.

METHODS

The subjects were 26 women who underwent LM at our institution from February 2015 to December 2016. Preoperative MRI was performed, and all myomas detected on MRI were removed during LM. Laparoscopic ultrasonography was then performed to assess for residual myomas, which were removed.

RESULTS

In six patients (23%), residual myomas were identified on laparoscopic ultrasonography after the first enucleation of the myomas detected on preoperative MRI. All detected residual myomas, the largest of which was less than 10 mm in diameter, were removed.

CONCLUSION

Small myomas undetectable on preoperative MRI were detected on laparoscopic ultrasonography and removed.

Barrier agents for adhesion prevention after gynaecological surgery

BACKGROUND

Pelvic adhesions can form secondary to inflammation, endometriosis, or surgical trauma. Strategies to reduce pelvic adhesion formation include placing barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene, and fibrin or collagen sheets between pelvic structures.

OBJECTIVES

To evaluate the effects of barrier agents used during pelvic surgery on rates of pain, live birth, and postoperative adhesions in women of reproductive age.

SEARCH METHODS

We searched the following databases in August 2019: the Cochrane Gynaecology and Fertility (CGF) Specialised Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), Epistemonikos, and trial registries. We searched reference lists of relevant papers, conference proceedings, and grey literature sources. We contacted pharmaceutical companies for information and handsearched relevant journals and conference abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs) on the use of barrier agents compared with other barrier agents, placebo, or no treatment for prevention of adhesions in women undergoing gynaecological surgery.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for eligibility and risk of bias and extracted data. We calculated odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) using a fixed-effect model. We assessed the overall quality of the evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods.

MAIN RESULTS

We included 19 RCTs (1316 women). Seven RCTs randomised women; the remainder randomised pelvic organs. Laparoscopy (eight RCTs) and laparotomy (11 RCTs) were the primary surgical techniques. Indications for surgery included myomectomy (seven RCTs), ovarian surgery (five RCTs), pelvic adhesions (five RCTs), endometriosis (one RCT), and mixed gynaecological surgery (one RCT). The sole indication for surgery in three of the RCTs was infertility. Thirteen RCTs reported commercial funding; the rest did not state their source of funding. No studies reported our primary outcomes of pelvic pain and live birth rate. Oxidised regenerated cellulose versus no treatment at laparoscopy or laparotomy (13 RCTs) At second-look laparoscopy, we are uncertain whether oxidised regenerated cellulose at laparoscopy reduced the incidence of de novo adhesions (OR 0.50, 95% CI 0.30 to 0.83, 3 RCTs, 360 participants; I² = 75%; very low-quality evidence) or of re-formed adhesions (OR 0.17, 95% CI 0.07 to 0.41, 3 RCTs, 100 participants; I² = 36%; very low-quality evidence). At second-look laparoscopy, we are uncertain whether oxidised regenerated cellulose affected the incidence of de novo adhesions after laparotomy (OR 0.72, 95% CI 0.42 to 1.25, 1 RCT, 271 participants; very low-quality evidence). However, the incidence of re-formed adhesions may have been reduced in the intervention group (OR 0.38, 95% CI 0.27 to 0.55, 6 RCTs, 554 participants; I² = 41%; low-quality evidence). No studies reported results on pelvic pain, live birth rate, adhesion score, or clinical pregnancy rate. Expanded polytetrafluoroethylene versus oxidised regenerated cellulose at gynaecological surgery (two RCTs) We are uncertain whether expanded polytetrafluoroethylene reduced the incidence of de novo adhesions at second-look laparoscopy (OR 0.93, 95% CI 0.26 to 3.41, 38 participants; very low-quality evidence). We are also uncertain whether expanded polytetrafluoroethylene resulted in a lower adhesion score (out of 11) (MD -3.79, 95% CI -5.12 to -2.46, 62 participants; very low-quality evidence) or a lower risk of re-formed adhesions (OR 0.13, 95% CI 0.02 to 0.80, 23 participants; very low-quality evidence) when compared with oxidised regenerated cellulose. No studies reported results regarding pelvic pain, live birth rate, or clinical pregnancy rate. Collagen membrane with polyethylene glycol and glycerol versus no treatment at gynaecological surgery (one RCT) Evidence suggests that collagen membrane with polyethylene glycol and glycerol may reduce the incidence of adhesions at second-look laparoscopy (OR 0.04, 95% CI 0.00 to 0.77, 47 participants; low-quality evidence). We are uncertain whether collagen membrane with polyethylene glycol and glycerol improved clinical pregnancy rate (OR 5.69, 95% CI 1.38 to 23.48, 39 participants; very low-quality evidence). One study reported adhesion scores but reported them as median scores rather than mean scores (median score 0.8 in the treatment group vs median score 1.2 in the control group) and therefore could not be included in the meta-analysis. The reported P value was 0.230, and no evidence suggests a difference between treatment and control groups. No studies reported results regarding pelvic pain or live birth rate. In total, 15 of the 19 RCTs included in this review reported adverse events. No events directly attributed to adhesion agents were reported.

