Postoperative adhesion development following cesarean and open intra-abdominal gynecological operations: a review

Epigenetics: new insights into postoperative adhesion development

BACKGROUND

The link between post-operative adhesion development and epigenetic modifications is important in understanding the mechanism behind their formation. The aim of this study was to determine whether epigenetic differences exist between primary fibroblasts of normal peritoneum and adhesion tissues isolated from the same patient(s).

METHODS

DNA from fibroblasts isolated from normal peritoneum and adhesion tissues was isolated using Qiagen's EZ1 Advanced Kit. Methylation patterns of genes were quantified and compared in both cell lines using the Infinium Human Methylation 27 BeadChip® system (Illumina, San Diego, CA, USA).

RESULTS

A total of 7364 genes had been found to manifest significantly different DNA methylation levels in adhesion fibroblasts as compared to normal peritoneal fibroblasts (P<0.01). A total of 1685 genes were found to have increased DNA methylation by 50% in adhesion compared to peritoneal fibroblasts, and were enriched in gene ontology categories, glycoprotein, and defense response. Furthermore, 1287 genes were found to have decreased DNA methylation patterns with enriched gene ontology categories, "homeobox," and transcription factor activity in adhesion fibroblasts.

CONCLUSIONS

Epigenetic differences in fibroblasts isolated from normal peritoneum and adhesion tissues were observed. Future studies focusing on the precise role of these genes in the development of postoperative adhesions will allow us to more fully appreciate regulatory mechanisms leading to adhesion development, thereby establishing targets for therapeutic interventions to prevent or limit adhesion development.

Extraperitoneal Cesarean Section after two Medial Laparotomies, Anus Prater, and Surgical Treatment of the Rectovaginal Fistula in a Patient with Crohn's Disease: A Case Report

The aim of this case report is to show the advantages of the extraperitoneal cesarean section (ECS) approach in a pregnant patient with multiple previous abdominal transperitoneal colon surgeries and Crohn's disease. A pregnant nulliparous woman with Crohn's disease was admitted for delivery. After delivery, a large rupture and lesion of the rectum was observed. Suturing of the vagina, rectum and sphincter was performed by an abdominal surgeon. Because of a very large and irregularly shaped rectum rupture, the patient underwent infraumbilical medial laparotomy and sigmoidostomy. After 18 months, the patient started to experience vaginal discharge and Y-shaped rectovaginal fistula was confirmed. Surgical reconstruction was performed. The patient's second pregnancy began one year later. At 38 weeks of pregnancy, elective extraperitoneal cesarean section was performed. A healthy newborn was delivered. Follow-up showed full and fast recovery after the ECS. In cases of pregnant women who have had multiple colon surgeries, gynecology surgeons can choose to perform an ECS to avoid transperitoneal entrance into the abdomen. ECS avoids lysis of postoperative adhesions after repetitive gastrointestinal surgeries, the formation of new adhesions by lysis of the old adhesions, and most importantly, the possibility of colon or small intestine lesions during lysis of dense or firm adhesions.

Operative delivery in the second stage of labor and preterm birth in a subsequent pregnancy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to quantify the association between mode of operative delivery in the second stage of labor (cesarean delivery vs operative vaginal delivery) and spontaneous preterm birth in a subsequent pregnancy.

DATA SOURCES

MEDLINE, Embase, EmCare, CINAHL, the Cochrane Library, Web of Science: Core Collection, and Scopus were searched from database inception to April 1, 2023.

STUDY ELIGIBILITY CRITERIA

All retrospective cohort studies with participants who had a second-stage cesarean delivery (defined as intrapartum cesarean delivery at full cervical dilation) or operative vaginal delivery (including forceps- and/or vacuum-assisted delivery) and that reported the rate of preterm birth (either spontaneous or not specified) in subsequent pregnancy were included.

METHODS

Both a descriptive analysis and a meta-analysis were performed. A meta-analysis was performed for dichotomous data using the Mantel-Haenszel random-effects model and used the odds ratio as an effect measure with 95% confidence intervals. The risk of bias was assessed using Cochrane's 2022 Risk Of Bias In Non-randomized Studies of Exposure tool.

RESULTS

After screening 2671 articles from 7 databases, a total of 18 retrospective cohort studies encompassing 605,138 patients were included. The pooled rates of spontaneous preterm birth in a subsequent pregnancy were 6.9% (12 studies) after second-stage cesarean delivery and 2.6% (8 studies) after operative vaginal delivery. A total of 7 studies encompassing 75,460 patients compared the primary outcome of spontaneous preterm birth after second-stage cesarean delivery vs operative vaginal delivery in an index pregnancy with an odds ratio of 2.01 (95% confidence interval, 1.57-2.58) in favor of operative vaginal delivery. However, most studies did not include important confounding factors, did not address exposure misclassification because of failed operative vaginal delivery, and considered operative vaginal delivery as a homogeneous category with no distinction between forceps- and vacuum-assisted deliveries.

CONCLUSION

Although a synthesis of the existing literature suggests that the risk of spontaneous preterm birth is higher in those with a previous second-stage cesarean delivery than in those with operative vaginal delivery, the risk of bias in these studies is very high. Findings should be interpreted with caution.

Can we predict peritoneal adhesions formation after cesarean delivery?

OBJECTIVE

To examine demographic and obstetrical factors that are associated with adhesion formation following cesarean delivery.

METHODS

We conducted a population-based study that included all women over 18 years og age who underwent two cesarean deliveries between the years 1988 and 2016 in a large tertiary medical center. We excluded women with adhesions already diagnosed during the first cesarean delivery, history of other abdominal or pelvic surgery, history of pelvic infection or pelvic inflammatory disease, history of endometriosis and history of uterine Müllerian anomalies. In addition, women with a classical or T-shaped uterine incision, non-singleton pregnancies, and fetal chromosomal or structural abnormalities were excluded.

RESULTS

During the study period, 32.6% (n = 2283) of women were diagnosed with peritoneal adhesions during the second cesarean delivery. Factors found to be significantly associated with peritoneal adhesions were maternal age 35 years or older at the first cesarean delivery, Bedouin Arab ethnicity, composite of intrapartum and postpartum infectious morbidity, and cesarean deliveries that were performed after the onset of labor. In contrast, having a previous vaginal birth was found to be protective.

CONCLUSIONS

Our results suggest that a woman's characteristics at her first cesarean delivery and her obstetrical history may be predictive of the likelihood of adhesion formation.

Assessment of the clinical outcomes and complications of hysteroscopic and laparoscopic approaches in the treatment of symptomatic isthmocele: An observational study

OBJECTIVES

To investigate the outcomes of patients undergoing laparoscopic or hysteroscopic approaches for isthmoplasty.

METHODS

A total of 99 isthmocele patients with an average age of 38.45 ± 4.72 years were included in the 2 years of this retrospective cohort study. Forty-five underwent laparoscopic and 54 underwent hysteroscopic isthmocele excision and myometrial repair.

RESULTS

Pain scores were significantly higher in the hysteroscopy group before the procedure, but there were no significant pain score differences after the surgery. In 1 year of follow up, dysmenorrhea and dyspareunia were higher among hysteroscopy patients. Furthermore, hysteroscopy significantly improved postmenstrual spotting after surgery better than laparoscopy, but in the follow up, there was no significant difference between the two groups in this regard (mean rank for hysteroscopy vs. laparoscopy: 32.30 vs. 37.48, U = 418, P = 0.29).

CONCLUSION

In patients with a history of infertility, ectopic pregnancy, lower gravidity, lower parity, and a lower number of cesarean sections, laparoscopic isthmoplasty is preferred over the hysteroscopic approach. Both methods have similar effects on midcycle vaginal bleeding, duration of postmenstrual spotting, and pain. However, a higher rate of dyspareunia and dysmenorrhea could be associated with hysteroscopy.

