Effect of previous abdominal surgery on robotic-assisted rectal cancer surgery

BACKGROUND

The effect of previous abdominal surgery (PAS) in laparoscopic surgery is well known and significantly adds to longer hospital length of stay (LOS), postoperative ileus, and inadvertent enterotomies. However, little evidence exists in patients with PAS undergoing robotic-assisted (RA) rectal surgery.

METHODS

All patients undergoing RA surgery for rectal cancer were reviewed. Patients with PAS were divided into minor and major PAS groups, defined as surgery involving >1 quadrant. The primary outcome was the risk of conversion to open surgery.

RESULTS

A total of 750 patients were included, 531 in the no-PAS (NPAS) group, 31 in the major PAS group, and 188 in the minor PAS group. Patients in the major PAS group had significantly longer hospital LOS (P < .001) and lower adherence to enhanced recovery pathways (ERPs; P = .004). The conversion rates to open surgery were similar: 3.4% in the NPAS group, 5.9% in the minor PAS group, and 9.7% in the major PAS group (P = .113). Estimated blood loss (EBL; P = .961), operative times (OTs; P = .062), complication rates (P = .162), 30-day readmission (P = .691), and 30-day mortality (P = .494) were similar. Of note, 53 patients underwent lysis of adhesions (LOA). On multivariate analysis, EBL >500 mL and LOA significantly influenced conversion to open surgery. EBL >500 mL, age >65 years, conversion to open surgery, and prolonged OT were risk factors for prolonged LOS, whereas adherence to ERPs was a protector.

CONCLUSION

PAS did not seem to affect the outcomes in RA rectal surgery. Given this finding, the robotic approach may ultimately provide patients with PAS with similar risk to patients without PAS.

Laparoscopic adhesiolysis versus open adhesiolysis in acute adhesive small bowel obstruction

Introduction

Exploratory laparotomy is still the standard therapy for patients who need surgical intervention for adhesive small bowel obstruction (SBO). However, the use of laparoscopy in the management of adhesive SBO is still controversial. We aimed to detect the short-term outcomes between open and laparoscopic adhesiolysis for SBO.

Patients and Methods

This is a retrospective study of patients with adhesive SBO who underwent either laparoscopic or open surgery from June 2019 to July 2022 at Ain Shams University Hospitals. Intraoperative and early post-operative outcomes were compared in the two groups.

Results

A total of 89 patients with adhesive SBO were included in our study. Fifty-one cases underwent open adhesiolysis and 38 cases underwent laparoscopic adhesiolysis. Laparoscopic adhesiolysis is associated with a remarkable decrease in the operative time (71 min vs. 107 min, P = 0.001) and blood loss (50 ml vs. 120 ml, P = 0.001) in comparison to open adhesiolysis. In addition to that, those who underwent adhesiolysis by laparoscopy had a short hospital stay (2.4 days vs. 3.8 days, P = 0.001), early recovery (time to pass flatus 1.3 days vs. 2.8 days) and less post-operative complications (surgical site infection [SSI] 2.6% vs. 19.6%, P = 0.001). Moreover, open adhesiolysis is associated with a higher rate of early post-operative mortality. In addition to that, the incidence of iatrogenic injury was higher in the open group.

Conclusion

Laparoscopic adhesiolysis is a safe and feasible approach for the management of SBO and has better short-term outcomes, especially if done by skilled surgeons in advanced laparoscopic techniques.

Idiopathic Sclerosing Encapsulating Peritonitis - Preoperative diagnostic challenges: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Idiopathic Sclerosing Encapsulating Peritonitis (ISEP) is an uncommon condition of intestinal bowel obstruction due to encapsulation of the abdominal organs in a thick fibro-collagenous membrane. The case presented here describes the emergency acute presentation of septic peritonitis discovered intraoperatively upon laparotomy.

CASE PRESENTATION

A middle-aged woman was admitted to the emergency department and presented with generalized colicky abdominal pain associated with repetitive vomiting, abdominal distention, and absolute constipation. A digital rectal examination revealed an empty rectum and a bilious output was observed in the nasogastric tube. Abdominal X-Ray demonstrated multiple air-fluid levels with no air under the diaphragm. The patient was treated with fluid therapy and antibiotics intravenously (IV).

CLINICAL DISCUSSION

The clinical impression of acute-on-chronic intestinal obstruction with peritonitis and the possibility of bowel strangulation was made. Emergency exploratory laparotomy revealed viable bowel loops encased in thickened fibrous capsules covering the entire abdominal viscera establishing the existence of ISEP. The fibrous capsule layer was excised out in small pieces from all the abdominal organs excluding stomach through extensive adhesiolysis without loop resection.

CONCLUSION

The emergency presentation of acute peritonitis observed in this study could only be identified through diagnostic laparoscopy and differential radiological imaging techniques. Further, better reporting of such rare cases may help clinicians understand the different clinical features that could indicate the occurrence of ISEP.

A feasible and safe approach for repeat laparoscopic liver resection and patient selection based on standardized preoperative prediction of surgical difficulty

PURPOSE

This study was performed to propose a strategy for repeat laparoscopic liver resection (RLLR) and investigate the preoperative predictive factors for RLLR difficulty.

METHODS

Data from 43 patients who underwent RLLR using various techniques at 2 participating hospitals from April 2020 to March 2022 were retrospectively reviewed. Surgical outcomes, short-term outcomes, and feasibility and safety of the proposed techniques were evaluated. The relationship between potential predictive factors for difficult RLLR and perioperative outcomes was evaluated. Difficulties associated with RLLR were analyzed separately in two surgical phases: the Pringle maneuver phase and the liver parenchymal transection phase.

