Preventing intraperitoneal adhesions with vitamin E and sodium hyaluronate/carboxymethylcellulose: a comparative study in rats

İntrabdominal Adezyon Oluşum Mekanizmalarına ve Tedavi Stratejilerine Histopatolojik Bakış

Hayat standartlarını olumsuz etkileyen abdominal adezyonlar, postoperatif dönemde görülen önemli bir sağlık sorunudur. Peritoneal kavite ve serozal yüzeylerde oluşan, abdominal travmalara sebep olan kimyasal ve termal faktörler ya da enfeksiyon ve yabancı cisim reaksiyonları adezyon oluşumuna sebep olabilir. Abdominal adezyonların sınıflandırması genellikle adezyon yoğunluğuna ve prognoz ciddiyetine göre yapılsa da henüz dünya çapında kabul görmüş standart bir sınıflandırma sistemi mevcut değildir. Abdominal adezyonlar ağrı, infertilite, cerrahi sonrası hastanede yatış süresinin uzaması ve ekonomik yük gibi olumsuz sonuçlarla klinik yansımalar gösterir. Sonuç olarak, postoperatif süreçte karşılaşılan adezyonlar ciddi bir sorundur ve adezyon oluşumunu engellemek için ileri çalışmaların laboratuvar ortamından klinik araştırma modellerine uyarlanması gerekmektedir. Bu derleme çalışması intraabdominal adezyon oluşumu, histopatolojisi, derecelendirilmesi, önlenmesi ve klinik önemi ile ilgili literatürü gözden geçirmek için hazırlanmıştır.

Efficacy of gelatin sponge in the prevention of post-surgical intra-abdominal adhesion in a rat model

Although different products have been developed to prevent post-surgical adhesion, their efficacy remains unsatisfactory. This study aimed to evaluate the efficacy of the gelatin sponge in the prevention of post-surgical intra-abdominal adhesions in a rat model. Rats were randomly divided into sham, adhesion, and gelatin groups. All rats, except the sham group, underwent cecal abrasion to establish an adhesion model. After celiotomy, a sterile gelatin sponge was applied intra-abdominal on the abraded cecum in the gelatin group. Rats were sacrificed on day 14 post-surgery and intra-abdominal adhesions were evaluated and scored. Adhesion tissues were evaluated by histological, histochemical, and immunohistochemical analysis. Intra-abdominal adhesions were recorded in all rats of the adhesion group. Intra-abdominal application of gelatin sponge significantly (P < 0.001) reduced intra-abdominal adhesions by 91% in the gelatin group relative to the adhesion group. The histological analysis revealed a marked decrease (P < 0.001) in the inflammatory score and neovascularization in the gelatin group. The histochemical analysis found that gelatin sponge administration reduced adhesion formation and thickness of adhesion tissue. Moreover, gelatin sponge significantly (P < 0.0001) increased MMP-9 expression and decreased macrophage marker expression in adhesive tissue. This study revealed that the application of gelatin sponge markedly reduced the post-surgical intra-abdominal adhesions and suggests new guidance for using gelatin sponge as an anti-adhesive substance in clinical practice.

Punica granatum seed oil detracts peritoneal adhesion: Perusing antioxidant, anti-inflammatory, antifibrotic, and antiangiogenic impacts