Prediction of intraperitoneal adhesions in repeated cesarean sections: A Systematic review and Meta-analysis

OBJECTIVE

With the rate of repeated cesarean sections on the rise, intraperitoneal adhesions caused by repeated cesareans could give rise to maternal morbidity during delivery. As a result, it's critical to have the ability to predict adhesions. The current meta-analysis aims to determine if intraperitoneal adhesions are likely to be present based on the characteristics of the cesarean scar, striae gravidarum, and sliding sign.

MATERIALS AND METHODS

We systematically searched electronicdatabases beforeretrieving articles up until October 13th, 2022 for analysis. After data extraction and literature screening, we first performed a quality assessment using the QUADAS-2 score system. Following that, a bivariate random-effect meta-analysis model was used to obtain the combined diagnostic and predictive values. To pinpoint the origins of heterogeneity, we conducted a subgroup analysis. Fagan's Nomogram was used to validate the clinical utility. Sensitivity analysis was used to gauge the reliability of each included study, and Egger's test and funnel plot asymmetry was used to investigate publication bias.

RESULTS

25 studies totaling 1840 patients with intra-abdominal adhesions and 2501 controls without adhesions were included in the systematic review. Diagnostic values from 8 studies regarding skin characteristics were combined, and the results for depressed scar showed: sensitivity[95 %CI] = 0.38[0.34-0.42]; Specificity[95 %CI] = 0.88[0.85-0.90]; DOR[95 %CI] = 4.78[2.50-9.13]; AUC = 0.65. Negative sliding sign from 7 studies, although not showing a diagnostic difference between cases and controls, had excellent predictive values: sensitivity[95 %CI] = 0.71[0.65-0.77]; Specificity[95 %CI] = 0.87[0.85-0.89]; DOR[95 %CI] = 6.88[0.6-78.9]; AUC = 0.77. Subgroup analysis illustrated non-Turkish studies to reveal more significant associations than Turkish studies.

CONCLUSION

Our meta-analysis found that the occurrence of adhesions can be predicted by the characteristics of abdominal wounds, particularly depressed scar, and scar width,as well as a negative sliding sign following a previous cesarean section.

A Randomized Double-Blind Controlled Proof-of-Concept Study of Alanyl-Glutamine for Reduction of Post-Myomectomy Adhesions

STUDY OBJECTIVE

To test the hypothesis that intraperitoneal instillation of a single bolus dose of l-alanyl-l-glutamine (AG) will reduce the incidence, extent and/or severity of adhesions following myomectomy and establish preliminary safety and tolerability of AG in humans.

DESIGN

Phase 1,2 Randomized, double-blind, placebo-controlled study (DBRCT).

SETTING

Tertiary care gynecology surgical centre.

PATIENTS

Thirty-eight women who underwent myomectomies by laparoscopy (N = 38; AG-19 vs Placebo-19) or laparotomy (N = 10; AG-5 vs Placebo-5) with a scheduled second-look laparoscopy (SLL) 6-8 weeks later. Thirty-two patients in the laparoscopy arm completed SLL.

INTERVENTIONS

Bolus dose of AG or normal saline solution control (0.9% NaCl) administered intraperitoneally immediately prior to suture closure of the laparoscopic ports. The average dose was 170 mL of AG or control based on a dosing scheme of 1 g/kg bodyweight.

MEASUREMENTS

Digital recordings obtained for all procedures. The primary endpoint was reduction in the incidence, severity and extent of post-operative adhesions analyzed by intention-to-treat (ITT) approach. Three independent, blinded reviewers evaluated all operative video recordings to assess presence of adhesions. Post-hoc analysis assessed presence or absence of adhesions in the peritoneal cavity. Secondary endpoints assessed safety and tolerability of AG.

MAIN RESULTS

Administration of AG reduced the incidence, severity and/or extent of post-operative adhesions (p = 0.046). The presence of adhesions in the AG group was lower than in the Control group (p = 0.041). Adhesion improvement was achieved in 15 of 15 (100%) in the AG group versus 5 of 17 (29.6%) in the placebo group. No serious adverse events were reported. No differences in safety parameters were observed.

CONCLUSIONS

Intraperitoneal l-alanyl-l-glutamine reduced adhesion formation in all patients following laparoscopic myomectomy. Complete absence of adhesions was achieved at all abdominal sites in 93% of patients. Results confirm AG's known effects on cellular mechanisms of adhesiogenesis and lay the foundation for new adhesion prophylaxis research and treatment.

Does surgeon seniority affect adhesion assessment at cesarean delivery? A prospective study

BACKGROUND

Intraabdominal adhesions may develop following cesarean delivery and are considered a major concern.

OBJECTIVE

This study aimed to determine the effect of surgeon seniority in evaluating intraabdominal adhesions at cesarean delivery.

STUDY DESIGN

A prospective study to estimate interrater reliability between surgeons was conducted. Women who underwent cesarean delivery (January-July 2021) in a single tertiary university-affiliated medical center were included. Blinded questionnaires assessing adhesions were completed by the surgeons. Questions were limited to 4 main anatomic sites and 3 possible categories of adhesion (each site was scored between 0 and 2; the sum score range was 0-8). The surgeons were ranked by increasing seniority (1-4) as: (1) junior residents (less than half of residency completed), (2) senior residents (more than half of residency completed), (3) young attending physicians (attending physicians for <10 years), and (4) senior attendings (attending physicians for >10 years). The weighted percentage of agreement was calculated between the 2 surgeons assessing the same adhesions. Scoring differences between the 2 surgeons (senior vs less senior) were also calculated.

RESULTS

A total of 96 pairs of surgeons were included in the study. The sum interrater reliability found in the weighted agreement tests between surgeons was 0.918 (confidence interval, 0.898-0.938). When scoring differences between surgeons (senior vs less senior) were calculated, nonsignificant difference was found (mean sum score difference of 0.09 with a standard deviation of 1.03 in favor of the more experienced surgeon).

CONCLUSION

Surgeon seniority does not affect subjective scoring of adhesion reports.

Peritoneal adhesion findings during laparoscopy: Determinants of occurrence and effect of severity on operative outcomes in a Nigerian Hospital

Context

Peritoneal adhesions unlike other immediately recognizable complications of the surgery may produce long-term consequences, which include infertility and intestinal obstruction.

Aims

The study aimed to determine the prevalence, the determinants, and the outcomes of laparoscopic surgery associated with intraperitoneal adhesion findings.

Settings and Design

This was a retrospective observational study.

Materials and Methods

The study included all laparoscopic gynecological surgeries done between January 2017 and December 2021. Adhesion severity was graded, using the peritoneal adhesion index (PAI), by Coccolini et al.

Statistical Analysis

The data were analyzed using the SPSS version 21.0. Binary logistic regression was used to assess the factors associated with adhesion finding during laparoscopy.

Results

There were 158 laparoscopic surgeries with 26.6% prevalence of peritoneal adhesions. The prevalence of adhesions among women with previous surgery was 72.7%. Previous peritoneal surgery was a significant determinant of occurrence of adhesions (odds ratio = 8.291, 95% confidence interval [CI] = 4.464-15.397, P < 0.001), and such patients had significantly (P = 0.025, 95% CI = 0.408-5.704) more severe adhesions (PAI = 11.16 ± 3.94) than those without prior surgery (PAI = 8.10 ± 3.14). Abdominal myomectomy (PAI = 13.09 ± 2.95) was the most important primary surgical determinant of adhesion formation. There was no significant relationship between adhesion occurrence and conversion to laparotomy (P = 0.121) or mean duration of surgery (P = 0.962). Greater adhesion severity was, however, observed in individuals with operative blood loss <100 ml (PAI = 11.73 ± 3.56, P = 0.003) and those hospitalized for ≤2 days (PAI = 11.12 ± 3.81, P = 0.022).

