Implications of late complications from adhesions for preoperative informed consent

Polysaccharide-based emulsion gels for the prevention of postoperative adhesions and as a drug delivery system using 5-fluorouracil

Postoperative tissue adhesion is a well-recognized and common complication. Despite ongoing developments in anti-adhesion agents, complete prevention remains a challenge in clinical practice. Colorectal cancer necessitates both adhesion prevention and postoperative chemotherapy. Accordingly, drug-loading into an anti-adhesion agent could be employed as a treatment strategy to maximize the drug effects through local application and minimize side effects. Herein, we introduce an anti-adhesion agent that functions as a drug delivery system by loading drugs within an emulsion that forms a gel matrix in the presence of polysaccharides, xanthan gum, and pectin. Based on the rheological analysis, the xanthan gum-containing emulsion gel formed a gel matrix with suitable strength and mucosal adhesiveness. In vitro dissolution tests demonstrated sustained drug release over 12 h, while in vivo pharmacokinetic studies revealed a significant increase in the Tmax (up to 4.03 times) and area under the curve (up to 2.62 times). However, most of the drug was released within one day, distributing systemically and raising toxicity concerns, thus limiting its efficacy as a controlled drug delivery system. According to in vivo anti-adhesion efficacy evaluations, the xanthan gum/pectin emulsion gels, particularly F2 and F3, exhibited remarkable anti-adhesion capacity (P < 0.01). The emulsion gel formulation exhibited no cytotoxicity against fibroblasts or epithelial cell lines. Thus, the xanthan gum/pectin emulsion gel exhibits excellent anti-adhesion properties and could be developed as a drug delivery system.

Evaluation of the effect of previous endometriosis surgery on clinical and surgical outcomes of subsequent endometriosis surgery

PURPOSE

Patients often undergo repeat surgery for endometriosis, due to recurrent or residual disease. Previous surgery is often considered a risk factor for worse surgical outcome. However, data are scarce concerning the influence of subsequent endometriosis surgery.

METHODS

A retrospective study in a centre of expertise for endometriosis was conducted. All endometriosis subtypes and intra-operative steps were included. Detailed information regarding surgical history of patients was collected. Surgical time, intra-operative steps and major post-operative complications were obtained as outcome measures.

RESULTS

595 patients were included, of which 45.9% had previous endometriosis surgery. 7.9% had major post-operative complications and 4.4% intra-operative complications. The patient journey showed a median of 3 years between previous endometriosis surgeries. Each previous therapeutic laparotomic surgery resulted on average in 13 additional minutes (p = 0.013) of surgical time. Additionally, it resulted in more frequent performance of adhesiolysis (OR 2.96, p < 0.001) and in a higher risk for intra-operative complications (OR 1.81, p = 0.045), however no higher risk for major post-operative complications (OR 1.29, p = 0.418). Previous therapeutic laparoscopic endometriosis surgery, laparotomic and laparoscopic non-endometriosis surgery showed no association with surgical outcomes. Regardless of previous surgery, disc and segmental bowel resection showed a higher risk for major post-operative complications (OR 3.64, p = 0.017 respectively OR 3.50, p < 0.001).

CONCLUSION

Previous therapeutic laparotomic endometriosis surgery shows an association with longer surgical time, the need to perform adhesiolysis, and more intra-operative complications in the subsequent surgery for endometriosis. However, in a centre of expertise with experienced surgeons, no increased risk of major post-operative complications was observed.

What We Have Learned from Animal Models to Understand the Etiology and Pathology of Endometrioma-Related Infertility

Endometrioma (OMA) is the most common subtype of endometriosis, in which the endometriotic lesions are implanted in the ovary. Women with OMA are usually associated with infertility, presenting with reduced ovarian reserve, low oocyte quantity and quality, and poor fertility outcomes. However, the underlying pathological mechanisms in OMA-related infertility are still unclear. Due to the limitations and ethical issues of human studies in reproduction, animal models that recapitulate OMA characteristics and its related infertility are critical for mechanistic studies and subsequent drug development, preclinical testing, and clinical trials. This review summarized the investigations of OMA-related infertility based on previous and latest endometrioma models, providing the possible pathogenesis and potential therapeutic targets for further studies.