RESULTS

The open conversion rate was 7%. The median surgical time and intraoperative blood loss were 235 min and 200 mL, respectively. The Pringle maneuver was successfully performed in 81% of patients using the laparoscopic Satinsky vascular clamp (LSVC). Clavien-Dindo class ≥III postoperative complications were observed in 12% of patients without mortality. An analysis of the risk factors for predicting difficult RLLR showed that a history of open liver resection was an independent risk factor for difficulty in the Pringle maneuver phase.

CONCLUSION

We present a feasible and safe approach to address RLLR difficulty, especially difficulty with the Pringle maneuver using an LSVC, which is extremely useful in RLLR. The Pringle maneuver is more challenging in patients with a history of open liver resection.

Complete resolution of syrinx after circumferential adhesiolysis without deformity correction in a case of 6 year old neglected cervical facet dislocation

Neglected traumatic cervical dislocation can be difficult to treat as such and more so if they are accompanied by an associated post traumatic syringomyelia (PTS). We present the case of a 55 year old gentleman who had a traumatic C6-C7 grade 2 listhesis which was neglected and presented 6 year later with 6 months history of neck pain, spastic quadriparesis and bowel bladder involvement. The patient was diagnosed with a PTS extending from C4 to D5. The possible aetiology and management of such cases has been discussed. The patient was successfully treated with decompression, adhesiolysis of arachnoid bands and syringotomy without the correction of deformity. The patient improved neurologically and had complete resolution of syrinx at final followup.

Elective adhesiolysis for chronic abdominal pain reduces long-term risk of adhesive small bowel obstruction

BACKGROUND

Selected patients with adhesion-related chronic abdominal pain can be treated effectively by adhesiolysis with the application of adhesion barriers. These patients might also have an increased risk to develop adhesive small bowel obstruction (ASBO). It is unknown how frequently these patients develop ASBO, and how elective adhesiolysis for pain impacts the risk of ASBO.

METHODS

Patients with adhesion-related chronic pain were included in this cohort study with long-term follow-up. The diagnosis of adhesions was confirmed using CineMRI. The decision for operative treatment of adhesions was made by shared agreement based on the correlation of complaints with CineMRI findings. The primary outcome was the 5-years incidence of readmission for ASBO. Incidence was compared between patients with elective adhesiolysis and those treated non-operatively and between patients with and without previous ASBO. Univariable and multivariable Cox regression analysis was performed to identify predictive factors for ASBO. Secondary outcomes included reoperation for ASBO and self-reported pain and other abdominal symptoms.

RESULTS

A total of 122 patients were included, 69 patients underwent elective adhesiolysis. Thirty patients in both groups had previous episodes of ASBO in history. During 5-year follow-up, the readmission rate for ASBO was 6.5% after elective adhesiolysis compared to 26.9% after non-operative treatment (p = 0.012). These percentages were 13.3% compared to 40% in the subgroup of patients with previous episodes of ASBO (p = 0.039). In multivariable analysis, elective adhesiolysis was associated with a decreased risk of readmission for ASBO with an odds ratio of 0.21 (95% CI 0.07-0.65), the risk was increased in patients with previous episodes with a odds ratio of 19.2 (95% CI 2.5-144.4). There was no difference between the groups in the prevalence of self-reported abdominal pain. However, in surgically treated patients the impact of pain on daily activities was lower, and the incidence of other symptoms was lower.

CONCLUSION

More than one in four patients with chronic adhesion-related pain develop episodes of ASBO when treated non-operatively. Elective adhesiolysis reduces the incidence of ASBO in patients with chronic adhesion-related symptoms, both in patients with and without previous episodes of ASBO in history. Trial registration The study was registered at Clinicaltrials.gov under NCT01236625.

Disturbed passage of jejunal limb near esophageal hiatus after overlapped esophagojejunostomy following laparoscopic total gastrectomy

BACKGROUND

Overlapped esophagojejunostomy (OEJ) is a secure purely laparoscopic reconstruction after laparoscopic total gastrectomy (LTG). However, long-term surgical results have not been documented well.

AIM

In this paper, we report unusual patients who manifested jejunal limb stricture near the esophageal hiatus without anastomotic stenosis during long-term observation after surgery.

METHODS

From April 2009 until May 2020, we retrospectively reviewed 211 patients underwent LTG following by OEJ for gastric carcinoma and took a standard surveillance program. We aimed to characterize a novel complicated disorder observed in these patients to assist treatment and prevention.

RESULTS

Five patients (2.4%) had unusual jejunal limb stricture after LTG and OEJ, occurring at a mean of 10 mo after initial radical LTG. All five patients had disturbed oral intake and marked weight loss, and two had aspiration pneumonia. Various diagnostic modalities and intraoperative findings in each patient revealed an intact anastomosis, bent or tortuous jejunal limb resulting from loose fibrous adhesions on the left crus at the esophageal hiatus and no cancer recurrence. All five patients were successfully treated by reoperation for adhesiolysis, division of the left crus and rearrangement of the jejunal limb.

CONCLUSION

Disturbed passage through the jejunal limb near the hiatus can occur after some types of OEJ following LTG. We speculate that it may result from a short remnant esophagus, excessive mobilization of the jejunal limb that permits bending or tortuosity and adhesions on the left crus at the hiatus. Prevention for this complication is possible during the original LTG procedure.