Conclusion

The prevalence of postoperative adhesions during laparoscopy in our center is comparable to what has been earlier reported. Abdominal myomectomy is associated with the greatest risk and severity of adhesions. Laparoscopy in patients with more severe adhesions resulted in less blood loss and shorter duration of hospitalization, suggesting an association of better outcomes with a cautious approach to adhesions.

Early Initiation of Breastfeeding Among Adolescent Mothers: A Quality Improvement Study

BACKGROUND

The prevalence of early initiation of breastfeeding (EIBF) was found to be low among adolescent postnatal mothers. EIBF is associated with improved parenting skills and better neurodevelopment in babies. We aimed to improve the prevalence of EIBF among teenage mothers to at least 90% through a quality improvement (QI) initiative.

MATERIALS AND METHODS

It was a QI intervention conducted over a period of 15 months involving mothers under the age of 20 years at the time of present delivery. Six Plan-Do-Study-Act (PDSA) cycles consisting of multiple interventions, each lasting for one month, were conducted to improve the prevalence of EIBF. Rate of improvement in EIBF was noted and plotted against time. Post-intervention follow-ups of observations were done for six months.

RESULTS

The prevalence of EIBF among adolescent mothers was 28.5% during the pre-intervention baseline phase. QI team meeting was held and the barriers to EIBF among the adolescent mothers were discussed and depicted in the form of a fish-bone analysis model. The prevalence of EIBF increased during each intervention cycle to 50%, 60%, 62.5%, 72.7%, 88%, and 100%. At the end of six months follow-up phase, the prevalence of EIBF sustained at around 100%.

CONCLUSION

This QI initiative has proven to be effective in improving the prevalence of EIBF with simple but effective measures. Adolescent women comprise of a vulnerable sub-population of high-risk mothers. Proper counseling and respectful maternity care will help them face the challenges of motherhood boldly.

Dural puncture epidural technique provides better anesthesia quality in repeat cesarean delivery than epidural technique: Randomized controlled study

BACKGROUND

Repeat cesarean deliverys involve a longer surgery and more severe visceral traction than primary cesarean deliverys. The dural puncture epidural (DPE) technique provides faster and more effective analgesia for labor, but there is no sufficient evidence to indicate whether it is suitable for parturients undergoing repeat cesarean delivery.

AIM

To determine the efficacy and safety of the DPE anesthesia technique in patients undergoing repeat cesarean delivery.

METHODS

Patients undergoing repeat cesarean delivery were randomly divided into the DPE and epidural anesthesia (EA) groups. A 25-G spinal needle was used for dural puncture via a 19-G epidural needle. The patients in the two groups were injected with 5 mL of 2% lidocaine followed by 15 mL of a mixture of 1% lidocaine + 0.5% ropivacaine as the epidural dosage. The primary outcome was the onset time of sensory block to the T6 dermatome level and the sensory and motor block degree.

RESULTS

A total of 115 women were included (EA: 57, DPE: 58). The mean time to sensory block to the T6 Level was significantly shorter in the DPE group than in the EA group (14.7 min vs 16.6 min; 95% confidence interval, 13.9 to 15.4 vs 15.8 to 17.4; P = 0.001). The cranial sensory block level was significantly higher at 5, 10, and 15 min after the initial dose in the DPE group than in the EA group (P < 0.05). The sacral sensory block level was significantly higher and the modified bromage score was significantly lower in the DPE group at each time point (P < 0.05). Adverse effects and neonatal outcomes were comparable between the two groups (P > 0.05).

CONCLUSION

The DPE technique provided higher-quality anesthesia than the EA technique, with a rapid onset of surgical anesthesia, better cranial and sacral sensory block spread and a higher motor block degree, without increasing the incidence of maternal or fetal side effects in patients undergoing repeat cesarean delivery.

Evaluation of the treatment of high intensity focused ultrasound combined with suction curettage for exogenous cesarean scar pregnancy

PURPOSE

To evaluate the effectiveness of high-intensity focused ultrasound (HIFU) combined with suction curettage in the treatment of exogenous cesarean scar pregnancy (CSP).

METHODS

A retrospective single-center observational study was conducted. A total of 41 patients diagnosed with exogenous CSP were enrolled in this study. All patients received HIFU combined with suction curettage.

RESULTS

Twenty-nine patients were administered one session of HIFU ablation. In addition, the other 12 patients received 2 HIFU sessions. Suction curettage was performed in all patients after HIFU, and no patient was converted to laparoscopy or hysterectomy. The mean blood loss during suction curettage was 99 ml. Three patients received two sessions of suction curettage. The success rate of our study was 92.68%. The mean time for serum β-HCG normalization was 23.18 ± 3.13 days. The average menstruation recovery time was 29.38 ± 3.34 days. Based on the blood loss during suction curettage, 41 patients were divided into a bleeding group and a control group. The size of the gestational sac in the bleeding group (3.80 ± 0.87 cm) was larger than that in the control group (3.39 ± 0.77 cm) (P < 0.05). The thickness of the myometrium between the bladder and gestational sac in the bleeding group (2.37 ± 0.89 mm) was less than that in the control group (2.75 ± 0.75 mm) (P < 0.05).

CONCLUSION

The results suggested that HIFU combined with suction curettage could be considered an effective treatment for exogenous CSP of < 9 weeks. The size of the gestational sac and the thickness of the myometrium between the bladder and gestational sac might be high-risk factors for blood loss during this treatment.

Local renin-angiotensin system molecular mechanisms in intrauterine adhesions formation following gynecological operations, new strategy for novel treatment

It has recently been proposed that local tissue renin-angiotensin system activation has a role in post-surgical adhesion. Intrauterine adhesions are scar tissues that form in the endometrial cavity causing the walls of the uterine to adhere together. Women, undergoing major gynecological surgery, are exposed to a high risk of adhesion formation. Post-operative uterine adhesion is associated with chronic pain and infertility that are important problems following post-operation uterine adhesion. A local renin-angiotensin system has been found in the organs of the female reproductive system, for example in the endometrium. Data about the physiological roles of local RAS in the gynecological tract are largely unknown, but dysfunctional local RAS in the endometrium may contribute to this pathological condition. Local AngII/AT1R may be over-activated after surgical injury or hypoxia leading to an up-regulation of the molecular mechanisms that may lead to a chronic immune response, oxidative stress, and increase the expression of fibrotic molecules like TGF-β to induce the risk of connective fibrotic tissues. Based on AngII/AT1R pathological potential to induce pelvic and uterine adhesions, using angiotensin receptor blockers could be a therapeutic strategy for the prevention and treatment of post-surgical adhesions.IMPACT STATEMENTWhat is already known on this subject? Intrauterine adhesions are described as fibrotic scar tissues following gynecological surgeries. It's reported that 55-100% of women are at risk of intrauterine adhesion after gynecological surgeries. Injury to tissues and hypoxia during the surgery, promote molecular mechanisms to contribute post-surgical adhesion. Recently evidence supports the existence of renin-angiotensin system components in the gynecological tract. Abnormal expression of local angiotensin II and AT1R in uterus tissue following gynecological surgeries up-regulate molecular mechanisms to induce post-operative adhesions.What do the results of this study add? Recently there has been an increased focus on the role of the local renin-angiotensin system in organ fibrosis. The results of this Mini-review article refer to the pathological roles of the local renin-angiotensin system in fibrotic bands formation after gynecological operations. Over-activation of local renin-angiotensin systems up-regulate molecular mechanisms such as inflammation and the TGF-β1 signalling pathway. TGF-β as a profibrotic molecule strongly induces the expression of some fibrotic molecules such as PAI and TIMP to increase the risk of intrauterine adhesions.What are the implications of these findings for clinical practice and/or further research? According to the biological roles of local renin-angiotensin system and AT1R following injuries to develop post-operative adhesion, the administration of ARBs may be considered as a new therapeutic strategy for the prevention of IUA.

