The effect of 4% icodextrin solution on adhesiolysis surgery time at the Hartmann's reversal: a pilot, multicentre, randomized control trial vs lactated Ringer's solution

Efficacy and safety of purified starch for adhesion prevention in colorectal surgery

Background

Adhesions within the abdominal cavity develop in as many as 90 % of individuals following abdominal surgery. However, the true adhesive condition of patients can only be ascertained during the second surgery.

Methods

We conducted a prospective, non-randomized study to assess the anti-adhesion properties of purified starch in patients who had undergone colorectal surgery in the past and then needed a subsequent surgical intervention. Adhesion scores have been prospectively recorded in operation notes since January 2020 when patients underwent a second surgery. Patients who had received purified starch during their initial surgery constituted the purified starch group, while those who had not received anti-adhesion medical materials were the control group. The main objectives of the study were to evaluate the extent and severity of adhesions as primary outcomes, while secondary outcomes included measuring blood loss, operation time, and postoperative complications.

Results

We analyzed the data of 101 patients, with 61 in the purified starch group and 40 in the control group. In multivariate analysis, adhesion severity (Odds ratio, 0.20, 95 % confidence interval 0.08-0.54, P < 0.01) and adhesion area scores (Odds ratio, 0.13, 95 % confidence interval 0.04-0.45, P < 0.01) were significantly lower in the purified starch group than in the control group. There was no significant difference in operation times, blood loss, and postoperative complications between the two groups.

Conclusion

Purified starch is a safe and effective anti-adhesion material that can significantly reduce the severity and extent of adhesion after colorectal surgery.

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.

Epidemiology and Prevention of Postsurgical Adhesions Revisited

OBJECTIVE

To provide a comprehensive review of recent epidemiologic data on the burden of adhesion-related complications and adhesion prevention. Second, we elaborate on economic considerations for the application of antiadhesion barriers.

BACKGROUND

Because the landmark SCAR studies elucidated the impact of adhesions on readmissions for long-term complications of abdominal surgery, adhesions are widely recognized as one of the most common causes for complications after abdominal surgery. Concurrently, interest in adhesion prevention revived and several new antiadhesion barriers were developed. Although these barriers have now been around for more than a decade, adhesion prevention is still seldom applied.

METHODS

The first part of this article is a narrative review evaluating the results of recent epidemiological studies on adhesion-related complications and adhesion prevention. In part II, these epidemiological data are translated into a cost model of adhesion-related complications and the potential cost-effectiveness of antiadhesion barriers is explored.

RESULTS

New epidemiologic data warrant a shift in our understanding of the socioeconomic burden of adhesion-related complications and the indications for adhesion prevention strategies. Increasing evidence from cohort studies and systematic reviews shows that difficulties during reoperations, rather than small bowel obstructions, account for the majority of adhesion-related morbidity. Laparoscopy and antiadhesion barriers have proven to reduce adhesion formation and related morbidity. The direct health care costs associated with treatment of adhesion-related complications within the first 5 years after surgery are $2350 following open surgery and $970 after laparoscopy. Costs are about 50% higher in fertile-age female patients. Application of an antiadhesion barriers could save between $328 and $680 after open surgery. After laparoscopy, the costs impact ranges from $82 in expenses to $63 of savings.

CONCLUSIONS

Adhesions are an important cause for long-term complications in both open and laparoscopic surgery. Adhesiolysis during reoperations seems to impact adhesion-related morbidity most. Routine application of antiadhesion barriers in open surgery is safe and cost-effective. Application of antiadhesion barriers can be cost-effective in selected cases of laparoscopy. More research is needed to develop barriers suitable for laparoscopic use.

Role of icodextrin in the prevention of small bowel obstruction. Safety randomized patients control of the first 300 in the ADEPT trial

AIM

Adhesions are the most common cause of small bowel obstruction (SBO). The costs of hospitalization and surgery for SBO are substantial for the health-care system. The adhesion-limiting potential of icodextrin has been shown in patients undergoing surgery for gynaecological diseases. A randomized, multicentre trial in colorectal cancer surgery started in 2009 with the aim of evaluating whether icodextrin could reduce the long-term risk of surgery for SBO. Because of some concerns about complications (especially anastomotic leakage) after icodextrin use, a preplanned interim analysis of morbidity and mortality was conducted.