Effect of Previous Caudal Block to Predict Successful Outcome after Adhesiolysis using a Steerable Catheter in Lumbar Failed Back Surgery Syndrome: A Retrospective Study

Adhesiolysis is minimally invasive and commonly used for pain associated with adhesion after lumbar spine surgery. Caudal epidural block may be used for radiating pain due to failed back surgery syndrome. We evaluated the predictive value of response to caudal block performed prior to adhesiolysis in failed back surgery syndrome. Between January 1, 2013 and June 30, 2020, 150 patients with failed back surgery syndrome were treated with adhesiolysis using a steerable catheter at the pain clinic of a tertiary hospital after failed conservative treatment (including caudal block). Patient demographics, pain duration, and lumbar magnetic resonance imaging findings were examined. Response to previous caudal block was determined as a binary result (yes or no). Patients were followed up 3 months after adhesiolysis. Successful outcome was defined as a ≥2-point reduction in the numeric rating scale scores for radicular pain 3 months after adhesiolysis, evident in 81/150 (46%) patients. Multivariable logistic regression analysis revealed that caudal block response was an independent predictor of successful adhesiolysis (odds ratio = 4.403; p = 0.015). Response to prior caudal block is a positive predictor of successful adhesiolysis.

Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report

BACKGROUND

Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.

CASE SUMMARY

A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.

CONCLUSION

We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.

Prophylactic procedures associated with gynecological surgery for the management of superficial endometriosis and adhesions. Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF)✰

OBJECTIVE

To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best currently available evidence, for the prophylactic procedures associated with gynecological surgery for benign disease such as superficial endometriosis lesions and adhesions.

METHODS

The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade that reflects the quality of evidence (QE) (clinical practice guidelines).

RESULTS

Endometriosis and pelvic pain Superficial endometriosis can be entirely asymptomatic. Surgical treatment of asymptomatic superficial peritoneal endometriosis is not recommended in women of childbearing age for the prevention of pelvic pain, especially in case of proximity to noble organs (e.g., the ureters, rectum and sigmoid, and ovaries in nulligravida) as there is no evidence that the disease will progress to become symptomatic (low level of evidence). In case of accidental discovery of superficial endometriosis in women of childbearing age with pelvic pain, it is recommended that the lesions are excised, if surgically accessible. Removal of superficial endometriosis lesions in patients with painful symptoms improves quality of life and pain (low level of evidence). Endometriosis and infertility It appears that women with isolated superficial endometriosis diagnosed by laparoscopy with histological confirmation have a significantly higher incidence of primary infertility than patients without endometriosis. However, there is no data regarding the impact of treatment of these lesions on the fertility in these women or on the natural course of their disease (low level of evidence). It is recommended that excision is performed rather than monopolar coagulation of superficial endometriosis lesions in infertile women, as this results in a higher spontaneous pregnancy rate (low level of evidence). Adhesions and pelvic pain There is limited data in the literature regarding the benefit of performing systematic adhesiolysis during laparoscopy to prevent pelvic pain when incidental pelvic adhesions are discovered. For patients with pelvic pain, it is probably better not to perform adhesiolysis to prevent pelvic pain, although this can be decided on a case-by-case basis depending on the extent of the adhesions, the topography, and the type of surgery considered (low level of evidence). For asymptomatic patients, it is recommended not to perform adhesiolysis to prevent pelvic pain due to the lack of clear efficacy both short- or long-term and due to the increased risk of surgical injuries (low level of evidence). Adhesions and infertility There is limited data in the literature regarding the potential benefit of performing systematic adhesiolysis when there is an incidental discovery of pelvic adhesions during laparoscopy to prevent infertility. For infertile women, in the event of fortuitous discovery of adhesions at laparoscopy, it is probably better not to perform complex adhesiolysis. Only adhesiolysis of tubo-ovarian adhesions that are minimal or slight in terms of their extension and/or their nature may be useful to improve the chances of spontaneous pregnancy. However, it remains to be decided on a case-by-case basis depending on other potential causes of infertility (low level of evidence). For women without known infertility issues, it is probably better not to perform systematic adhesiolysis in order to improve their pregnancy chances, considering the balance between the unknown benefit and the risks of complications inherent to surgery (low level of evidence).

CONCLUSION

Further investigations are needed in order to increase the quality of management regarding associated interventions such as the treatment of superficial endometriosis or adhesions performed during a gynecologic surgical procedure and, thereby, bolster these recommendations.

Changed inflammatory markers after application of 4DryField PH for adhesion prevention in gynecological surgery

Introduction

The development of peritoneal adhesions and the effects of different antiadhesion agents on such mechanisms are not fully understood. Temporary rises of the C-reactive protein (CRP) level have been reported after antiadhesion agent application. We present the changes of inflammation markers observed after use of a starch-based polysaccharide certified for adhesion prevention and hemostasis 4DF (4DryField^® PH).

Method

Retrospective comparative analysis of inflammation markers in 40 patients undergoing laparoscopic adhesiolysis with or without adhesion prophylaxis was conducted. Statistical comparisons were performed by means of paired or unpaired t tests (for normally distributed continuous data), Wilcoxon matched pairs signed-rank tests or Mann–Whitney tests (for not-normally distributed continuous data), Mantel–Cox tests (for continuous data describing time intervals), and Fisher’s exact tests (for discrete data).

Results

The maximum post-operative CRP level was significantly elevated in the 4DF group (87 vs. 29%; p < 0.001), whereas leukocyte concentration and body temperature did not differ between groups. No signs of infection were detected in any of the patients and CRP levels spontaneously dropped to normal values within few days. No side effects or complications were observed in both groups. In second-look surgeries performed for other diagnoses 1–56 weeks after the first interventions, no remnants of 4DF or any peritoneal inflammatory reactions were observed.