Preoperative sonographic prediction of intra-abdominal adhesions using sliding sign at repeat caesarean section at the University of Maiduguri Teaching Hospital, Nigeria: a prospective observational study

OBJECTIVE

To determine if the presence or absence of sonographic sliding sign preoperatively is a good predictor of the presence and type of intra-abdominal adhesions; and to determine the time taken to demonstrate this sign.

DESIGN

A prospective, observational, triple-blind study using tests of diagnostic accuracy.

SETTING

Single-centre tertiary health institution in north-east Nigeria.

PARTICIPANTS

67 women in the third trimester scheduled for repeat elective caesarean sections (CS) had transabdominal sonography to determine the absence or presence and degree of sliding sign. The time taken to make these decisions were noted. Surgeons blinded to the ultrasound findings graded adhesions intraoperatively and comparison between sonographic and intraoperative findings made. Women who were scheduled for emergency CS were excluded.

MAIN OUTCOME MEASURES

Accuracy of preoperative ultrasound to determine no/mild, moderate and severe adhesions. Secondary outcomes were interobserver correlations and time taken to determine sliding.

RESULTS

When classified as adhesion and no adhesion, the sliding sign demonstrated a sensitivity of 100.00% (CI₉₅ 85.18% to 100.00%), specificity of 100.00% (CI₉₅ 92.13% to 100.00%). In predicting presence of moderate intra-abdominal adhesions, a sensitivity of 65.0% (CI₉₅ 40.78% to 84.61%) and specificity of 82.98% (CI₉₅ 69.19% to 92.35%) was found. For predicting severe intra-abdominal adhesions, it had a sensitivity of 25.00% (CI₉₅ 0.63% to 80.59%) and specificity of 98.41 (CI₉₅ 91.47 to 99.96). Disease prevalence for mild, moderate and severe adhesions was 33.82% (CI₉₅ 22.79% to 46.32%), 29.85% (CI₉₅ 19.28% to 42.27%) and 5.97% (CI₉₅ 1.65% to 14.59%), respectively. Interobserver Cohen's kappa coefficient and PPA were 0.58 (CI₉₅ 0.39 to 0.76) and 58.82 (CI₉₅ 52.82 to 64.82), respectively. The mean duration to determine sliding sign was 7.56±2.86 s.

CONCLUSION

This study supports the role of transabdominal sliding sign in preoperative prediction of intra-abdominal adhesions in women with previous CS without significant increase in sonography duration. This information can encourage planning for CS by ensuring that surgeons of appropriate seniority are deployed to undertake anticipated complex operations.

Sonographic Evaluation of Various Causes of Female Infertility: A Literature Review

Objective:

Female infertility may be a commonly encountered problem that presently accounts for a great percentage of women seeking gynecologic services. A systematic review was preformed to evaluate the most common cause of infertility, using sonography.

Materials and Methods:

A search was executed with Google Scholar, PubMed, NCBI, and Medscape databases, from 2001 to 2020. Two investigators independently reviewed and assessed those studies for eligibility. The data were tabulated in a Microsoft Excel sheet. The Statistical Package for the Social Sciences (SPSS), version 24 software was used to evaluate the data.

Results:

Out of 70 studies, the contributing factors, detected with sonography, for infertility were as follows: polycystic ovarian syndrome (PCOS), 44.9%; fibroids, 43.6%; endometriosis, 33.3%; polyps, 29.5%; adhesions, 29.5%; pelvic inflammatory disease, 23.1%; ovarian cysts, 23.1%; congenital anomalies, 20.5%; and adenomyosis, 11.5%.

Conclusion:

The most common cause of infertility, detected with sonography, was PCOS, and the least contributor to infertility was adenomyosis.

The association between prior cesarean delivery and subsequent in vitro fertilization outcomes in women undergoing autologous, frozen-thawed single euploid embryo transfer

BACKGROUND

The rates of cesarean deliveries continue to increase worldwide. Previous work suggests an association between a previous cesarean delivery and reduced fertility in natural conception and in vitro fertilization treatment cycles. To our knowledge, there is no published research that explored the relationship between a previous cesarean delivery and the clinical outcomes after in vitro fertilization and the subsequent transfer of a single frozen-thawed euploid embryo.

OBJECTIVE

This study aimed to investigate the relationship between the previous mode of delivery and subsequent pregnancy outcomes in patients undergoing a single frozen-thawed euploid embryo transfer after in vitro fertilization.

STUDY DESIGN

A retrospective cohort study was performed at a single academic fertility center from January 2012 to April 2020. All women with a history of a live birth undergoing autologous, frozen-thawed single euploid embryo transfers were identified. Cases included patients with a single previous cesarean delivery; controls included patients with a single previous vaginal delivery. Only the first embryo transfer cycle was included. The primary outcome was the implantation rate. Secondary outcomes included ongoing pregnancy and live birth rates, biochemical pregnancy rate, and clinical miscarriage rate.

RESULTS

A total of 525 patients met the inclusion criteria and were included in the analysis. Patients with a previous cesarean delivery had a higher body mass index (24.5±4.5 vs 23.4±4.1; P=.004) than those in the vaginal delivery cohort; the rest of the demographic data were otherwise similar. In a univariate analysis, the implantation rate was significantly lower in patients with a previous cesarean delivery (111/200 [55.5%] vs 221/325 [68.0%]; P=.004). After adjusting for the relevant covariates, a previous cesarean delivery was associated with a 48% reduction in the odds of implantation (adjusted odds ratio, 0.52; 95% confidence interval, 0.34-0.78; P=.002). In addition, after adjusting for the same covariates, a previous cesarean delivery was significantly associated with a 39% reduction in the odds of an ongoing pregnancy and live birth (adjusted odds ratio, 0.61; 95% confidence interval, 0.41-0.90; P=.01). There were no differences in the biochemical pregnancy rates or clinical miscarriage rates.

CONCLUSION

This study demonstrated a marked reduction in implantation and ongoing pregnancy and live birth associated with a previous cesarean delivery in patients undergoing a single euploid embryo transfer. Our work stresses the importance of reducing the primary cesarean delivery rates at a national level and elucidating the mechanisms behind the substantially lower implantation rates after a cesarean delivery.

Use of hypertonic glucose (10%) in the prevention of postoperative adhesions in rats

Purpose

To evaluate the efficacy of hypertonic glucose (10%), alone or in combination with the corticoid dexamethasone, to prevent peritoneal adhesion following hysterectomy in rats.

Methods

Forty-two adult rats underwent hysterectomy with peritoneal lavage: G1 – glucose (10%); G2 – glucose (10%) and dexamethasone 3 mg·kg^–1; and G3 – physiological saline (PS) 0.9%.