Peritoneal adhesion is a significant problem following gastrointestinal surgeries, accompanied by a significant economic burden and morbidity for patients. Punica granatum seed oil (PSO) possesses antioxidative, anti-inflammatory, and anticancer effects. Thus, we aimed to evaluate the antiperitoneal adhesive properties of PSO in rats. Forty-eight Wistar rats (200-250 g) were randomly and equally divided into six groups: sham group, control group; peritoneal adhesion without any treatment, vehicle group; peritoneal adhesion with saline + Tween-80.5% treatment, and experimental groups; peritoneal adhesion with 0.5%, 1.5%, and 4.5% v/v PSO treatment. In addition, peritoneal adhesion was examined macroscopically along with evaluating the oxidative stress (malondialdehyde [MDA], nitric oxide [NO], and glutathione [GSH]) inflammatory (interleukin [IL]-6, IL-1β, and tumor necrosis factor-α [TNF-α]), fibrotic (transforming growth factor-β [TGF-β]), and angiogenic (vascular endothelial growth factor [VEGF]) factors. Our results revealed that the levels of adhesion scores, MDA, NO, IL-6, TNF-α, IL-1β, TGF-β, and VEGF, were propagated in the vehicle group while the GSH level was alleviated (p < 0.001). In contrast, premedication with PSO, especially at the lowest concentration, notably lessened the levels of adhesion scores, MDA, NO, IL-6, TNF-α, IL-1β, TGF-β, and VEGF as well as GSH in comparison to the vehicle group following the peritoneal adhesion induction (p < 0.001-0.05). As a result, PSO may prevent peritoneal adhesion through its antioxidant, anti-inflammatory, antifibrotic, and antiangiogenic properties. Therefore, PSO could be considered a beneficial candidate for the treatment of postoperative peritoneal adhesion.

Vitamin E administration as preventive measures for peritoneal/intra-abdominal adhesions: A systematic review and meta-analysis

Background

Peritoneal adhesion still becoming a common complication after abdominal surgeries and become a significant threat to digestive surgeons nowadays. Vitamin E might offer benefits for preventing peritoneal adhesions because of its antioxidant, anti-inflammatory, and anti-fibroblastic properties. This study sought to analyze the relationship between vitamin E administration and peritoneal/intra-abdominal adhesions in rat models.

Methods

Potential articles were searched by using specific keywords on Scopus, PubMed, PMC, and Cochrane Library databases until March 12th, 2022. All published studies on vitamin E and peritoneal/abdominal adhesions in rat models were collected. Statistical analysis was performed by using Review Manager 5.4 software.

Results

A total of 9 studies were included in the final analysis. Pooled analysis of the evidences yielded an association between vitamin E and decreased incidence of substantial peritoneal/intra-abdominal adhesions (RR 0.46; 95%CI: 0.33–0.64, p < 0.00001, I² = 61%, random-effect modeling); and reduction in the mean grade of adhesions (Mean Difference −1.53; 95%CI: −2.00, −1.06, p < 0.00001, I² = 98%, random-effect modeling).

Conclusions

This study proposes that vitamin E supplementation might offer benefits in the prevention of peritoneal/intra-abdominal adhesions. More in-vivo studies with larger sample sizes and proper methods are still needed to confirm the results of our study. If possible, studies on humans might also be warranted.

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Peritoneal adhesion still become common problem after abdominal surgery.

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Our study indicates vitamin E can reduce incidence of peritoneal adhesions.

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Vitamin E can also reduce the mean grade of abdominal adhesions.

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

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

Dose- and time-dependent systemic adverse reactions of sodium carboxy methyl cellulose after intraperitoneal application in rats

Sodium carboxy methyl cellulose (SCMC) is an important absorbable biomaterial for anti-adhesion and hemostasis medical devices used in the abdominal cavity. However, the systemic toxicity of SCMC following intraperitoneal route has not been revealed sufficiently. Three SCMC solutions with gradient concentrations were intraperitoneally injected into 3 groups of rats with the doses of 50 mg/kg, 320 mg/kg and 2000 mg/kg respectively all at once to observe the dose-dependence of systemic reactions of SCMC and 10 rats (5 rats per sex) of each group were sacrificed 3 days, 7 days, 28 days and 90 days after injection to evaluate the time-dependence of the reactions. A range of adverse effects were shown in rats of the high-dose group which were found varied with time extending and virtually disappeared 90 days after injection. Slight reactions were observed in the medium-dose group while negligible effects were found in the low-dose group. The intraperitoneal application of SCMC can induce reversible systemic adverse effects to rats at the dose higher than 320 mg/kg and it is essential to take both dose- and time-dependent effects into account while designing a systemic toxicity study for absorbable biomaterials.