METHOD

Patients with colorectal cancer without metastasis were randomized 1:1 to receive standard surgery, with or without instillation of icodextrin in the abdominal cavity. For the first 300 patients, the 30-day follow-up data were collected from the Swedish ColoRectal Cancer Registry (SCRCR). Pre-, per- and postoperative data, morbidity and mortality were analysed.

RESULTS

Of the 300 randomized patients, 288 had a data file in the SCRCR. Twelve patients did not have cancer and another five did not have a resection, leaving 283 for analysis. The authors were blinded to the randomization groups. Demographic data were similar in both groups. The overall complication rate was 24% in Group 1 and 23% in Group 2 (P = 0.89). Four cases of anastomotic leakage were reported in Group 1 and five were reported in Group 2 (P = 1.0). Mortality, intensive care unit (ICU) stay and re-operations did not differ between the groups.

CONCLUSION

The pre-planned safety analysis of the first 300 patients enrolled in this randomized trial did not show any differences in adverse effects related to the use of icodextrin. All data were gathered from the SCRCR, giving us a strong message that we can continue to include patients in the trial.

Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature

BACKGROUND

Postoperative intra-abdominal adhesions after GI surgery constitute a major burden for health care provision globally, causing chronic abdominal symptoms and necessitating repeated surgical intervention.

OBJECTIVE

This systematic review examines safety and efficacy data for current anti-adhesion strategies after GI surgery.

DATA SOURCES

PubMed, Medline, and Embase databases were searched for randomized control trials and nonrandomized clinical studies of anti-adhesion products from January 1980 to October 2013.

STUDY SELECTION

A list of predefined search terms was combined with the Cochrane Highly Sensitive Search Strategy to identify studies.

INTERVENTION

The use of an anti-adhesion strategy was investigated.

MAIN OUTCOME MEASURES

The primary outcome was the safety profile of anti-adhesion products. Secondary outcomes included the analysis of the reduction in the incidence, extent, and severity of adhesions; incidence of bowel obstruction; quality-of-life data; and oncological outcomes.

RESULTS

In total, 24 articles were included in the qualitative analysis: 17 randomized controlled trials and 7 nonrandomized studies, reporting on 5 anti-adhesion products. Data suggest that anti-adhesive products may be used safely; however, hyaluronic acid-based products should not be placed in contact with an anastomosis. The most studied product, a hyaluronic acid/carboxymethylcellulose membrane, reduces the incidence, extent, and severity of adhesions but without strong evidence of prevention of bowel obstruction.

LIMITATIONS

The size and quality of available studies varied greatly, reflected by the Jadad and MINORS scores. The majority of studies reported the use of a single product, hyaluronic acid/carboxymethylcellulose membrane.

CONCLUSIONS

Limiting adhesion formation after GI surgery is feasible. More evidence is needed regarding the efficacy in reducing chronic abdominal symptoms, repeated operative intervention, and improving quality of life.

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.

P.O.P.A. study: prevention of postoperative abdominal adhesions by icodextrin 4% solution after laparotomy for adhesive small bowel obstruction. A prospective randomized controlled trial

BACKGROUND

Adhesive small bowel obstruction (ASBO) is an important cause of hospital admission, is associated with significant morbidity and mortality, and therefore is a substantial burden for healthcare systems worldwide. Icodextrin 4% solution (Adept, Shire Pharmaceuticals, UK) is a high-molecular-weight a-1,4 glucose polymer approved in Europe for use as intraoperative lavage and postoperative instillation to reduce the occurrence of post-surgery intra-abdominal adhesions. The present clinical study aimed to evaluate the safety and effectiveness of icodextrin 4% in decreasing the incidence, extent, and severity of adhesions in patients after abdominal surgery for ASBO.

METHODS

The study was a single-center prospective, randomized investigation. The study is designed and conducted in compliance with the principles of Good Clinical Practice regulations. Safety and efficacy of icodextrin 4% in the study group are compared to no anti-adhesion treatment in a parallel control group with blinded evaluation of primary endpoints. Primary endpoints are the evaluation of the therapeutic role of icodextrin 4% in reducing ASBO recurrence incidence and the need of laparotomies for ASBO recurrence, as well as adhesion formation (with evaluation of their incidence, extent, and severity). A sum of 181 patients with ASBO and surgical indication to laparotomy were enrolled and randomized in two groups. Patients were submitted to adhesiolysis with bowel resection if required with or without anastomosis. The first group received traditional treatment (control group), whereas the second group was treated with the addition of icodextrin 4% solution before the abdominal closure.