Conclusion

The starch-based polysaccharide 4DF can be considered safe and does not induce inflammatory reactions of clinical significance. Further studies regarding 4DF degradation are recommended and, apart from macrophage migration, could also examine corresponding markers such as IL-6 and PCT.

Incidental finding of jejunal diverticula during laparotomy for suspected adhesive small bowel obstruction: A case report

INTRODUCTION AND IMPORTANCE

Jejunal diverticula are usually asymptomatic and are discovered incidentally. While rare, their complications may be life-threatening. They should be considered as differential diagnoses in undiagnosed complaints of chronic abdominal pain, malabsorption, anemia, gastrointestinal bleed and intestinal obstruction.

CASE PRESENTATION

A 66-year lady, known hypertensive and hypothyroidism with history of hysterectomy presented with symptoms suggestive of small bowel obstruction. Intraoperatively adhesions between loops of the small intestine, multiple diverticula with two of them impending perforation were found. Resection of 10 cm of jejunum containing diverticula with end-to-end anastomosis was performed. She had uneventful recovery and on 2 months of follow-up she was doing well.

CLINICAL DISCUSSION

Although diverticula can be found anywhere along the gastrointestinal tract, jejunal diverticula are rare. Most patients are asymptomatic, symptoms if present is non-specific that delay diagnosis causing patients to land up with complications. They are diagnosed incidentally on endoscopy or imaging rather than through clinical suspicion. Asymptomatic cases do not mandate treatment while symptomatic cases can be managed conservatively with surgery being reserved for those with complications.

CONCLUSION

Small bowel obstruction due to jejunal diverticula is a rare entity, a diagnosis of which can be confirmed only intra-operatively. So it must be borne as a differential in small bowel obstruction. Timely diagnosis and management will prevent life-threatening complications of it.

The impact of laparoscopy on emergency surgery for adhesional small bowel obstruction: prospective single centre cohort study

INTRODUCTION

Laparoscopic adhesiolysis is increasingly being used to treat adhesional small bowel obstruction (ASBO) as it has been associated with reduced postoperative length of stay (LOS) and faster recovery. However, concerns regarding limited working space, iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre's experience of adopting laparoscopy as the standard operative approach.

METHODS

A single-centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; January 2015 to December 2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and inhospital outcomes data were compared between different surgical approaches. Linear regression analysis was performed for LOS.

RESULTS

A total of 299 cases were identified. Overall, 76.3% of cases were started laparoscopically and 52.2% were completed successfully. Patients treated laparoscopically had lower Portsmouth - Physiological and Operative Severity Score for the enuMeration of Mortality and morbidity (P-POSSUM) predicted mortality (median 2.1 (interquartile range (IQR) 1.3-5.0) vs 5.7 (IQR 2.0-12.4), p=<0.001) and shorter postoperative LOS compared with open (median 4.2 days (IQR 2.5-8.2) vs 11.3 days (IQR 7.3-16.6), p=0.000). Inhospital mortality was lower in the laparoscopic group (2 vs 7 deaths, p=<0.001). In regression analysis, laparoscopic surgery was found to have the strongest association with postoperative LOS (β -8.51 (-13.87 to -3.16) p=0.002) compared with open surgery.

CONCLUSIONS

Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is associated with reduced LOS with no impact on complications or mortality.

Operative findings and outcome of microvascular decompression/adhesiolysis for trigeminal neuralgia in multiple sclerosis without demyelinating brain stem lesions

OBJECTIVE

Trigeminal neuralgia (TN) in multiple sclerosis (MS) poses several challenges for treatment. Although these patients often have typical attacks, they may not be considered as candidates for microvascular decompression (MVD). Here we report on surgical findings and long term follow-up of MVD/ adhesiolysis in a series of patients with multiple sclerosis but without demyelinating brain stem lesions.

METHODS

Fifteen patients with MS-related TN underwent MVD/ adhesiolysis. Demyelinating brain stem lesions were excluded radiologically. Outcome of the intervention was assessed according to the Barrow Neurological Institute (BNI) pain intensity score at 3, 12, 24 months follow-up and at the last available follow-up (mean 88.2 months, range 38-146).

RESULTS

All 15 patients benefited from MVD/adhesiolysis and were pain free on the first day of surgery. Intraoperative findings included arterial contact in 7/15 (47 %) patients, venous contact in 9/15 (60 %), and prominent arachnoid thickening in 12/15 (80 %). The distribution of the BNI pain intensity scores showed marked improvement at all follow-up evaluations. Five patients underwent repeat MVD/adhesiolysis for pain recurrence at a mean of 43 months after the first surgery. Long term evaluation at the last available follow-up demonstrated favorable outcome in 13/15 patients (BNI I-IIIa) (87 %), while 2/15 patients had limited benefit (BNI IV).

CONCLUSIONS

MS-related TN in patients without demyelinating brain stem lesions may be related either to vascular conflicts or to focal arachnoiditis at the trigeminal nerve entry zone. MVD/ adhesiolysis may be considered as a useful treatment option in this subgroup of patients with regard to long term outcome.

Small bowel obstruction after laparoscopic gastrectomy: An atypical clinical presentation. Report of a case

INTRODUCTION

Postoperative adhesions represent the most common cause of acute small bowel obstruction (80%) and are usually a consequence of abdomino-pelvic surgery performed with open technique.

PRESENTATION OF CASE

A 45-year-old black man arrived at the emergency room with abdominal pain and distension three months after laparoscopic distal gastrectomy with Roux-en-Y anastomosis performed for benign pyloric stenosis. CT abdominal scan revealed some air-fluid levels in the center of the abdomen with distension of proximal jejunal loops caused by intestinal adhesions. Laparoscopic adhesiolysis was performed to restore the intestinal transit.