Results

In the macroscopic analysis after 14 days, G1 had a median score of 1, G2 of 1, and G3 of 2.5 (p < 0.0001), G3 compared to G1 and G2. There was no difference between groups after 28 days. In the microscopic analysis, the median vascular proliferation after 14 days was 2 for G1, 1 for G2, and 3 for G3 (p = 0.0037, G3 vs. G1 and G2). After 28 days, G1 showed a median vascular proliferation score of 2, G2 of 2.5, and G3 of 3 (p < 0.0001, G3 vs. G1 and G2). Regarding the inflammatory reaction after 14 days, G1 had a median score of 2, G2 of 1, and G3 of 3 (p = 0.7916). After 28 days, G1 had a median score of 0.5 (0–1.75), G2 of 1.5, and G3 of 2.5 (p < 0.0001, G3 vs. the others and G2 vs. G1). In the evaluation of fibrosis after 14 days, G1 had a median score of 1, G2 of 1, and G3 of 2.5 (p < 0.0001, G3 vs. G1and G2). After 28 days, G1 had a median fibrosis score of 1, G2: 2, and G3: 2.5 (p < 0.0001), G3 vs. the others andG2 vs. G1).

Conclusions

The use of hypertonic glucose (10%) solution seems to reduce macroscopic and microscopic pelvic adhesions.

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.

A resorbable hyaluronic acid hydrogel to prevent adhesion in porcine model under laparotomy pelvic surgery

Surgical post-operative adhesions can lead to serious clinical complications. Barrier agent is the broad usage for the prevention of post-operative adhesions. This study aimed to evaluate the reducing adhesion efficacy of non-animal hyaluronic acid (HA) hydrogel in pigs undergoing conventional laparotomy pelvic surgery. HA hydrogel was applied to eighteen female pigs who underwent conventional laparotomy. The adhesion degrees and histopathology were evaluated in bilateral uterine horns as well as peritoneal sidewall excision. In the present study, all animals survived and had no complications after the surgery. The histopathological observations were demonstrated that HA obviously improved laparotomy pelvic surgery-induced adhesion in peritoneal sidewall and uterine horn. The anastomotic healing score of injury + HA group was significantly lower than the injury alone group. We conclude HA hydrogel can attenuate the post-operative adhesions in porcine.

Outcome of Laparoscopic Adhesiolysis in Infertile Patients with Pelvic Adhesions Following Cesarean Delivery: A Randomized Clinical Trial

OBJECTIVES

To evaluate results of laparoscopic adhesiolysis in patients with post cesarean infertility regards restoration of the fertility and achievement of pregnancy. To identify a group of patients who should primarily be offered laparoscopic adhesiolysis and those who should be treated by IVF.

DESIGN

Randomized prospective clinical trial MATERIALS AND METHODS: 184 patients with secondary infertility diagnosed to have periadnexal and pelvic adhesions, were randomly allocated into two groups: group I (92 cases) treated by laparoscopic adhesiolysis and group II (92 cases) who treated for a year by controlled ovarian stimulation and IUI up to 3 trials. Diagnostic work-up of infertility was carried out denoting normal semen, patent both tubes at HSG, and ovulatory at ovulation testing with normal hormonal profile. The outcomes, cumulative pregnancy rates calculated for each group after one year.

RESULTS

According to the adhesions, the patients classified into 4 groups: 8 cases inoperable, 43 cases with mild type adhesions, 26 cases with moderate type adhesions, and 5 cases with severe type adhesions. The patients followed up postoperatively for year. Overall pregnancy rate 54.35 %. For patients with mild adhesions 76.7%, for patients with moderate adhesions 61.5%, and for patients with severe adhesions 20%. Complications present in (1.57%), cost is (125.7-180.9 $). Over all pregnancy rate was 11.96% in group (II) CONCLUSIONS: laparoscopic adhesiolysis is the method of choice for dealing with mild to moderate periadnexal adhesions after C.S. The pregnancy outcome after lysis of severe periadnexal adhesions is poor. So, such patients are best treated by IVF.

A Pictorial Review of Postpartum Complications

The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Peritoneal adhesions do not increase intra-operative organ injury or adverse neonatal outcomes during a repeated cesarean delivery

PURPOSE

To examine whether the presence of peritoneal adhesions at the second cesarean delivery (CD), attributable to the first CD, are associated with maternal intra-operative organ injury and adverse neonatal outcomes.

METHODS

A retrospective cohort study was conducted, comparing severe maternal intra-operative organ injury and adverse neonatal outcomes, between women with and without peritoneal adhesions. All women with two CDs during the follow-up period were included. Women with adhesions diagnosed during the first CD, history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies and newborns with known chromosomal or structural abnormalities were excluded, resulting in 7925 women. Intra-operative peritoneal organ injury was defined as a composite of bladder injury, ureteral injury, small bowel injury or hysterectomy. The examined adverse neonatal outcomes were low 1 and 5 min Apgar scores, intrapartum death (IPD) and postpartum death (PPD). Multivariate logistic regression was performed.

RESULTS

Peritoneal adhesions at the second CD, attributable to the first CD were diagnosed in 32.6% of patients (n = 2581). The presence of peritoneal adhesions was not found to be independently associated with intra-operative organ injury nor with 5 min Apgar scores, IPD and PPD. Second CDs complicated with adhesions were found to be associated with low (< 7) 1 min Apgar scores (adjusted OR 1.38, CI 1.20-1.58, p < 0.001).

CONCLUSION

Adhesions attributable to a previous CD do not seem to increase the risk for intra-operative organ injury and adverse neonatal outcomes. These findings may assist in reassuring patients who are facing a second CD.

Maternal obesity and intra-abdominal adhesion formation at cesarean delivery

Objective: The aim of the study was to evaluate whether maternal obesity increases the risk of intra-abdominal adhesion formation at cesarean delivery.Methods: Two hundred and two pregnant women of at least 37 weeks' gestation and who had undergone only one prior cesarean delivery were included in this prospective observational study. The study population was divided into two groups according to body mass index (BMI) upon cesarean delivery (<30 kg/m² and ≥30 kg/m²). The intra-abdominal adhesion incidence and the scar characteristics of the groups were compared.Results: Intra-abdominal adhesions were more common in women ≥30 kg/m² than in those <30 kg/m² (OR 2.0, 95% CI 1.1-3.6). BMI upon cesarean delivery (32.6 ± 6.2 kg/m² vs. 30.5 ± 4.8 kg/m², p = .018) and pre-pregnancy BMI (27.9 ± 6.8 kg/m² vs. 25.7 ± 5.2 kg/m², p = .026) were higher in women with dense adhesions than in those with either filmy or no adhesions. The omentum was the most adherent tissue, and the omental adhesion rate was also higher in women ≥30 kg/m² than in those <30 kg/m² (39.6% vs. 23.7%, p = .016). When the scar characteristics were compared, it was observed that the hyperpigmented scar rate was significantly lower (17.8% vs. 39.6%, p = .001) in women ≥30 kg/m² with intra-abdominal adhesions (16.7% vs. 35.4%, p = .005).Conclusion: Intra-abdominal adhesion formation following cesarean delivery is more common in obese women.

Anesthetic considerations for repeat cesarean section

PURPOSE OF REVIEW

The prevalence of cesarean delivery is increasing worldwide despite the advance of Trial of Labor After Cesarean section. In many countries, a history of previous cesarean section is an almost absolute indication for a repeat cesarean section. The purpose of this review was to examine if the perioperative anesthetic management of patients with repeat cesarean section is different from the anesthetic management of patients with primary cesarean section.

RECENT FINDINGS

This review discusses important topics, such as early diagnosis of cases with a potentially high risk for complications; the need for assessment of patients diagnosed with abnormal placentation; the importance of a multidisciplinary approach that includes interaction of the anesthesiologist, gynaecologist, and invasive radiologist; emphasizing the need for reinforcement of new methods of invasive procedures; management of massive bleeding, use of new technologies, and development of an institutional protocol for management of patients with abnormal placentation.