AUTHORS' CONCLUSIONS

We found no evidence on the effects of barrier agents used during pelvic surgery on pelvic pain or live birth rate in women of reproductive age because no trial reported these outcomes. It is difficult to draw credible conclusions due to lack of evidence and the low quality of included studies. Given this caveat, low-quality evidence suggests that collagen membrane with polyethylene glycol plus glycerol may be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. Low-quality evidence also shows that oxidised regenerated cellulose may reduce the incidence of re-formation of adhesions when compared with no treatment at laparotomy. It is not possible to draw conclusions on the relative effectiveness of these interventions due to lack of evidence. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. Common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.

Cellulose absorbable barrier for prevention of de-novo adhesion formation at the time of laparoscopic myomectomy: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Myomectomy is the standard surgical treatment for symptomatic uterine leiomyomas, especially for patients wishing to preserve their fertility. However, this procedure is associated with adhesion formation. Several strategies have been proposed to reduce them. Cellulose absorbable barrier is widely used. We aimed to assess its effectiveness in the prevention of de-novo adhesion formation after laparoscopic myomectomy.

STUDY DESIGN

A systematic review and meta-analysis was performed by searching electronic databases (i.e. MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) from their inception until May 2019. We included all randomized clinical trials (RCT) comparing use of cellulose absorbable barrier (i.e. intervention group) with either placebo or no treatment (i.e. control group) in the prevention of de-novo adhesion formation at the time of laparoscopic myomectomy. Primary and secondary outcomes were defined before data extraction. The primary outcome was the incidence of adhesions at second-look laparoscopy. The secondary outcome was the operative time.

RESULTS

Three RCT, including 366 participants, were included. All trials evaluated women undergoing laparoscopic myomectomy who were randomized to intervention (either oxidized regenerated cellulose or carboxymethylcellulose powder adhesion barrier) or no treatment (control group). Women who received treatment had significantly lower incidence of adhesions at the second look laparoscopy (RR 0.63, 95 % CI 0.40-0.99). Interventions with use of cellulose absorbable barrier were 4 min longer (MD 4 min, 95 % CI 2.82-5.18).

CONCLUSION

Use of cellulose absorbable barrier at the time of laparoscopic myomectomy reduces the risk of postoperative adhesions.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

External Use of an Oxidized Regenerated Cellulose Agent in the Treatment of Labial Agglutination in Postmenopausal Women

BACKGROUND

Vulvovaginal diseases affect women of all ages. Vaginal atrophy and vulvar lichen sclerosus are common etiologies for chronic vulvovaginal pruritus and labial agglutination in both prepubertal and postmenopausal women.

CASES

We present two cases of a novel approach in management of symptomatic labial agglutination in postmenopausal women. At the time of surgical intervention, an oxidized regenerated cellulose gauze was sutured in place within the operative field of separation of the labia minora and clitoral hood adhesions. At more than 18-months' follow-up, no recurrence of agglutination has been noted.