Carboxymethyl Cellulose, Pluronic, and Pullulan-Based Compositions Efficiently Enhance Antiadhesion and Tissue Regeneration Properties without Using Any Drug Molecules

Pharmacological-based treatment approaches have been used over time to prevent postlaparotomy adhesion. However, the rapid elimination of therapeutics from the peritoneum, and their unwanted side effects, easy flow from the wound site by gravity, and low therapeutic efficacy increase the urgent need for the next generation of antiadhesion agents. This article represents the development of biocompatible and biodegradable antiadhesion agents that consist of carboxymethyl cellulose (CMC) and pullulan with three different types of physical characteristics such as the solution type (ST), film type (FT), and thermosensitive type (TST). These antiadhesion agents that contain no drugs exhibit excellent physical characteristics and superior stability over 30 days in the operative sites without any toxicity and side effects that make the compositions strong candidates as novel antiadhesion agents. Also, the proposed samples reveal superior antiadhesion and tissue regeneration properties in Sprague-Dawley (SD) rats after surgery over Medicurtain. Medicurtain effectively prevented postlaparotomy adhesion in ∼42% of experimental animals, whereas ST 2.25-10, ST 2.5-5, ST 2.5-10, FT 20, and TST 1.5 were effective in 100% of animals. Thus, we believe these antiadhesion agents could be promising to reduce adhesion-related complications during and post-surgical operations and deserve consideration for further study for clinical purposes.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Vaginal Cuff Dehiscence Presenting with Free Air 60 Days after Robotic-Assisted Hysterectomy

Introduction

The vast majority of patients presenting with pneumoperitoneum have visceral organ perforation and require urgent diagnostic laparoscopy. Nonsurgical causes are relatively rare and may be attributed to multiple etiologies.

Case Presentation

Here we describe the case of a 38-year-old Caucasian female who presented to the emergency department with three days of cramping, epigastric abdominal pain. Her physical exam was notable for tenderness to palpation in the epigastric area and abdominal and chest X-rays showed free air under the diaphragm. Free air around the porta hepatis was verified on CT scan. Approximately 90% of pneumoperitoneum cases are due to perforation of visceral organs and therefore require operative management. An urgent exploratory laparoscopy revealed no clear source of free air, but postoperatively the patient developed a large volume of watery discharge from her vagina. Subsequent workup revealed a 1 cm vaginal cuff dehiscence which was later repaired with no postoperative complications.

Conclusion

Although the majority of patients with pneumoperitoneum require urgent exploratory laparoscopy, a careful diagnostic workup may reveal sources of free air that are not related to hollow viscous perforation. Vaginal cuff dehiscence represents a rare yet nonurgent source of pneumoperitoneum. This differential should be considered in light of the possible intra- and postoperative complications of surgery.

Comparison of the effects of Mitomycin-C and sodium hyaluronate/carboxymethylcellulose [NH/CMC] (Seprafilm) on abdominal adhesions

Introduction

Intra-abdominal adhesions (IA) may occur after abdominal surgery and also may lead to complications such as infertility, intestinal obstruction and chronic pain. The aim of this study was to compare the effects of Mitomycin-C (MM-C) and sodium hyaluronate/carboxymethylcellulose [NH/CMC] on abdominal adhesions in a cecal abrasion model and to investigate the toxicity of MM-C on complete blood count (CBC) and bone marrow analyses.

Methods

The study comprised forty rats in four groups (Control, Sham, Cecal abrasion + MM-C, and Cecal abrasion + NH/CMC). On postoperative day 21, all rats except for the control (CBC + femur resection) group, were sacrificed. Macroscopical and histopathological evaluations of abdominal adhesions were performed. In order to elucidate the side effects of MM-C; CBC analyses and femur resections were performed to examine bone marrow cellularity.

Results

CBC analyses and bone marrow cellularity assessment revealed no statistically significant differences between MM-C, NH/CMC and control groups. No significant differences in inflammation scores were observed between the groups. The MM-C group had significantly lower fibrosis scores compared to the NH/CMC and sham groups. Although the adhesion scores were lower in the MM-C group, the differences were not statistically significant.

Conclusion

Despite its potential for systemic toxicity, MM-C may show some anti-fibrosis and anti-adhesive effects. MM-C is a promising agent for the prevention of IAs, and as such, further trials are warranted to study efficacy.

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.

Pain and its effects on physical activity and quality of life before operation in patients undergoing elective inguinal and ventral hernia repair

BACKGROUND

Pain is the most common symptom associated with hernias. The aim was to assess the frequency of pain and its effects on physical activity and quality of life in patients with inguinal and ventral hernias.

METHODS

All patients undergoing elective inguinal or ventral hernia repair over a 16-month period were asked to complete a questionnaire including a 4-point Verbal Rating Scale, Visual Analog Scale, and Brief Pain Inventory (BPI) to assess pain severity and interference.

RESULTS

One hundred twenty-four patients (72 inguinal, 52 ventral) completed the questionnaire and 75% registered pain on the BPI. There was good correlation between scoring systems (correlation coefficient >.8). Ventral hernia patients had more pain (P = .037), interference with mood (P = .027), sleep (P = .004), relation with other people (P = .019), and enjoyment of life (P = .029) than their inguinal hernia counterparts.