SUMMARY

According to this review, we show that the management of patients with repeat cesarean section without abnormal placentation is almost the same as the management of patients for primary cesarean section. Timely diagnosis of patient with abnormal placentation and multidisciplinary approach is crucial for prevention of morbidity or even mortality.

Peritoneal adhesions during cesarean delivery are an independent risk factor for peri-partum hemorrhagic complications

OBJECTIVE

To investigate whether the presence of peritoneal adhesions at the second cesarean delivery (CD) are associated with peri-partum hemorrhagic complications.

STUDY DESIGN

A retrospective cohort study was undertaken, comparing hemorrhagic complications in the second CD, between women with and without adhesions. All women with two CDs who delivered a singleton in their second CD between the years 1988-2016 at a large regional medical center in Israel were included. Women with adhesions diagnosed at the first CD and women with a history of other abdominal or pelvic surgery, pelvic infection or inflammatory disease, endometriosis, uterine Mullerian anomalies and fetal chromosomal or structural abnormalities were excluded from the analysis, resulting in a sample of 7925 women. Peri-partum hemorrhagic complications were defined as a composite of vessel ligation, B lynch procedure during the CD or uterine rupture, third stage or immediate postpartum hemorrhage, blood component transfusion, hemorrhagic shock and maternal anemia [hemoglobin (Hb) levels prior to maternal discharge below 9.0 g\dl]. In order to identify variables that are independently associated with the composite peri-partum hemorrhagic complications a multivariate logistic regression analysis was performed, to control for potential confounders. In addition, a linear regression model was constructed with Hb levels as the outcome variable.

RESULTS

During the study period, 32.6 % of patients (n = 2581) suffered from adhesions during the second CD. After adjusting for potential confounders, peri-partum hemorrhagic complications were found to be significantly associated with the presence of peritoneal adhesions (adjusted OR 1.18, CI 1.04-1.33, P = 0.008). A multivariate linear regression analysis revealed that peritoneal adhesions were independently associated with a decline in post-partum Hb levels (β=-0.055, P < 0.001).

CONCLUSION

Adhesions attributable to a previous CD increase the risk for hemorrhagic complications. Interventions aimed at preventing adhesions formation during the primary CD may have a role in reducing hemorrhagic complications in subsequent CDs.

The use of absorbable adhesion barriers to reduce the incidence of intraperitoneal adhesions at repeat cesarean delivery

PURPOSE

We aimed to evaluate the effect of an absorbable adhesion barrier (oxidized regenerated cellulose) for the prevention of peritoneal adhesions in women undergoing repeat cesarean delivery (CD).

METHODS

This is a retrospective, single center study that included all women who underwent two consecutive CDs, 2011-2018. Women in whom an absorbable adhesion barrier (oxidized regenerated cellulose) was placed at the time of the initial CD (index CD) were compared to women in whom no such barrier was placed. The association between absorbable adhesion barrier placement at index CD and the presence of intraperitoneal adhesions at subsequent CD was assessed. Factors evaluated included intraperitoneal adhesion severity, time from skin incision to newborn delivery and total duration of surgery.

RESULTS

We identified 2125 women that met the inclusion criteria. They were divided into two groups; those in whom an absorbable adhesion barrier was placed at index CD and those in whom no such absorbable barrier was placed. 161 (7.6%) had an absorbable adhesion barrier placed at index CD. At the time of index CD, the rate of intra-peritoneal adhesions was 34.8% in the absorbable adhesion barrier group vs 26.5% in the group without the absorbable adhesion barrier (p = 0.02). At the time of subsequent CD, the rate of intraperitoneal adhesions was 39.8% in the absorbable adhesion barrier group vs 46% in the group without the absorbable adhesion barrier (p = 0.13). Notably, the use of an absorbable adhesion barrier lowered the mean increase in adhesions rate 0.05 ± 0.55 vs 0.20 ± 0.55 (p < 0.01). Absorbable adhesion barrier placement at index CD was found to be independently associated with a lower rate of intraperitoneal adhesions at subsequent CD, aOR 0.67 (0.47-0.96). Overall, absorbable adhesion barrier placement at index CD was associated with a shorter mean duration of subsequent surgery (min), 37.7 ± 18.9 vs. 42.7 ± 27.1 (p = 0.02).

CONCLUSION

Absorbable adhesion barrier placement is associated with reduction in intraperitoneal adhesions and duration of surgery in subsequent CD.

Outcomes of subsequent pregnancies in patients following treatment of cesarean scar pregnancy with high intensity focused ultrasound followed by ultrasound-guided dilation and curettage

Objective: To evaluate the outcomes of subsequent pregnancies in patients with a history of cesarean scar pregnancy (CSP) treated with high intensity focused ultrasound (HIFU) followed by ultrasound-guided dilation and curettage (USg-D&C). Methods: A retrospective analysis was performed on data collected from 154 patients with CSP who were treated by HIFU followed by USg-D&C in Suining Central Hospital between January 2015 and January 2018. Among them, 28 patients wanted to conceive following treatment. Baseline characteristics, treatment results, intraoperative hemorrhages during USg-D&C, post-curettage serum beta human chorionic gonadotropin (β-hCG) levels and vaginal bleeding were investigated. Subsequent pregnancy outcomes, including intervals between pregnancy and treatment of CSP, complications during pregnancy, and outcomes of newborns were evaluated. Results: All patients with CSP were successfully treated by HIFU combined with USg-D&C. Of the 28 CSP patients who intended to conceive after the treatment, 23 patients (82.14%) successfully conceived. The average interval between conception and HIFU treatment was 18.38 ± 10.04 months. Eighteen patients (78.26%) had an intrauterine pregnancy, in which 12 had delivery by cesarean section, 1 had an ongoing pregnancy, and 5 had an abortion in the first trimester. Among the other 5 women, 3 had tubal ectopic pregnancy and 2 had recurrent CSP. These five patients underwent laparoscopy within the first trimester. Conclusion: HIFU followed by USg-D&C is an effective and safe treatment for patients with CSP who wish to conceive. Prospective multi-center studies with larger sample sizes and longer follow-up periods are needed to compare this treatment with others.

Perioperative Complications of Hysterectomy After a Previous Cesarean Section: A Systematic Review and Meta-Analysis

Background

With increasing rates of cesarean sections (CS), the number of hysterectomies performed among women with a previous CS is on the rise.

Objective

To provide the association between the odds of complications following a hysterectomy performed later in life and a previous CS.

Search strategy

A comprehensive search was performed using major electronic databases, ie, MEDLINE, Scopus, ISI Web of Science, from their inception to April 2019.

Selection criteria

Analytical studies, irrespective of language or publication status, were included.

Data collection and analysis

Outcomes were extracted in duplicate. The methodological quality of the included studies was independently evaluated by two review authors. A three-level meta-analysis was applied for outcomes with dependent effect sizes.

Main results

Twenty-six studies were included involving 54,815 women. The odds of the following complications were increased in women with a previous CS: urinary tract injury (pooled unadjusted odds ratio (OR)=3.15, 95% CI=2.01-4.94, 15 studies, 33,902 women, and pooled adjusted OR=2.21, 95% CI=1.46-3.34, 3 studies, 31,038 women), gastrointestinal tract injury (pooled unadjusted OR=1.73, 95% CI=1.19-2.53; 7 studies, 30,050, and pooled adjusted OR=1.83, 95% CI=1.11-3.03, 1 study, 25,354 women), postoperative infections (pooled unadjusted OR=1.44, 95% CI=1.22-1.71, 6 studies, 37,832 women), wound complications (pooled unadjusted OR=2.24, 95% CI=1.94-2.57, 9 studies, 37,559 women), reoperation (pooled unadjusted OR=1.46, 95% CI=1.19-1.78, 2 studies, 9,899 women), and blood transfusion (pooled unadjusted OR=1.35, 95% CI=1.03-1.76, 7 studies, 13,430 women).