CONCLUSION

The use of an oxidized regenerated cellulose agent may create an effective barrier to recurrence of labial agglutination in postmenopausal women.

Recurrence of uterine myoma after myomectomy: Open myomectomy versus laparoscopic myomectomy

AIM

Open myomectomy (OM) was previously frequently performed; however, laparoscopic myomectomy (LM) has recently become more common. Nevertheless, myoma can recur after both LM and OM. In this study, we report our retrospective investigation of myoma recurrence by comparing LM and OM.

METHODS

A total of 474 patients underwent LM and 279 patients underwent OM. The patients were followed-up postoperatively from six months to eight years. Recurrence was confirmed when a myoma with a diameter of ≥ 1 cm was detected. Post-LM, post-OM and cumulative recurrence rates were investigated, and a Cox hazard test was performed.

RESULTS

The cumulative recurrence rates between the two groups were 76.2% (LM) vs. 63.4% (OM) at eight years postoperatively. A log-rank test revealed a significant difference between the two groups. Cox hazard testing revealed that LM, a larger number of enucleated myoma masses and the absence of postoperative gestation significantly contributed to the postoperative recurrence rate.

CONCLUSIONS

LM yielded a higher recurrence rate than OM, likely a result of manual myoma removal in OM, which is a more exhaustive extraction of smaller myoma masses than performed in LM. In other words, fewer residual myoma masses after OM contribute to a lower postoperative recurrence rate.

The Improvement of Laparoscopic Surgical Skills Obtained by Gynecologists after Ten Years of Clinical Training Can Reduce Peritoneal Adhesion Formation during Laparoscopic Myomectomy: A Retrospective Cohort Study

OBJECTIVE

To evaluate if improvement of laparoscopic skills can reduce postoperative peritoneal adhesion formation in a clinical setting.

STUDY DESIGN

We retrospectively evaluated 25 women who underwent laparoscopic myomectomy from January 1993 to June 1994 and 22 women who underwent laparoscopic myomectomy from March 2002 to November 2004. Women had one to four subserous/intramural myomas and received surgery without antiadhesive agents or barriers. Women underwent second-look laparoscopy for assessment of peritoneal adhesion formation 12 to 14 weeks after myomectomy. Adhesions were graded according to the Operative Laparoscopy Study Group scoring system. The main variable to be compared between the two cohorts was the proportion that showed no adhesions at second-look laparoscopy.

RESULTS

Demographic and surgical characteristics were similar between the two cohorts. No complications were observed during surgery. No adverse events were recorded during postoperative course. At second-look laparoscopy, a higher proportion of adhesion-free patients was observed in women who underwent laparoscopic myomectomy from March 2002 to November 2004 (9 out of 22) compared with women who underwent the same surgery from January 1993 to June 1994 (3 out of 25).

CONCLUSION

The improvement of surgeons' skills obtained after ten years of surgery can reduce postoperative adhesion formation.

Barrier agents for adhesion prevention after gynaecological surgery

BACKGROUND

Pelvic adhesions can form as a result of inflammation, endometriosis or surgical trauma. During pelvic surgery, strategies to reduce pelvic adhesion formation include placing barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene or fibrin sheets between the pelvic structures.

OBJECTIVES

To evaluate the effects of barrier agents used during pelvic surgery on rates of pain, live birth and postoperative adhesions in women of reproductive age.

SEARCH METHODS

We searched the following databases in February 2015: the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL) and trial registries. We handsearched relevant journals, conference proceedings and grey literature sources and we contacted pharmaceutical companies for information.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of the use of barrier agents compared with other barrier agents, placebo or no treatment for the prevention of adhesions in women undergoing gynaecological surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and risk of bias and extracted the data. We calculated odds ratios (ORs) or mean differences (MD) with 95% confidence intervals (CIs) using a fixed effect model. The overall quality of the evidence was assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods.