Battling adhesions: from understanding to prevention

Adhesions represent a major burden in clinical practice, particularly following abdominal, intrauterine, pericardial and tendon surgical procedures. Adhesions are initiated by a disruption in the epithelial or mesothelial layer of tissue, which leads to fibrin adhesion sites due to the downregulation of fibrinolytic activity and an increase in fibrin deposition. Hence, the metabolic events involved in tissue healing, coagulation, inflammation, fibrinolysis and angiogenesis play a pivotal role in adhesion formation. Understanding these events, their interactions and their influence on the development of post-surgical adhesion is crucial for the development of effective therapies to prevent them. Mechanical barriers, antiadhesive agents and combination thereof are customarily used in the battle against adhesions. Although these systems seem to be effective at reducing adhesions in clinical procedures, their prevention remains still elusive, imposing the need for new antiadhesive strategies.

Multi-functional electrospun antibacterial core-shell nanofibrous membranes for prolonged prevention of post-surgical tendon adhesion and inflammation

The possibility of endowing an electrospun anti-adhesive barrier membrane with multi-functionality, such as lubrication, prevention of fibroblast attachment and anti-infection and anti-inflammation properties, is highly desirable for the management of post-surgical tendon adhesion. To this end, we fabricated core-shell nanofibrous membranes (CSNMs) with embedded silver nanoparticles (Ag NPs) in the poly(ethylene glycol) (PEG)/poly(caprolactone) (PCL) shell and hyaluronic acid (HA)/ibuprofen in the core. HA imparted a lubrication effect for smooth tendon gliding and reduced fibroblast attachment, while Ag NPs and ibuprofen functioned as anti-infection and anti-inflammation agents, respectively. CSNMs with a PEG/PCL/Ag shell (PPA) and HA core containing 0% (H/PPA), 10% (HI10/PPA), 30% (HI30/PPA) and 50% (HI50/PPA) ibuprofen were fabricated through co-axial electrospinning and assessed through microscopic, spectroscopic, thermal, mechanical and drug release analyses. Considering nutrient passage through the barrier, the microporous CSNMs exerted the same barrier effect but drastically increased the mass transfer coefficients of bovine serum albumin compared with the commercial anti-adhesive membrane SurgiWrap®. Cell attachment/focal adhesion formation of fibroblasts revealed effective reduction of initial cell attachment on the CSNM surface with minimum cytotoxicity (except HI50/PPA). The anti-bacterial effect against both Gram-negative and Gram-positive bacteria was verified to be due to the Ag NPs in the membranes. In vivo studies using H/PPA and HI30/PPA CSNMs and SurgiWrap® in a rabbit flexor tendon rupture model demonstrated the improved efficacy of HI30/PPA CSNMs in reducing inflammation and tendon adhesion formation based on gross observation, histological analysis and functional assays. We conclude that HI30/PPA CSNMs can act as a multifunctional barrier membrane to prevent peritendinous adhesion after tendon surgery.

STATEMENT OF SIGNIFICANCE

A multi-functional anti-adhesion barrier membrane that could reduce fibroblasts attachment and penetration while simultaneously prevent post-surgical infection and inflammation is urgently needed. To this end, we prepared electrospun core-shell hyaluronic acid + ibuprofen/polyethylene glycol + polycaprolactone + Ag nanoparticles nanofibrous membranes by co-axial electrospinning as an ideal anti-adhesive membrane. The core-shell structure could meet the need of a desirable anti-adhesion barrier through release of ibuprofen and Ag nanoparticles to reduce infection and inflammation while hyaluronic acid can reduce fibroblasts adhesion. The superior performance of this multi-functional core-shell nanofibrous membrane in preventing peritendinous adhesion and post-surgical inflammation was demonstrated in a rabbit flexor tendon rupture model.