CONCLUSIONS

The BPI is an easy and effective way of assessing pain and its impact on physical activity and quality of life in patients with an inguinal or ventral hernia with most experiencing mild to moderate chronic pain and disability.

Practical implications of postoperative adhesions for preoperative consent and operative technique

Adhesions complicate most intra-peritoneal operations. Once adhesions have formed, patients are at life-long risk for complications that include small bowel obstruction, increased risks during subsequent operations and female infertility. This has two implications for the daily work of surgeons. On the one hand, surgeons need to include the risks from adhesions during pre-operative consent. On the other hand, surgeons need to use operative techniques that minimize adhesions. Therefore this review focuses on the practical implications of adhesions for preoperative consent and operative technique.

The effect of postoperative hyperbaric oxygen treatment on intra-abdominal adhesions in rats

Abdominal adhesions, whether caused by peritoneal trauma, radiation, infection, or a congenital condition, are associated with a wide range of complications. These complications include chronic abdominal or pelvic pain, infertility, and adhesive small bowel obstruction. Such adhesions render re-operation difficult, with attendant risks of inadvertent enterostomy and increased operation time. The purpose of this study was to investigate the potential of hyperbaric oxygen (HBO) therapy in the prevention of abdominal adhesions in an experimental animal study. A laparotomy was performed on Wistar rats to induce the formation of adhesions on the cecum and the intra-abdominal area (1 × 2 cm). A superficial layer of the underlying muscle from the right abdominal wall was also shaved and prepared for aseptic surgery. The rats were divided into four groups according to the duration of HBO therapy; five additional groups were designated according to the conditions of HBO therapy. When the rats were evaluated according to adhesion area and grade, a statistically significant difference was observed between the control and HBO treatment groups (p < 0.005). Results from this study suggest that HBO treatment could reduce adhesion formation; and further suggest that HBO therapy may have therapeutic potential in the treatment of postoperative peritoneal adhesion.

Medical ozone therapy decreases postoperative uterine adhesion formation in rats

PURPOSE

Various studies have been performed to find out novel treatment strategies to prevent postoperative adhesion formation. Ozone therapy (OT) is shown to reduce inflammation in several pathological conditions. Therefore, we aimed to evaluate the efficacy of OT in a rat model of experimental uterine adhesion (EUA).

METHODS

Thirty female Wistar rats (200-250 g) were divided into three groups: sham, EUA and EUA+OT. EUA and EUA+OT groups were subjected to the postoperative adhesion procedure by bipolar coagulation on the uterine horns and corresponding pelvic sidewall parietal peritoneum. EUA+OT group received 0.7 mg/kg daily single dose for 3 days of ozone/oxygen mixture intraperitoneally after adhesion induction. All animals were killed on the 7th day and uterine adhesions were scored. Uterine tissues and peritoneal washing fluid were harvested for all analyses.

RESULTS

Uterine malondialdehyde levels in the EUA group were significantly higher compared to the other groups. However, in the EUA group, uterine superoxide dismutase and glutathione peroxidase activities were lower than in other groups. Peritoneal fluid TNF-α levels were found to be significantly different for all groups (p < 0.001). Macroscopic total adhesion score was significantly higher in the EUA group compared to the other groups (p < 0.001). But, total score in the EUA+OT group was lower than in the EUA group (p = 0.006).

CONCLUSIONS

Medical OT prevents postoperative uterine adhesions by modulating TNF-α levels and oxidative/antioxidative status in an experimental uterine adhesion model.

Intraperitoneal adhesions--an ongoing challenge between biomedical engineering and the life sciences

Peritoneal adhesions remain a relevant clinical problem despite the currently available prophylactic barrier materials. So far, the physical separation of traumatized serosa areas using barriers represents the most important clinical strategy for adhesion prevention. However, the optimal material has not yet been found. Further optimization or pharmacological functionalization of these barriers could give an innovative input for peritoneal adhesion prevention. Therefore, a more complete understanding of pathogenesis is required. On the basis of the pathophysiology of adhesion formation the main barriers currently in clinical practice as well as new innovations are discussed in the present review. Physiologically, mesothelial cells play a decisive role in providing a frictionless gliding surface on the serosa. Adhesion formation results from a cascade of events and is regulated by a variety of cellular and humoral factors. The main clinically applied strategy for adhesion prevention is based on the use of liquid or solid adhesion barriers to separate physically any denuded tissue. Both animal and human trials have not yet been able to identify the optimal barrier to prevent adhesion formation in a sustainable way. Therefore, further developments are required for effective prevention of postoperative adhesion formation. To reach this goal the combination of structural modification and pharmacological functionalization of barrier materials should be addressed. Achieving this aim requires the interaction between basic research, materials science and clinical expertise.