MAIN RESULTS

Eighteen RCTs (1262 women) were included. Six RCTs randomised women; the remainder randomised pelvic organs. Laparoscopy (eight RCTs) and laparotomy (10 RCTs) were the primary surgical techniques. Indications for surgery included myomectomy (six RCTs), ovarian surgery (five RCTs), pelvic adhesions (five RCTs), endometriosis (one RCT) and mixed (one RCT). The sole indication for surgery in three of the RCTs was infertility. Twelve RCTs reported commercial funding; the rest did not state their source of funding.No studies reported either of our primary outcomes of pelvic pain and live birth. Oxidised regenerated cellulose (Interceed) versus no treatment at laparoscopy or laparotomy (13 RCTs)At second-look laparoscopy oxidised regenerated cellulose at laparoscopy was associated with reduced incidence of de novo adhesions (OR 0.50, 95% CI 0.30 to 0.83, three RCTs, 360 participants, I(2) = 75%, very low-quality evidence) and of re-formed adhesions (OR 0.17, 95% CI 0.07 to 0.41, three RCTs, 100 participants, I(2) = 36%, low quality evidence).At second-look laparoscopy no evidence was found of any difference between the groups in the incidence of de novo adhesions after laparotomy (OR 0.72, 95% CI 0.42 to 1.25, one RCT, 271 participants, I(2) = 41%, low-quality evidence). However, the incidence of re-formed adhesions was lower in the intervention group (OR 0.38, 95% CI 0.27 to 0.55, six RCTs, 554 participants, moderate-quality evidence). Expanded polytetrafluoroethylene (Gore-Tex) versus no treatment at gynaecological surgery (one RCT) The evidence suggested that at second-look laparoscopy expanded polytetrafluoroethylene was associated with a reduction in new adhesion formation (OR 0.17, 95% CI 0.03 to 0.94, one RCT, 42 participants, low-quality evidence). Expanded polytetrafluoroethylene (Gore-Tex) versus oxidised regenerated cellulose (Interceed) at gynaecological surgery (two RCTs)One RCT found no difference between the groups at second-look laparoscopy in the incidence of de novo adhesions (OR 0.93, 95% CI 0.26 to 3.41, 38 participants, very low-quality evidence). A second RCT suggested that the expanded polytetrafluoroethylene group had a lower adhesion score (out of 11) (MD -3.79, 95% CI -5.12 to -2.46, 62 participants, very low-quality evidence) and a lower risk of re-formed adhesions (OR 0.13, 95% CI 0.02 to 0.80, 23 participants, very low-quality evidence). This last finding was sensitive to choice of effect estimate and no longer suggested a difference between the groups when a risk ratio was calculated (RR 0.36, 95% CI 0.13 to 1.01). Sodium hyaluronate and carboxymethylcellulose (Seprafilm) versus no treatment at gynaecological surgery (one RCT)Sodium hyaluronate and carboxymethylcellulose was associated with a lower adhesion score (out of 4) at second-look laparoscopy (MD 0.49, 95% CI 0.53 to 0.45, one RCT, 127 participants, moderate-quality evidence). Fibrin sheet versus no treatment at laparoscopic myomectomy (one RCT)There was no evidence of a difference between the groups in the incidence of de novo adhesions at second-look laparoscopy (OR 1.20, 95% CI 0.42 to 3.41, one RCT, 62 participants) or in adhesion score (out of 4) (MD 0.14, 95% CI -0.67 to 0.39, one RCT, 48 participants, low-quality evidence).Fourteen of the 18 RCTs reported adverse events. No events directly attributed to adhesion agents were reported.