RESULTS

Ninety-one patients were randomized to have icodextrin 4% solution administered intraperitoneally, and 90 patients were randomized to have the traditional treatment. The two study groups were homogeneous regarding their baseline characteristics. The ASBO recurrence rate was 2.19% (2/91) in the icodextrin groups vs 11.11% (10/90) in the control group after a mean follow-up period of 41.4 months (p < 0.05). No differences were found in the need of laparotomies for ASBO recurrence in the studied groups. The adhesion severity score seems lower in the group treated with the addition of icodextrin (p = n.s.).

CONCLUSIONS

The data resulting from this RCT showed that the use of icodextrin 4% solution in ASBO is safe and reduces intra-abdominal adhesion formation and the risk of re-obstruction.

Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery

Background

There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications.

Methods

A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1^st International Congress of the World Society of Emergency Surgery and 9^th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus.

Recommendations

In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay.

NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended.

Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment.

Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.

Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

Intra-abdominal adhesions: definition, origin, significance in surgical practice, and treatment options

BACKGROUND

Intra-abdominal adhesions arise after more than 50% of all abdominal operations and are an important source of postoperative complications. They attach normally separated organs to each other and can cause major problems for the affected patients by giving rise to small bowel obstruction, chronic pelvic pain, dyspareunia, infertility, and higher complication rates in subsequent operations. They are also a frequent source of medicolegal conflict. Thus, every physician should be familiar with their mechanism of origin, their consequences, and the methods by which they can be prevented.

METHODS

A selective PubMed/Medline search from 1960 onward as well as articles to which these publications referred. The expert consensus position of the European Society for Gynaecological Surgery is also taken into consideration.

RESULTS

Adhesions arise through aberrant wound healing after peritoneal injury with further influence from a variety of other factors. Preventive measures include minimizing peritoneal injury intraoperatively through the meticulous observance of basic surgical principles, moistening the mesothelium to keep it from drying out, irrigating the peritoneal cavity to remove blood and clot, and keeping the use of intra-abdominal foreign material to a minimum.

CONCLUSION

Adhesions are an inevitable consequence of intra-abdominal surgery. They can be prevented to some extent with meticulous surgical technique and certain other measures. For operations carrying a high risk of postoperative adhesions, e.g., surgery on the adnexa or bowel, commercially available peritoneal instillates or barrier methods can be used to limit adhesion formation.

Two icodextrin exchanges per day in peritoneal dialysis patients with ultrafiltration failure: one center's experience and review of the literature

BACKGROUND

At present, only one exchange of an icodextrin-based solution is recommended to increase peritoneal ultrafiltration (UF) during long-dwell exchanges in peritoneal dialysis (PD) patients with impaired UF.

AIM

To review our experience with two icodextrin exchanges per day on net UF and body weight in PD patients with poor UF.

METHODS

Data were analyzed on nine patients with poor UF on chronic PD who were given two icodextrin exchanges per day for 6 months and had various clinical and biochemical parameters assessed monthly.

RESULTS

Administration of icodextrin twice daily reduced the body weight in six of nine patients by an average of 2.9 ± 1.2 kg, a reduction that was maintained throughout the study; two patients gained 0.5 kg; and, in one patient, the measurements were inadequate. Mean blood pressure was reduced. Mean serum creatinine increased slightly. Serum sodium levels decreased from a mean baseline level of 134 ± 3 to 132 ± 4 mmol/L at three and six months. Among the diabetics in this group, average daily insulin requirements were 44 ± 35 units/day at baseline and 40 ± 23 units/day after 6 months. Hb1Ac levels remained stable throughout the study period.

CONCLUSION

The use of two icodextrin exchanges per day reduced body weight in six of the nine patients and appeared to be safe. Long-term prospective studies are needed to assess the contribution of twice-daily icodextrin to the management of peritoneal dialysis patients with ultrafiltration failure and its long-term safety.

Prevention of postoperative adhesion formation by individual and combined administration of 4 per cent icodextrin and dimetindene maleate

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.