DISCUSSION

The formation of adhesions is more frequent after abdomino-pelvic surgery. CT abdominal scan is very useful tool to identify the level and the aetiology of obstruction and it may predict the need for surgery, the location of different adhesive bands in order to identify wich patients are likely candidates for laparoscopic treatment.

CONCLUSION

In selected cases, laparoscopic approach for small bowel obstruction is a good surgical option. In patients with adbominal dense adhesions or clinical signs of intestinal ischemia, conversion to laparotomy should be considered an alternative.

Experience with Hysteroscopy in a Private Specialist Hospital in Nigeria

Background

Hysteroscopy is a standard method for the evaluation and treatment of various gynecological disorders. Its availability and accessibility are limited in our setting owing to resource constraints. Nevertheless, the utilization is on the increase mostly in private health institutions in Nigeria and as an adjunct in infertility management.

Objectives

The objective is to document the experience and outcome of hysteroscopy surgeries at a private specialist-assisted reproduction and endoscopy unit.

Materials and Methods

A retrospective review of all hysteroscopic procedures conducted at the unit was undertaken. Relevant sociodemographic and clinical information were extracted for analysis. In addition, outcomes of the procedure and outcome for those who eventually had in vitro fertilization (IVF) treatment were documented for analysis.

Results

A total of 106 patients had hysteroscopy over the study period. The age of patients ranged from 24 to 55 years. The most common indication for hysteroscopy was uterine synechiae (50%) others were preparatory for IVF (30.2%), uterine fibroid/polyp (10.4%), and abnormal uterine bleeding (9.4%), respectively. The major findings at hysteroscopy were intrauterine adhesions 68.9%. Therapeutic adhesiolysis was done using the scissors in most cases (83%) while two patients (1.9%) had adhesiolysis and resection of uterine polyp. A complication of noncardiogenic pulmonary edema was recorded from fluid overload. Overall most had return to normal menses (65.1%). Thirty-nine (38.8%) women had IVF treatment after hysteroscopy of which outcome was successful in 16 (41%) women.

Conclusion

The utilization of hysteroscopic surgeries in management of endometrial pathologies is increasing. It offers a safe and effective treatment and is a useful adjunct for improving IVF outcome especially for those with repeated failed treatment.

Is Percutaneous Adhesiolysis Effective in Managing Chronic Low Back and Lower Extremity Pain in Post-surgery Syndrome: a Systematic Review and Meta-analysis

PURPOSE OF REVIEW

The growing prevalence of spinal pain in the USA continues to produce substantial economic impact and strain on health-related quality of life. Percutaneous adhesiolysis is utilized for recalcitrant, resistant conditions involving spinal pain when epidural injections have failed to provide adequate improvement, especially low back and lower extremity pain, specifically in post-lumbar surgery syndrome. Despite multiple publications and systematic reviews, the debate continues in reference to effectiveness, safety, appropriate utilization, and medical necessity of percutaneous adhesiolysis in chronic pain. This systematic review, therefore, was undertaken to evaluate and to update effectiveness of percutaneous adhesiolysis to treat chronic refractory low back and lower extremity pain, post-surgical patients of the lumbar spine.

RECENT FINDINGS

From 2009 to 2016, there was a decline of 53.2% utilization of percutaneous adhesiolysis with an annual decline of 10.3% per 100,000 fee-for-service (FFS) Medicare population. Multiple insurers, including Medicare, with Medicare area contractors of Noridian and Palmetto have issued noncoverage policies for percutaneous adhesiolysis resulting in these steep declines and continued noncoverage by Medicare Advantage plans, Managed Care plans of Medicaid, and other insurers. Since 2005, 4 systematic reviews of percutaneous adhesiolysis were published with 3 of them showing proper methodology and appropriate results with effectiveness of adhesiolysis, whereas one poorly performed systematic review showed negative results. In addition, there were only 4 randomized controlled trials (RCTs) to be included in the previous systematic reviews of post-surgery syndrome, whereas now, the RCTs and other studies have increased. This systematic review shows level I or strong evidence for the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain related to post-lumbar surgery syndrome.

A Randomized, Multicenter, Double-Blind, Parallel Pilot Study Assessing the Effect of Mechanical Adhesiolysis vs Adhesiolysis with Corticosteroid and Hyaluronidase Administration into the Epidural Space During Epiduroscopy

OBJECTIVE

Epiduroscopy is a proven method of diagnosis and treatment for chronic radicular pain after spinal surgery, which is known as failed back surgery syndrome (FBSS). The aim of the study was to compare the efficacy of drugs (the enzyme hyaluronidase and corticosteroid DEPO-Medrol) administrated into the epidural space during epiduroscopy, performed within the ventral and ventro-lateral epidural space with a focus on releasing foraminal adhesions.

METHODS

Forty-eight patients with diagnosed FBBS were randomized into two groups before epiduroscopy. Group A received the standard treatment-mechanical lysis of fibrotic tissue in the epidural space. Group B received hyaluronidase and corticosteroid methylprednisolone acetate during the procedure. Subjects were followed for six and 12 months via scheduled double-blinded examinations by pain physicians. Leg and back pain intensity was assessed by an 11-point numerical rating scale, and patients' functional disability was assessed by the Oswestry Disability Index (ODI).