AUTHORS' CONCLUSIONS

We found no evidence on the effects of barrier agents used during pelvic surgery on either pain or fertility outcomes in women of reproductive age.Low quality evidence suggests that oxidised regenerated cellulose (Interceed), expanded polytetrafluoroethylene (Gore-Tex) and sodium hyaluronate with carboxymethylcellulose (Seprafilm) may all be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. There is no conclusive evidence on the relative effectiveness of these interventions. There is no evidence to suggest that fibrin sheet is more effective than no treatment. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. The most common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.

Benefits and harms of adhesion barriers for abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Formation of adhesions after peritoneal surgery results in high morbidity. Barriers to prevent adhesion are seldom applied, despite their ability to reduce the severity of adhesion formation. We evaluated the benefits and harms of four adhesion barriers that have been approved for clinical use.

METHODS

In this systematic review and meta-analysis, we searched PubMed, CENTRAL, and Embase for randomised clinical trials assessing use of oxidised regenerated cellulose, hyaluronate carboxymethylcellulose, icodextrin, or polyethylene glycol in abdominal surgery. Two researchers independently identified reports and extracted data. We compared use of a barrier with no barrier for nine predefined outcomes, graded for clinical relevance. The primary outcome was reoperation for adhesive small bowel obstruction. We assessed systematic error, random error, and design error with the error matrix approach. This study is registered with PROSPERO, number CRD42012003321.

FINDINGS

Our search returned 1840 results, from which 28 trials (5191 patients) were included in our meta-analysis. The risks of systematic and random errors were low. No trials reported data for the effect of oxidised regenerated cellulose or polyethylene glycol on reoperations for adhesive small bowel obstruction. Oxidised regenerated cellulose reduced the incidence of adhesions (relative risk [RR] 0·51, 95% CI 0·31-0·86). Some evidence suggests that hyaluronate carboxymethylcellulose reduces the incidence of reoperations for adhesive small bowel obstruction (RR 0·49, 95% CI 0·28-0·88). For icodextrin, reoperation for adhesive small bowel obstruction did not differ significantly between groups (RR 0·33, 95% CI 0·03-3·11). No barriers were associated with an increase in serious adverse events.

INTERPRETATION

Oxidised regenerated cellulose and hyaluronate carboxymethylcellulose can safely reduce clinically relevant consequences of adhesions.

FUNDING

None.

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

Abdominal adhesions are associated with increased postoperative complications, cost and workload. We performed a systematic review with statistical pooling to estimate the formation rate, distribution and severity of postoperative adhesions in patients undergoing abdominal surgery. A literature search was carried out for all articles reporting on the incidence, distribution and severity of adhesions between January 1990 and July 2011. Twenty-five articles fulfilled the inclusion criteria. The weighted mean formation rate of adhesions after abdominal surgery was 54 % (95 % confidence interval [CI] 40-68 %), and was 66 % (95 % CI 38-94 %) after gastrointestinal surgery, 51 % (95 % CI 40-63 %) after obstetric and gynaecological surgery and 22 % (95 % CI 7-38 %) after urological surgery. The mean overall severity score was 1.11 ± 0.98 according to the Operative Laparoscopy Study Group classification. Laparoscopic surgery reduced the adhesion formation rate by 25 % and decreased the adhesion severity score (laparoscopic; 0.36 ± 0.69 vs. open; 2.14 ± 0.84) for gastrointestinal surgery. Our results demonstrate that the incidence and severity of abdominal adhesions varies between surgical specialties and procedures. An increased awareness of adhesions can help in identifying the underlying mechanisms of adhesion formation and novel therapeutic approaches, while also improving the surgical consent process.