Dexamethasone and sodium carboxymethyl cellulose prevent postoperative intraperitoneal adhesions in rats

We aimed to evaluate the effects of the barrier agent sodium carboxymethyl cellulose (SCMC) with and without dexamethasone for the prevention of postoperative adhesion formation in a rat model of postoperative peritoneal adhesion. A total of 160 three-month old male and female Wistar rats underwent a laparotomy, and adhesions were induced by ileocecal abrasion. Rats were randomly assigned to 4 groups (n=40 each): group A, untreated; group B, treated with SCMC only; group C1, treated with SCMC + 3 mg dexamethasone, and group C2, treated with SCMC + 8 mg dexamethasone. After 12 days, adhesion formation and histopathological changes were compared. In groups A, B, C1, and C2, the mortality rates were 10, 5, 5, and 5%, respectively. In groups C1 and C2, the adhesions were filmy and easy to dissect and were milder compared with those in groups A and B. The total adhesion score in group C1 (3.38±0.49) was significantly lower than that of group B (6.01±0.57; P<0.01) or group A (8.01±0.67; P<0.05). There was no significant difference in adhesion formation between groups C1 and C2. Compared with groups A and B, groups C1 and C2 exhibited milder histopathological changes. SCMC in combination with dexamethasone can prevent adhesion formation and is a better barrier agent than SCMC alone. The safety and feasibility of SCMC in combination with dexamethasone to prevent adhesion formation after abdominal surgery warrants further clinical study.

Effect of Hypericum perforatum on intraperitoneal adhesion formation in rats

INTRODUCTION

The aim of this study was to evaluate the efficacy of Hypericum perforatum for prevention of adhesion formation in rats.

MATERIAL AND METHODS

Twenty-four female wistar rats underwent left uterine horn adhesion model. Rats were randomised into 4 groups. Group 1 (Control): Closure of abdominal incision without any agent administration. Group 2: Closure of incision after administration of intraperitoneal (i.p.) Ringer's lactate solution. Group 3: Closure of incision after administration of i.p. olive oil (diluent of H. perforatum). Group 4: Hypericum perforatum extract (Ecodab(®)) was administered i.p. before the closure of incision. Fourteen days later, relaparatomy was performed and surgical adhesion scores, inflammation and fibrosis scores were noted. Groups were compared according to these scores.

RESULTS

There was statistical significant difference between ringer's lactate group and olive oil group according to surgical adhesion score (p = 0.009). However, groups were not different according to inflammation and fibrosis scores (p > 0.05).

CONCLUSIONS

Despite antiinflammatory, antioxidants and antimicrobial properties of H. perforatum, our results revealed no positive effect of H. perforatum on the prevention of intraperitoneal adhesion formation.

Pathophysiology and prevention of postoperative peritoneal adhesions

Peritoneal adhesions represent an important clinical challenge in gastrointestinal surgery. Peritoneal adhesions are a consequence of peritoneal irritation by infection or surgical trauma, and may be considered as the pathological part of healing following any peritoneal injury, particularly due to abdominal surgery. The balance between fibrin deposition and degradation is critical in determining normal peritoneal healing or adhesion formation. Postoperative peritoneal adhesions are a major cause of morbidity resulting in multiple complications, many of which may manifest several years after the initial surgical procedure. In addition to acute small bowel obstruction, peritoneal adhesions may cause pelvic or abdominal pain, and infertility. In this paper, the authors reviewed the epidemiology, pathogenesis and various prevention strategies of adhesion formation, using Medline and PubMed search. Several preventive agents against postoperative peritoneal adhesions have been investigated. Their role aims in activating fibrinolysis, hampering coagulation, diminishing the inflammatory response, inhibiting collagen synthesis or creating a barrier between adjacent wound surfaces. Their results are encouraging but most of them are contradictory and achieved mostly in animal model. Until additional findings from future clinical researches, only a meticulous surgery can be recommended to reduce unnecessary morbidity and mortality rates from these untoward effects of surgery. In the current state of knowledge, pre-clinical or clinical studies are still necessary to evaluate the effectiveness of the several proposed prevention strategies of postoperative peritoneal adhesions.

