Utilization and safety of sodium hyaluronate-carboxymethylcellulose adhesion barrier

Techniques for navigating postsurgical adhesions: Insights into mechanisms and future directions

Postsurgical adhesions are a common complication of surgical procedures that can lead to postoperative pain, bowel obstruction, infertility, as well as complications with future procedures. Several agents have been developed to prevent adhesion formation, such as barriers, anti-inflammatory and fibrinolytic agents. The Food and Drug Administration (FDA) has approved the use of physical barrier agents, but they have been associated with conflicting clinical studies and controversy in the clinical utilization of anti-adhesion barriers. In this review, we summarize the human anatomy of the peritoneum, the pathophysiology of adhesion formation, the current prevention agents, as well as the current research progress on adhesion prevention. The early cellular events starting with injured mesothelial cells and incorporating macrophage response have recently been found to be associated with adhesion formation. This may provide the key component for developing future adhesion prevention methods. The current use of physical barriers to separate tissues, such as Seprafilm®, composed of hyaluronic acid and carboxymethylcellulose, can only reduce the risk of adhesion formation at the end stage. Other anti-inflammatory or fibrinolytic agents for preventing adhesions have only been studied within the context of current research models, which is limited by the lack of in-vitro model systems as well as in-depth study of in-vivo models to evaluate the efficiency of anti-adhesion agents. In addition, we explore emerging therapies, such as gene therapy and stem cell-based approaches, that may offer new strategies for preventing adhesion formation. In conclusion, anti-adhesion agents represent a promising approach for reducing the burden of adhesion-related complications in surgical patients. Further research is needed to optimize their use and develop new therapies for this challenging clinical problem.

Adhesion barriers and intraperitoneal or uterine infections after cesarean section: A retrospective cohort study

BACKGROUND

Intraperitoneal adhesion is a common complication of cesarean section, and adhesion barriers are often used to prevent postoperative adhesion. However, the association between the use of adhesion barriers and infections after cesarean section remains unknown. This study aimed to evaluate the association.

METHODS

Using the administrative claims database of a single prefecture in Japan, we identified all patients who underwent cesarean section from June 2014 to February 2019. A multivariable logistic regression model fitted with a generalized estimating equation was used to compare the postoperative outcomes between patients who received intraperitoneal adhesion barriers during cesarean section and those who did not. The primary outcome was intraperitoneal or uterine infections within 3 months after cesarean section, including intraperitoneal abscess, pelvic inflammatory disease, peritonitis, uterine wound infection, endometritis, and adnexitis.

RESULTS

A total of 1,392 patients with 1,498 cesarean section cases were reviewed. Adhesion barriers were used in 1,153/1,498 (77.0%) cases. One hundred and fourteen (9.9%) intraperitoneal or uterine infections occurred in the group with and 15 (4.3%) in the group without adhesion barriers. The proportion of intraperitoneal or uterine infections was significantly higher in the group with than in the group without adhesion barriers (9.9% and 4.3%, respectively; adjusted odds ratio = 2.59; 95% confidence interval, 1.40-4.77; P = .002).

CONCLUSION

The use of adhesion barriers was associated with an increase in intraperitoneal or uterine infections after cesarean section.

Adhesion barriers and topical hemostatic agents are risk factors for post-cesarean section infections

BACKGROUND

Cesarean sections are the most common surgery worldwide, and post-cesarean section infections and hemorrhage are a major cause for morbidity and mortality. In recent years, many surgeons use adhesion barriers as well as hemostatic agents during primary and repeated cesarean section. The data regarding the safety of these agents is relatively limited. The objective of this study was to investigate whether the use of adhesion barriers and topical hemostatic agents pose a risk for post-cesarean section infections.

METHOD

A case-control study composed of women who were admitted to the Soroka University Medical Center between the years 2012 and 2016 was conducted. The study group was composed of women admitted owing to post-cesarean section infections (cases) and those who underwent cesarean sections without post-cesarean section infection (control subjects). Matching was done according to date and surgery setting (elective versus emergency). A univariate analysis was followed by a multiple regression model in order to examine the association between adhesion barriers/hemostatic agents and post-cesarean section infections.