Prevention of postoperative peritoneal adhesions: a review of the literature

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevention of intra-peritoneal adhesions in gynaecological surgery: theory and evidence

Post-operative adhesions are a significant complication of all abdominal surgical procedures. The major strategies for adhesion prevention in gynaecological surgery are focused on the optimization of surgical technique and use of anti-adhesive agents, which fall into two main categories: pharmacological agents and barriers. Surgical technique that minimizes peritoneal trauma can reduce, but cannot prevent post-operative adhesion formation. Various local and systemic drugs that can alter the local inflammatory response, inhibit the coagulation cascade and promote fibrinolysis have been evaluated. Limited data support the administration of post-operative corticosteroids in addition to systemic intra-operative corticosteroids for the prevention of adhesions after gynaecological surgery. None of the remaining pharmacological agents have been found effective for the reduction of post-operative adhesions. Barriers are currently considered the most useful adjuncts, which may reduce adhesion formation. They act by separating the traumatized peritoneal surfaces during the healing period. The separation can be achieved by solid barriers or fluids. There is limited evidence from randomized clinical trials that support the beneficial effect of most of these barrier agents in the prevention of intra-peritoneal adhesions after gynaecological surgery. However, the evidence is not adequate for definite conclusions to be drawn and further research in this field is warranted.

A novel polypeptide derived from human lactoferrin in sodium hyaluronate prevents postsurgical adhesion formation in the rat

OBJECTIVE

The objective of the study was to evaluate whether a peptide derived from human lactoferrin, PXL01 could act safely to reduce the formation of peritoneal adhesions in the rat model and to map the molecular mechanisms of its action.

SUMMARY BACKGROUND DATA

Adhesion formation is a significant problem within every surgical discipline causing suffering for the patients and major cost for the society. For many decades, attempts have been made to reduce postsurgical adhesions by reducing surgical trauma. It is now believed that major improvements in adhesion prevention will only be reached by developing dedicated antiscarring products, which are administrated in connection to the surgical intervention.

METHODS

Anti-inflammatory as well as fibrinolytic activities of PXL01 were studied in relevant human cell lines. Using the sidewall defect-cecum abrasion model in the rat, the adhesion prevention properties of PXL01 formulated in sodium hyaluronate were evaluated. Large bowel anastomosis healing model in the rat was applied to study if PXL01 would have any negative effects on intestine healing.

RESULTS

PXL01 exhibits an inhibitory effect on the most important hallmarks of scar formation by reducing infections, prohibiting inflammation, and promoting fibrinolysis. PXL01 formulated in sodium hyaluronate markedly reduced formation of peritoneal adhesions in rat without any adverse effects on wound healing.

CONCLUSIONS

A new class of synthetically derived water soluble low molecular weight peptide compound, PXL01 showed marked reduction of peritoneal adhesion formation in an animal model without any negative effects on healing. On the basis of these data, a comprehensive adhesion prevention regimen in clinical situation is expected.

Endoscopic management of uterine fibroids

Uterine fibroids are very common, but their relationship to fertility is still controversial. Data in relation to fibroids and fertility mainly come from retrospective case series and prospective uncontrolled trials. Although some authors advocate prospective controlled studies, it is unlikely that an easy answer will be found due to considerable variations in location, size and number of fibroids, presence of additional infertility factors and variation of surgical techniques. Submucosal fibroids are more likely to be associated with menstrual disorders and subfertility, and hysteroscopic myomectomy has been accepted as the standard treatment for them. Treatment of submucosal fibroids may be associated with better reproductive outcomes. There is bigger controversy over the impact of intramural and subserosal fibroids on fertility. Laparoscopic myomectomy is now used by a large number of groups for removal of these fibroids in selected cases, but still remains a challenging procedure which requires advanced laparoscopic skills. Its advantages over open myomectomy include reduced postoperative pain, shorter hospitalization, quicker recovery, reduced febrile morbidity and blood loss. It may also reduce the risk of postoperative adhesion formation. There are now large numbers of pregnancies following laparoscopic myomectomy and the risk of uterine rupture in future pregnancies seems to be very low with good surgical technique.

Laparoscopic management of large myomas

The objective of this article is to review the different techniques that have been adopted for removal of large myomas laparoscopically. We have also quoted literature about the impact of myomas on Pregnancy and obstetrical outcome and the effect of laparoscopic myomectomy on the same. Technical modifications to remove large myomas have been described along with methods to reduce intraoperative bleeding. This comprehensive review describes all possibilities of laparoscopic myomectomy irrespective of size, site and number.