The comparison of methylene blue and vitamin E in prevention of abdominal postoperative adhesion formation in rat uterine horn models: Biochemical and histopathologic evaluation

PURPOSE

To compare the effects of vitamin E and 1% methylen blue solutions on prevention of experimentally induced adhesions in rats.

METHODS

Thirty seven female Spraque Dawley rats were randomized into four groups. First group was kept as sham operated group. An adhesion model was constituted on the left uterine horn of the other groups. The lesion areas of rats from the second, the third and the fourth groups were coated with 2 ml 0.9 % saline solution (C group), 10 mg vitamin E (VE group) and 1% methylen blue solutions (MB group), respectively.

RESULTS

Histopathologically, adhesion scores, mononuclear cell infiltration, oedema and fibrosis were more prominent in the MB group compared with C and VE groups. There were no significant differences between the groups in tissue glutathione peroxidase (GPx), catalase (CAT) activities and glutation (GSH) level, these parameters were slightly increased in group with VE supplementation though. The administration of VE and MB significantly decreased NO (P<0.01) levels when compared to the C group. The level of malondialdehyde (MDA) in the VE group was significantly lower (P<0.05) than those of the Sh and C groups.

CONCLUSION

Intraperitoneal methylen blue solutions treatments were more effective according to vitamin E in preventing the formation of intra-abdominal adhesion in a rat uterine horn model.

Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model

OBJECTIVE

Peritoneal adhesions are almost ubiquitous following surgery. Peritoneal adhesions can lead to bowel obstruction, digestive problems, infertility, and pain, resulting in many hospital readmissions. Many approaches have been used to prevent or treat adhesions, but none offer reliable results. A method that consistently prevented or treated adhesions would benefit many patients. We hypothesized that an anatomically-based visceral mobilization, designed to promote normal mobility of the abdominal contents, could manually lyse and prevent surgically-induced adhesions.

MATERIAL AND METHODS

Cecal and abdominal wall abrasion was used to induce adhesions in 3 groups of 10 rats (Control, Lysis, and Preventive). All rats were evaluated 7 days following surgery. On postoperative day 7, unsedated rats in the Lysis group were treated using visceral mobilization, consisting of digital palpation, efforts to manually lyse restrictions, and mobilization of their abdominal walls and viscera. This was followed by immediate post-mortem adhesion evaluation. The rats in the Preventive group were treated daily in a similar fashion, starting the day after surgery. Adhesions in the Control rats were evaluated 7 days after surgery without any visceral mobilization.

RESULTS

The therapist could palpate adhesions between the cecum and other viscera or the abdominal wall. Adhesion severity and number of adhesions were significantly lower in the Preventive group compared to other groups. In the Lysis and Preventive groups there were clear signs of disrupted adhesions.

CONCLUSIONS

These initial observations support visceral mobilization may have a role in the prevention and treatment of post-operative adhesions.

Efficacy of vitamin E and selenium for the prevention of intra-abdominal adhesions in rats: uterine horn models

OBJECTIVE

This study compares the efficacies of vitamin E and selenium, both individually and in combination, for the prevention of postoperative intra-abdominal adhesions in rats.

METHODS

Forty-seven female rats were divided into five groups. The sham animals (S group, n = 7) were given only laparotomies and intraperitoneally received 0.9% NaCl (2 ml). In the 40 other rats, abrasions of the left uterine horn were performed, followed by intraperitoneal administration of either 2 ml 0.9% NaCl (C group), 10 mg vitamin E (vitamin E group), 0.2 mg/kg selenium (Se group) or 10 mg vitamin E with 0.2 mg/kg selenium (vitamin E + Se group), with 10 animals in each treatment group.