RESULTS

During the study period, 113 patients developed postoperative infection (cases); 71.7% were diagnosed with surgical site infection, 7.1% with endometritis, and 21.2% with other infections. These were compared with 226 control subjects. In the univariate analysis, the use of adhesion barriers/hemostatic agents were found to be associated with post-cesarean section infection. Using a multivariable analysis controlling for previous cesarean section, skin closer technique, preterm delivery, and duration of surgery >60 minutes, the use of adhesion barriers as well as hemostatic agents was found to be independently associated with post-cesarean section infection (adjusted odds ratio = 2.11, 95% confidence interval = 1.17-3.84; adjusted odds ratio = 2.29, 95% confidence interval = 1.37-3.8, respectively) CONCLUSION: Adhesion barriers and hemostatic agents were found to be independently associated with post-cesarean section infections. Further larger studies are needed to reinforce our findings. The use of these materials should be carefully considered, and their cost-effectiveness re-examined.

[Existing and forward-looking ways to prevent adhesions in IPOM hernia repair. A research overview]

IPOM intraperitoneal hernia repair, in comparison with other abdominal wall reconstruction methods, has a number of significant advantages. Among them are a reduction in operative time, low rate of surgical site infections, quick rehabilitation, and good cosmetic results. At the same time, one of the main constraining factors for its widespread use is the rather high frequency of adhesion formation between the implant and the abdominal organs. The first way to solve this serious problem is to improve the structure of the implant itself, and in the first place, its anti-adhesive layer. The second is the search for adjuvant tools that work in «problematic» areas, prone to adhesions formation, such as the points of implant fixation, its edges, or the areas of damage to antiadhesive layer due to a violation of the operative technique. It is desirable that they could exert their effect also in other parts of the abdominal cavity, which, despite the absence of a zone of «active» intervention, can also undergo adhesions. Based on this, the purpose of this review was to summarize modern data on the anti-adhesive activity of both composite implants and specialized membranes and liquid agents.

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast follow-through and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.

Evaluation of the effects of hyaluronic acid-carboxymethyl cellulose barrier on ovarian tumor progression

Background

Hyaluronic acid is a prognostic factor in ovarian cancers. It is also a component of Hyaluronic Acid-Carboxymethyl Cellulose (HA-CMC) barrier, an anti-adhesion membrane widely used during abdominal surgeries in particular for ovarian carcinosis. 70% of patients who undergo ovarian surgery will relapse due to the persistence of cancer cells. This study’s objective was to determine the oncological risk from use of this material, in the presence of residual disease, despite the benefit gained by it decreasing post-surgical adhesions in order to provide an unambiguous assessment of its appropriateness for use in ovarian surgical management.

Methods

We assessed the effects of HA-CMC barrier on the in vitro proliferation of human ovarian tumor cell lines (OVCAR-3, IGROV-1 and SKOV-3). We next evaluated, in vivo in nude mice, the capacity of this biomaterial to regulate the tumor progression of subcutaneous and intraperitoneal models of ovarian tumor xenografts.

Results

We showed that HA-CMC barrier does not increase in vitro proliferation of ovarian cancer cell lines compared to control. In vivo, HA-CMC barrier presence with subcutaneous xenografts induced neither an increase in tumor volume nor cell proliferation (Ki67 and mitotic index). With the exception of an increased murine carcinosis score in peritoneum, the presence of HA-CMC barrier with intraperitoneal xenografts modified neither macro nor microscopic tumor growth. Finally, protein analysis of survival (Akt), proliferation (ERK) and adhesion (FAK) pathways highlighted no activation on the xenografts imputable to HA-CMC barrier.

Conclusions

For the most part, our results support the lack of tumor progression activation due to HA-CMC barrier. We conclude that the benefits gained from using HA-CMC barrier membrane during ovarian cancer surgeries seem to outweigh the potential oncological risks.