RESULTS

Study subjects showed a significant decrease in ODI score in both groups (P < 0.05). Significantly lower pain scores for leg pain (P < 0.05) and back pain (P < 0.05) were also recorded after the six-month follow-up. However, the one-year follow-up showed a return to the baseline ODI values of most monitored pain scores in both groups (P > 0.05). Improvement was only noted on the NRS for back pain at one-year follow-up (P < 0.05).

CONCLUSIONS

A significant improvement of leg and back pain was found in both groups after six months. ODI was significantly improved only in group B in both the six- and 12-month intervals. Back pain at one-year follow-up was only improved in group B.

Endoscopic-Assisted Spinal Arachnoiditis Adhesiolysis and Placement of a Spinal Cysto-Subarachnoid Shunt

BACKGROUND

Spinal arachnoiditis and associated arachnoid adhesions can cause debilitating neurological symptoms due to nerve root and spinal cord compression or tethering. Adhesiolysis using a microscopic approach has traditionally been used for this condition. This procedure has been further refined in recent years with the use of flexible endoscopes.

CASE DESCRIPTION

We report the case of a patient with progressive thoracic myelopathy secondary to arachnoid adhesions associated with arachnoiditis. A minimally invasive technique of adhesiolysis and placement of a cysto-arachnoid shunt was performed with the assistance of a flexible endoscope.

CONCLUSIONS

The present case report has highlighted the advantages of using a flexible endoscope to treat spinal arachnoiditis adhesiolysis and placement of a cysto-arachnoid shunt, including a smaller skin incision and extended visualization.

Viable cryopreserved umbilical tissue (vCUT) reduces post-operative adhesions in a rabbit abdominal adhesion model

Post-operative adhesions, a common complication of surgery, cause pain, impair organ functionality, and often require additional surgical interventions. Control of inflammation, protection of injured tissue, and rapid tissue repair are critical for adhesion prevention. Adhesion barriers are biomaterials used to prevent adhesions by physical separation of opposing injured tissues. Current adhesion barriers have poor anti-inflammatory and tissue regenerative properties. Umbilical cord tissue (UT), a part of the placenta, is inherently soft, conforming, biocompatible, and biodegradable, with antimicrobial, anti-inflammatory, and antifibrotic properties, making it an attractive alternative to currently available adhesion barriers. While use of fresh tissue is preferable, availability and short storage time limit its clinical use. A viable cryopreserved UT (vCUT) "point of care" allograft has recently become available. vCUT retains the extracellular matrix, growth factors, and native viable cells with the added advantage of a long shelf life at -80 °C. In this study, vCUT's anti-adhesion property was evaluated in a rabbit abdominal adhesion model. The cecum was abraded on two opposing sides, and vCUT was sutured to the abdominal wall on the treatment side; whereas the contralateral side of the abdomen served as an internal untreated control. Gross and histological evaluation was performed at 7, 28, and 67 days post-surgery. No adhesions were detectable on the vCUT treated side at all time points. Histological scores for adhesion, inflammation, and fibrosis were lower on the vCUT treated side as compared to the control side. In conclusion, the data supports the use of vCUT as an adhesion barrier in surgical procedures.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

Thermoresponsive polysaccharide-based composite hydrogel with antibacterial and healing-promoting activities for preventing recurrent adhesion after adhesiolysis

Postoperative adhesions are very common complications after general abdominal surgery. Although adhesiolysis has been proven effective in eliminating the preexisting adhesions, the new trauma caused by surgical lysis can induce recurrent adhesion. The prevention of recurrent adhesion after adhesiolysis is more difficult because the injury is more severe and adhesion mechanism is more complicated compared with the primary adhesion. In this study, a thermoresponsive hydrogel contained galactose modified xyloglucan (mXG) and hydroxybutyl chitosan (HBC) was developed as a barrier device for recurrent adhesion prevention after adhesiolysis due to its injectability and spontaneous gelling behaviors at the body temperature without any chemical reactions or extra driving factors. First, mXG and HBC were synthesized via enzymatic modification and etherification reaction, respectively. Rheological measurements indicated that the mXG/HBC composite system showed excellent thermosensitivity properties, and their gelation temperature and time can be modulated via adjusting the mXG/HBC ratio. Moreover, the mXG/HBC hydrogel exhibited excellent cytocompatibility and hemocompatibility in vitro. Furthermore, the mXG/HBC hydrogel could promote wound healing in the rat skin wound model. Finally, the efficacy of the mXG/HBC composite hydrogel in the prevention of recurrent adhesion was evaluated in a more rigorous rat repeated-injury adhesion model. The results demonstrated that the composite hydrogel could not only effectively prevent recurrent adhesion after adhesiolysis, but also promote wound healing and reduce scare formation. These results suggested that the mXG/HBC composite hydrogel may be a promising candidate as an injectable anti-adhesion system for clinical applications.

STATEMENT OF SIGNIFICANCE

Although adhesiolysis has been proven effective in eliminating the preexisting adhesions, the new trauma caused by surgical lysis can induce recurrent adhesion. So far, most of the existing barrier systems and pharmacological approaches were developed for primary adhesion prevention while few attention has paid on prevention of recurrent adhesion after adhesiolysis. In the present study, we developed a thermoresponsive polysaccharide-based composite hydrogel by simple mixing galactose modified xyloglucan (mXG) and hydroxybutyl chitosan (HBC). The resulting mXG/HBC composite hydrogel not only was easy to handle and highly effective in preventing the recurrent adhesion after adhesiolysis, but also could promote wound healing and reduce scare formation. Our study provide an effective anti-adhesion system for preventing recurrent adhesion after adhesiolysis.