Conclusion

Previous CS increases risks of various complications following hysterectomy. This information reminds the gynecologists to be aware of the associations between previous CS and potential complications among women undergoing hysterectomy.

Prospero registration number

CRD42018085061.

Preliminary design of a new degradable medical device to prevent the formation and recurrence of intrauterine adhesions

Intrauterine adhesions lead to partial or complete obliteration of the uterine cavity and have life-changing consequences for women. The leading cause of adhesions is believed to be loss of stroma resulting from trauma to the endometrium after surgery. Adhesions are formed when lost stroma is replaced by fibrous tissue that join the uterine walls. Few effective intrauterine anti-adhesion barriers for gynecological surgery exist. We designed a degradable anti-adhesion medical device prototype to prevent adhesion formation and recurrence and restore uterine morphology. We focused on ideal degradation time for complete uterine re-epithelialization for optimal anti-adhesion effect and clinical usability. We developed a triblock copolymer prototype [poly(lactide) combined with high molecular mass poly(ethylene oxide)]. Comparative pre-clinical studies demonstrated in vivo anti-adhesion efficacy. Ease of introduction and optimal deployment in a human uterus confirmed clinical usability. This article provides preliminary data to develop an intrauterine medical device and conduct a clinical trial.

Pharmacological Mobilization and Recruitment of Stem Cells in Rats Stops Abdominal Adhesions After Laparotomy

Adhesions are a very common complication in the abdominal surgery. Animal studies and human trials have evaluated strategies designed to reduce and prevent postsurgical adhesions but few have an evidence base that justifies routine use. A strategy to prevent adhesions effectively remains an urgent need. We studied a reproducible model of intra-peritoneal adhesion formation in rats using laparotomy with several peritoneal sutures to produce the adhesions. Here we show that entraining endogenous stem cells into injury sites using the combined effect of AMD3100 and low-dose FK-506 (AF) can reduce the adhesion score significantly and abolish peritoneal adhesions in 45% of animals in a rat model of severe postsurgical intra-abdominal adhesions, compared with saline controls. Searching for mechanisms, we found AF treatment dramatically increased SDF-1 expressing cells, HGF expressing Ym1+ M2 macrophages and CD133+ stem cells in the injury sites of peritoneal surface at day 5 post-operation. Our results demonstrate that medically induced recruitment of autologous stem cells using AF significantly reduced postsurgical intra-abdominal adhesions. These findings suggest a novel effective therapeutic approach to preventing adhesions in patients.

Isthmocele: From Risk Factors to Management

OBJECTIVE

 The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition.

METHODS

 A comprehensive review of the literature was performed to identify the most relevant studies about this topic.

RESULTS

 Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data.

CONCLUSION

 Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.

Captive uterus syndrome: An unrecognized complication of cesarean sections?

Cesarean sections are a common surgical procedure at risk of complications including adhesions and chronic pelvic pain. This case series presents 10 cases of patients presenting with chronic pelvic pain following a cesarean section which were found upon surgical exploration to have developed adhesions between the abdominal wall and the uterus. When they first consulted, patients were evaluated clinically with a questionnaire and physical exam, and with ultrasonography to evaluate pelvic anatomy when necessary. The evaluation was completed with diagnostic laparoscopy which revealed atypical post-cesarean adhesions which were treated by adhesion lysis or hysterectomy. Surgical protocols of the cesarean sections were retrieved and analysed for potential adhesion risk factors. Patients presented with chronic pelvic pain that appeared in the early post-operative period. Physical exam revealed a subinvoluted uterus with a high fixed cervix. Ultrasound examination revealed clues of adhesions manifested by points of traction and an irregular uterine border. No other diagnosis such as endometriosis, pelvic inflammatory disease, ovarian or bowel anomalies were identified during surgery. After laparoscopic adhesion lysis or hysterectomy, all patients who were treated noted a complete resolution of the pain that lasted during a follow-up of at least 5 years. These findings suggest that adhesions that create traction and fix the uterus to the abdominal wall following caesarian section can be the cause of severe chronic pelvic pain. In the presence of such pain, clinicians should suspect the presence of adhesions and investigate and treat patients accordingly.

Evitar (l-Alanyl-l-Glutamine) Regulates Key Signaling Molecules in the Pathogenesis of Postoperative Tissue Fibrosis

Aims:

Hypoxia and the resulting oxidative stress play a major role in postoperative tissue fibrosis. The objective of this study was to determine the effect of l-alanyl-l-glutamine (Ala-Gln) on key markers of postoperative tissue fibrosis: hypoxia-inducible factor (HIF) 1α and type I collagen.

Methods:

Primary cultures of human normal peritoneal fibroblasts (NPF) established from normal peritoneal tissue were treated with increasing doses of Ala-Gln (0, 1, 2, or 10 mM) with hypoxia ([2% O2] 0-48 hours; continuous hypoxia) or after hypoxia (0.5, 1, 2, 4 hours) and restoration of normoxia (episodic hypoxia) with immediate treatment with Ala-Gln. Hypoxia-inducible factor 1α and type 1 collagen levels were determined by enzyme-linked immunosorbent assay. Data were analyzed with 1-way analysis of variance followed by Tukey tests with Bonferroni correction.

Results:

Hypoxia-inducible factor 1α and type I collagen levels increased in untreated controls by 3- to 4-fold in response to continuous and episodic hypoxia in human NPF. Under continuous hypoxia, HIF-1α and type I collagen levels were suppressed by Ala-Gln in a dose-dependent manner. l-alanyl-l-glutamine treatment after episodic hypoxia also suppressed HIF-1α and type I collagen levels for up to 24 hours for all doses and up to 48 hours at the highest dose, regardless of exposure time to hypoxia.

Conclusions:

l-alanyl-l-glutamine significantly suppressed hypoxia-induced levels of key tissue fibrosis (adhesion) phenotype markers under conditions of continuous as well as episodic hypoxia in vitro. This effect of glutamine on molecular events involved in the cellular response to insult or injury suggests potential therapeutic value for glutamine in the prevention of postoperative tissue fibrosis.

Effect of soft tissue mobilization techniques on adhesion-related pain and function in the abdomen: A systematic review

OBJECTIVE

To systematically review the effects of soft tissue mobilization (STM) on both surgical and non-surgical abdominal adhesion-related symptoms.

STUDY DESIGN

Systematic Review.

BACKGROUND

It is known that abdominal adhesions can cause a variety of symptoms with one of the most common being abdominal pain. To date, there is no known systematic review that documents the effects of STM on adhesion-related abdominal symptoms.

METHODS AND MEASURES

A systematic review of literature was indexed in the following databases: PubMed, Cochrane, Google Scholar, OVID, and EBSCO. The quality of the studies was assessed using the MINORS scale.

RESULTS

Nine studies satisfied the eligibility criteria for this systematic review. The studies' population age ranged from 10.7 to 89.4 years. Four articles were nonrandomized and had scores ranging from 3 to 14 out of 16 total on the MINORS scale. Five articles were randomized controlled trials or comparative studies and scores ranged from 16 to 23 out of 24 total on the MINORS scale. There were five articles that used pain as an objective measure and all of them reported a decrease in pain after treatment. Two studies looked at quality of life and function and both saw objective improvements following abdominal adhesion treatment. Collectively, there were also improvements seen in scar mobility, infertility, posture, a reduction in medication, increased pressure tolerance and decreased postoperative ileus.