RESULTS

Adhesion formation was significantly reduced in animals in the Se and vitamin E + Se groups (p<0.05). Tissue catalase and glutathione peroxidase activities did not significantly differ between the groups. However, catalase and glutathione peroxidase activities and reduced glutathione levels were slightly increased in the vitamin E, Se and vitamin E + Se groups. In the vitamin E group, malondialdehyde concentrations were significantly lower than in the C group (p<0.05), but no significant differences were present among the S, C, Se and vitamin E + Se groups. Levels of nitric oxide were significantly higher in the C group than in the other groups (p<0.01).

CONCLUSION

Intraperitoneal administration of selenium or combined vitamin E and selenium appears to be effective in preventing intra-abdominal adhesion formation in rat models through the reduction of lipid peroxidation products.

Prevention of peritoneal adhesions by intraperitoneal administration of vitamin E and human amniotic membrane

BACKGROUND

Our objective was to evaluate the comparative effectiveness of intraperitoneally administered vitamin E and human amniotic membrane in preventing postoperative intraperitoneal adhesion formation.

MATERIAL AND METHODS

75 Wistar-albino rats were separated into 5 groups: Group 1 (control), Group 2 (intraperitoneal olive oil, the diluent of vitamin E), Group 3 (Intraperitoneal vitamin E diluted in olive oil), Group 4 (Amniotic membrane group) and Group 5 (Amniotic membrane and Intraperitoneal vitamin E diluted in olive oil). The same experimental method, consisting of cecal abrasion and ligature of the adjacent parietal peritoneum, was used in all rats to produce adhesions. Relaparotomy was performed on the 15th postoperative day. intra-abdominal adhesions were scored according to macromorphological characteristics and adhesion-carrying tissues underwent standard histologic examination. Inflammation, vascularization and fibrosis in granulation sites were graded in all samples. The results were analyzed using a Mann-Whitney-U test.

RESULTS

In terms of inflammation, neovascularization and fibrosis scores obtained by histology and macromorphologic adhesion scores. There were no significant differences between Groups 1 and 2 (p=0.176). The results of Groups 3, 4 and 5 showed a significant difference when compared with both Group 1 and 2 (p=0.001). The difference between Groups 3, 4 and 5 were not significant with respect to these 4 parameters.

CONCLUSION

Intraperitoneal vitamin E and amniotic membrane treatment were both effective in the prevention of peritoneal adhesions. The combination of these agents did not produce a synergistic effect. Easy applicability of the intraperitoneal administration of vitamin E was its major advantage.

Reduction of postsurgical adhesions in a rat model: a comparative study

BACKGROUND

Adhesion formation after peritoneal surgery is a major cause of postoperative bowel obstruction, infertility, and chronic pelvic pain. In this study, we compared the possible individual effects of phosphatidylcholine (PC), Seprafilm II, and tissue plasminogen activator (t-PA) and the combined effects of phosphatidylcholine and t-PA on postoperative adhesion formation in a rat surgical model.

MATERIALS AND METHODS

A total of 50 Wistar male rats underwent median laparotomy and standardized abrasion of the visceral and parietal peritoneum. phosphatidylcholine, Seprafilm II, and t-PA alone and phosphatidylcholine and t-PA in combination were applied intraperitoneally at the end of the surgical procedure. Seven days after surgery, a relaparotomy was performed for adhesion grading and histopathological examination.

RESULTS

A comparison of adhesion stages demonstrated a significant difference between the control group and the study groups (p<0.001). The adhesion grade of the combined treatment group was statistically different from that of the other groups (p<0.05). In the t-PA group and the combined group, six and two rats, respectively, developed hematomas locally on the cecum.

CONCLUSIONS

PC, t-PA, and Seprafilm II used individually reduced the adhesion grade. The t-PA and phosphatidylcholine combination was most effective in reducing adhesion formation. On the other hand, usage of t-PA alone or in combination may increase risk of bleeding. More detailed studies are needed, and future studies on the efficacy of a material for decreasing adhesion formation should include a comparison of several control materials in the same model.