Relationship between duration of preoperative symptoms and postoperative ileus for small bowel obstruction

BACKGROUND

Factors associated with postoperative ileus and increased resource utilization for patients who undergo operative intervention for small-bowel obstruction are not extensively studied. We evaluated the association between total duration of preoperative symptoms and postoperative outcomes in this population.

MATERIALS AND METHODS

We performed a retrospective review of patients who underwent surgery for small-bowel obstruction (2013-2016). Clinical data were recorded. Total duration of preoperative symptoms included all symptoms before operation, including those before presentation. Primary endpoint was time to tolerance of diet. Secondary endpoints included length of stay, total parenteral nutrition use, and intensive care unit admission. Association between variables and outcomes was analyzed using univariable analysis, multivariable Poisson modeling, and t-test to compare groups.

RESULTS

Sixty-seven patients were included. On presentation, the median duration of symptoms before hospitalization was 2 d (range 0-18 d). Total duration of preoperative symptoms was associated with time to tolerance of diet on univariable analysis (Pearson's moment correlation: 0.28, 95% confidence interval: 0.028-0.5, P = 0.03). On multivariable analysis, ascites was correlated with time to tolerance of diet (P < 0.01), but total duration of preoperative symptoms (P = 0.07) was not. Length of stay (Pearson's correlation: 0.24, 95% confidence interval: -0.02 to 0.47, P = 0.07) was not statistically different in patients with longer preoperative symptoms. Symptom duration was not statistically associated with intensive care unit (P = 0.18) or total parenteral nutrition (P = 0.3) utilization.

CONCLUSIONS

Our findings demonstrate that preoperative ascites correlated with increased time to tolerance of diet, and duration of preoperative symptoms may be related to postoperative ileus.

Effect of early second-look hysteroscopy on reproductive outcomes after hysteroscopic adhesiolysis in patients with intrauterine adhesion, a retrospective study in China

OBJECTIVE

The aim of this study was to assess the effect of early second-look hysteroscopy after hysteroscopic adhesiolysis for intrauterine adhesions (IUAs) on the pregnancy rate (PR) and live birth rate (LBR).

STUDY DESIGN

It is a retrospective, observational study of 151 women were referred to our institution from January 2010 to January 2016. Operative hysteroscopy for treatment of IUAs and office hysteroscopic follow-up to assess IUAs. We investigated demographic characteristics, menstrual pattern, previous intrauterine surgery, reproductive history, ovarian preservation assessment, tubal patency examination, husband's semen test, obstetric parameters, and surgical variables to evaluate the effect of early second-look hysteroscopy after hysteroscopic adhesiolysis on the PR and LBR.

RESULTS

Of 151 women treated for IUAs, the general PR was 71.5% and LBR was 53.0%. The PR and LBR were higher in the earlier second-look group (compared with second hysteroscopy later than 2 months group) and the group which received less than three times adhesiolysis (p < 0.05). The PR was higher in the amenorrhea group (compared with normal menses group) and recurrent miscarriage group (compared with infertility group) (p < 0.05). Logistic regression showed that the second-look time interval, times of operation to relieve adhesion, and pregnancy history were associated with the PR, while age and the second-look time interval were associated with the LBR.

CONCLUSIONS

Early second-look hysteroscopic examinations within 2 months may increase the cumulative PR and LBR.

The Results of Treating Failed Back Surgery Syndrome by Adhesiolysis: Comparing the One- and Three-Day Protocols

Background

The optimal treatment of failed back surgery syndrome (FBSS) is controversial. Limited studies have demonstrated the satisfactory outcomes of percutaneous adhesiolysis in FBSS, which can be performed as a 1 day or 3 days procedure. In the current randomized clinical trial, we compared the clinical and functional outcomes of these 2 techniques.

Methods

In this study, 60 patients with FBSS were randomly assigned into 2 equal groups: 1 day group and 3 days group. Before and at 4 and 12 weeks after the procedure, pain intensity was measured using visual analogue scale (VAS). The Oswestry disability index (ODI) was also completed. Pain reduction of 50% or more was defined as treatment success.

Results

Significant pain relief and ODI improvement were obtained in the 2 groups with adhesiolysis (P < 0.001). However, pain intensity remained the same before and at 4 and 12 weeks after adhesiolysis. ODI score was significantly lower in 1 day group in the 1 month visit (P < 0.001). Treatment was successful in 76.7% and 83.3% of the patients in 1 day and 3 days groups, respectively (P = 0.519).

Conclusions

Adhesiolysis is an effective treatment for pain relief and functional improvement in FBSS. The results of 1 day and 3 days procedures are comparable. Based on these findings, the authors recommend using 1 day technique, which can potentially decrease the patients' discomfort, hospital stay, and cost of treatment.

Quality of life, functional status and adhesiolysis during elective abdominal surgery

BACKGROUND

Adhesiolysis during abdominal surgery can cause iatrogenic organ injury, increased operative time and a more complicated convalescence. We assessed the impact of adhesiolysis and adhesiolysis-related complications on quality of life and functional status following elective abdominal surgery.

METHODS

Prospective cohort study, comparing patients requiring and not requiring adhesiolysis during an elective laparotomy or laparoscopy using the SF-36 and DASI questionnaire scores.

RESULTS

518 patients were included. Pre- and postoperative quality of life did not significantly differ between both groups. Patients with adhesiolysis had a significantly lower pre- and postoperative functional status (p < 0.01). Higher age, concomitant pulmonary disease, postoperative complications, readmissions and chronic abdominal pain 6 months after surgery were all associated with a significant and independent decline in quality of life and functional status six months after surgery.