CONCLUSION

The results of this review indicate preliminary strong evidence for the benefits of STM on symptoms relating to acute post-surgical adhesions, preliminary moderate evidence for the benefits of STM on symptoms relating to chronic non-surgical related adhesions (fertility and SBO) and moderate evidence for the benefits of STM on symptoms relating to chronic post-surgical adhesions.

Incidence and sites of pelvic adhesions in women with post-caesarean infertility

This cross-sectional study was designed to evaluate the incidences and sites of pelvic adhesions in women with post-caesarean unexplained infertility. This study was conducted at the Tanta University Hospitals in the period from August 1 2015 to July 31 2016. The enrolled patients were assessed by a diagnostic laparoscopy for the presence and sites of abdominal and pelvic adhesions. Pelvic adhesions were found in 98 cases (73.13%) and the remaining 36 cases (26.87%) were free of adhesions. Adhesions were tubal in 55.10%, ovarian in 20.40%, combined tubo-ovarian and omental adhesions in 11.22%, uterine adhesions in 6.12% and a frozen pelvis was found in 7.14%. There was no correlation between the severity of the adhesions and the number of previous caesarean sections (CS). The data of this study led us to conclude that pelvic adhesions are common in patients with unexplained infertility following a caesarean delivery. Tubal and ovarian adhesions to the lateral pelvic wall represent a pathognomonic feature in post-caesarean infertility. Impact Statement What is already known on this subject? Adhesions following a caesarean delivery have been assessed by many studies at the time of the next caesarean delivery. These adhesions have not been studied well in the patients with unexplained infertility. What the results of this study add? The results of this study specify the incidences and the sites of the adhesions which are considered to be pathognomonic for caesarean section. What the implications are of these findings for clinical practice and/or further research? These findings should be applied when the cases of post-caesarean infertility are evaluated in order to shorten the duration and burdens of infertility.

Is Striae Gravidarum related to Cesarean Scar and Peritoneal Adhesions?

Objective

To evaluate the relationship between striae gravidarum (SG) score and abdominal scar characteristics together with intraperitoneal adhesion (IPA) grades of patients who were hospitalized for second cesarean delivery.

Methods

A total of 145 consecutive women undergoing scheduled cesarean section (CS) in a tertiary level maternity hospital between November 2013 and January 2014 were included in the study. All women had transverse suprapubic skin incision due to the previous CS and none of them had a history of vaginal delivery. Patients were classified according to the SG status, as women with no SG: Group-1(n=53), mild SG: Group-2(n=27) and severe SG: Group 3(n=65). Groups were compared between themselves with regard to various sociodemographic properties, cesarean scar characteristics and IPA scores.

Results

No significant difference in the length, width and color of the scar was detected among groups. While flat scar was the most prominent form of scar, the elevated scar was significantly more frequent in Group-1 compared to other groups (p=0.009). IPA grades were 0 or 1 in 77.3% of Group-1, 81.3% of Group-2 and 76% of Group-3. There was no significant difference in IPA scores between groups (p=0.884). After combining CS scar characteristics (flat, depressed and elevated) and SG status [SG (+) or SG (-)], we found no significant difference between the groups in terms of IPA severity.

Conclusion

Striae gravidarum (SG) was found to be associated with scar characteristics, but not associated with the severity of intraperitoneal adhesion (IPA).

Lidocaine/ketorolac-loaded biodegradable nanofibrous anti-adhesive membranes that offer sustained pain relief for surgical wounds

The aim of this study was to develop and evaluate the effectiveness of biodegradable nanofibrous lidocaine/ketorolac-loaded anti-adhesion membranes to sustainably release analgesics on abdominal surgical wounds. The analgesic-eluting membranes with two polymer-to-drug ratios (6:1 and 4:1) were produced via an electrospinning technique. A high-performance liquid chromatography (HPLC) assay was employed to characterize the in vivo and in vitro release behaviors of the pharmaceuticals from the membranes. It was found that all biodegradable anti-adhesion nanofibers released effective concentrations of lidocaine and ketorolac for over 20 days post surgery. In addition, a transverse laparotomy was setup in a rat model for an in vivo assessment of activity of postoperative recovery. No tissue adhesion was observed at 2 weeks post surgery, demonstrating the potential anti-adhesion capability of the drug-eluting nanofibrous membrane. The postoperative activities were recorded for two groups of rats as follows: rats that did not have any membrane implanted (group A) and rats that had the analgesic-eluting membrane implanted (group B). Rats in group B exhibited faster recovery times than those in group A with regard to postoperative activities, confirming the pain relief effectiveness of the lidocaine- and ketorolac-loaded nanofibrous membranes. The experimental results suggested that the anti-adhesion nanofibrous membranes with sustainable elution of lidocaine and ketorolac are adequately effective and durable for the purposes of postoperative pain relief in rats.

Use of Modified Polysaccharide 4DryField (®) PH for Adhesion Prevention and Hemostasis in Gynecological Surgery: A Two-Center Observational Study by Second-Look Laparoscopy

Purpose. This study evaluates both scopes of 4DryField PH, certified for adhesion prevention and hemostasis, in patients undergoing surgery for various and severe gynecological disorders. Methods. This is a two-institutional study. Adhesion prevention efficacy was evaluated using video documentation of first-look laparoscopies (FLL) and second-look laparoscopies (SLL); other patient data were analyzed retrospectively. Twenty patients with various disorders were evaluated, 4 assigned to a uterus pathology, 10 to endometriosis, and 6 to an adhesion disease group. Nine patients received 4DryField primarily for hemostasis and 11 solely for adhesion prevention. Nineteen patients had SLL after 5 to 12 weeks and one after 13 months. Results. At FLL with 4DryField, immediate hemostasis could be achieved in diffuse bleeding. At SLL, effective adhesion prevention was observed in 18 of all 20 women, with only 2 revealing major adhesions. In particular, only 1 of the 6 women with adhesion disease as predominant disorder showed major adhesions at SLL. Conclusions. Modified polysaccharide 4DryField is not only effective in diffuse bleeding. In this cohort with extensive surgery for various gynecological pathologies, 4DryField showed effective adhesion prevention as confirmed at SLL, too. Its use as premixed gel is a convenient variant for treatment of large peritoneal wounds.

Dual crosslinked hyaluronic acid nanofibrous membranes for prolonged prevention of post-surgical peritoneal adhesion

A HA NFM crosslinked with FeCl₃and BDDE shows prolonged degradation to prevent peritoneal adhesion.

Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development

Caesarean section (CS) results in the occurrence of the phenomenon 'niche'. A 'niche' describes the presence of a hypoechoic area within the myometrium of the lower uterine segment, reflecting a discontinuation of the myometrium at the site of a previous CS. Using gel or saline instillation sonohysterography, a niche is identified in the scar in more than half of the women who had had a CS, most with the uterus closed in one single layer, without closure of the peritoneum. An incompletely healed scar is a long-term complication of the CS and is associated with more gynaecological symptoms than is commonly acknowledged. Approximately 30% of women with a niche report spotting at 6-12 months after their CS. Other reported symptoms in women with a niche are dysmenorrhoea, chronic pelvic pain and dyspareunia. Given the association between a niche and gynaecological symptoms, obstetric complications and potentially with subfertility, it is important to elucidate the aetiology of niche development after CS in order to develop preventive strategies. Based on current published data and our observations during sonographic, hysteroscopic and laparoscopic evaluations of niches we postulate some hypotheses on niche development. Possible factors that could play a role in niche development include a very low incision through cervical tissue, inadequate suturing technique during closure of the uterine scar, surgical interventions that increase adhesion formation or patient-related factors that impair wound healing or increase inflammation or adhesion formation.