Barrier agents for adhesion prevention after gynaecological surgery

BACKGROUND

Pelvic adhesion can form as a result of inflammation, endometriosis or surgical trauma. During pelvic surgery, strategies to reduce pelvic adhesion formation may include placing synthetic barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene or Fibrin sheets between the pelvic structures.

OBJECTIVES

To assess the effect of physical barriers used during pelvic surgery in women of reproductive age on pregnancy rates, pelvic pain, or postoperative adhesion reformation.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched September 2007) which is based on regular searches of MEDLINE, EMBASE, CINAHL, PsycINFO and CENTRAL, plus handsearching of 20 relevant journals and conference proceedings, and searches of several key grey literature sources. In addition, companies were contacted for unpublished trials.

SELECTION CRITERIA

Any randomised controlled trials (RCTs) comparing the use of physical barriers versus no treatment or other physical barriers in the prevention of adhesions in women undergoing gynaecological surgery.

DATA COLLECTION AND ANALYSIS

Review authors assessed trial eligibility and quality.

MAIN RESULTS

Sixteen RCTs were included. Five trials randomised patients while the remainder randomised pelvic organs. Laparoscopy (six trials) and laparotomy (10 trials) were the primary surgical techniques. Indications for surgery included myomectomy (five trials), ovarian surgery (five trials), pelvic adhesions (four trials), endometriosis (one trial), and mixed (one trial). Eleven trials assessed Interceed versus no treatment, two assessed Interceed versus Gore-Tex, one trial assessed Gore-Tex versus no treatment, and one trial assessed Seprafilm versus no treatment. A single trial assessed Fibrin sheet versus no treatment. No studies reported pregnancy or reduction in pain as outcomes. The use of Interceed was associated with reduced incidence of pelvic adhesion formation, both new formation and reformation following laparoscopic surgery or laparotomy. However, this result should be interpreted with caution. Gore-Tex was more effective than no barrier or Interceed in preventing adhesion formation. There was only limited evidence that Seprafilm was effective in preventing adhesion formation following myomectomy and no evidence to support Fibrin sheet.

AUTHORS' CONCLUSIONS

The absorbable adhesion barrier Interceed reduces the incidence of adhesion formation following laparoscopy and laparotomy, but there are insufficient data to support its use to improve pregnancy rates. Gore-Tex may be superior to Interceed in preventing adhesion formation but its usefulness is limited by the need for suturing and later removal. There was no evidence of effectiveness of Seprafilm and Fibrin sheet in preventing adhesion formation.

Prevention of adhesion formation following ovarian surgery in a standardized animal model: comparative study of Interceed and double layer Surgicell

AIM

Comparison of antiadhesive performances of double layer Surgicell and single layer Interceed following ovarian surgery in a rabbit model.

METHODS

Prospective randomized controlled trial performed at the animal laboratory of a university. Thirty-nine New Zealand White female rabbits of reproductive age were included. Ovaries were bivalved with a no. 15 scalpel. One of the ovaries was covered with a single layer of Interceed while the other was covered with a double layer of Surgicell. In the control group no adhesion barriers were used. Four weeks later adhesions were scored macroscopically. Following oophorectomy specimens were evaluated microscopically for mesothelial proliferation. The macroscopic adhesion score according to Blauer's criteria and the number of mesothelial cell layers were compared.

RESULTS AND CONCLUSION

The control group had significantly higher adhesion scores than the barrier groups. Macroscopic adhesion scores were not different among the barrier groups. The average number of mesothelial cell layers was 1.77+/-2.68, 1.69+/-2.58 (range 0-8) and 2.04+/-2.84 (range 0-10) for ovaries in the control, Interceed and Surgicell groups, respectively: the difference was not significant. Our results demonstrate that a double layer of Surgicell is as effective as Interceed in reducing postoperative adhesion formation in a rabbit model.