CONCLUSION

Adhesiolysis in itself does not affect functional status and quality of life six months after surgery. Postoperative complications, readmissions and chronic abdominal pain are associated with a lower health status.

Operative versus non-operative management of adhesive small bowel obstruction: A systematic review and meta-analysis

OBJECTIVES

To investigate outcomes of operative and non-operative management of adhesive small bowel obstruction (SBO).

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of operative versus non-operative management of patients with adhesive SBO. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We found one RCT, two prospective and three retrospective observational studies, enrolling a total of 876 patients. The analyses showed that operative management of adhesive SBO was associated with a lower risk of future recurrence [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.38-0.76, P = 0.0005] but a higher risk of mortality [risk difference (RD) 0.03, 95% CI 0.01-0.06, P = 0.01] and complications (OR 5.39, 95% CI 2.97-9.78, P < 0.00001). There was no difference in need for surgical re-intervention rate (OR 0.72, 95% CI 0.35-1.47, P = 0.36) and length of stay [mean difference (MD) 5.07, 95% CI -2.36-12.49, P = 1.0] between operative and non-operative managements. The baseline suspicion of strangulation was a major confounding factor. When the baseline suspicion of strangulation was higher in the operative group, the risk of mortality (RD 0.04, 95% CI 0.02-0.07, P = 0.0006) and complications (OR 8.14, 95% CI 4.16-15.94, P = 0.00001) were higher in the operative group but the risk of recurrence was lower (OR 0.62, 95% CI 0.43-0.90, P = 0.01). When the baseline suspicion of strangulation was low in both groups, there was no difference in any of the outcomes except recurrence (OR 0.09, 95% CI 0.02-0.37, P = 0.0009) which was lower in the operative group.

CONCLUSIONS

The difference in baseline suspicion of strangulation between operative and non-operative groups is a major confounding factor in current literature. The benefit of surgical treatment should be balanced with the risks associated with surgery, patient's co-morbidities, and presence or absence of strangulation. Based on the best available evidence it could be argued that surgical intervention could be preserved for cases with high suspicion or evidence of bowel strangulation. The controversy still remains for optimum length of conservative management and timing of surgery (early or late) for cases with low baseline suspicion of strangulation. Randomised controlled trials are required to compare outcomes of early operation (<24 h) versus late operation (>24 h) and early operation versus conservative management in patients with low suspicion of strangulation.

Laparoscopic versus Hybrid Approach for Treatment of Incisional Ventral Hernia

BACKGROUND

The aim of this study was to compare the efficacy of a hybrid approach (HA) versus laparoscopy in reducing the risk of complications related to complex adhesiolysis in incisional ventral hernia repair (IVHR).

METHODS

This study included 269 adult patients who underwent laparoscopic IVHR at the Oulu University Hospital, Finland during 2006-2012. Baseline, operative and postoperative data was collected and compared between the treatment groups; that is, a comparison was made between the laparoscopic approach (LA, 38 patients) and the hybrid approach (HA, 24 patients).

RESULTS

In the LA group, 11 (28.9%) patients experienced postoperative complications. There were 4 undetected enterotomies that led to major complications, reoperations and one death. In the HA group, 6 (25%) patients experienced mild and moderate complications. During adhesiolysis, 4 enterotomies occurred but were immediately sutured without any complication.

CONCLUSION

Adhesiolysis through a minimally invasive open technique may be associated with a lower risk of undetected enterotomy in patients with complex adhesions. In IVHR, the hybrid should be considered the operative method of choice when adhesions are foreseeable.

Impact of hospital volume on outcomes for laparoscopic adhesiolysis for small bowel obstruction

BACKGROUND

Volume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs.

MATERIALS AND METHODS

The Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant.

RESULTS

A total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017).

CONCLUSIONS

This study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.

Laparoendoscopic Single-Site Total Laparoscopic Hysterectomy: Clinical Factors that Affect Operative Times and Techniques to Overcome Difficulties

STUDY OBJECTIVE

To compare surgical outcomes of patients who underwent laparoendoscopic single-site total laparoscopic hysterectomy (LESS-TLH) with operative times < 150 minutes and ≥150 minutes to determine the clinical factors that influence operative times. We also describe techniques that help overcome difficulties involved in this procedure.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University medical center.

PATIENTS

Two hundred thirty-four patients underwent LESS-TLH for benign uterine disease and cervical disease between September 2011 and February 2015. Thirty-seven patients (15.8%) were excluded from analysis. One hundred ninety-seven patients were divided into 2 groups according to the total operative time (median, 150 minutes): <150 minutes (n = 93) and ≥150 minutes (n = 104).

INTERVENTIONS

LESS-TLH was performed using anterior, lateral, and posterolateral colpotomy techniques, and knife-in-bag morcellation was used for specimen extraction.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, except for body mass index (BMI) and age, were generally similar in the 2 groups. Age, BMI, adhesiolysis, time to completion of colpotomy, stump repair time, specimen extraction time, blood loss, and weight of the uterus showed statistically significant differences between the 2 groups. Clinical factors that affected operative time were adhesiolysis of the posterior uterus (p = .010), time to completion of colpotomy (>65 minutes; p = .000), specimen extraction time (>34.4 minutes; p = .000), and weight of the uterus (>270 g; p = .015). Conversion to additional port laparoscopy occurred in 14 patients (5.98%). Conversion to laparotomy occurred in 1 patient (.43%). The surgical complication rates were 3.2% (3 patients) in the <150 minutes group and 3.8% (4 patients) in the ≥150 minutes group. No urologic injuries occurred in either group. One postoperative ileus occurred in the ≥150 minutes group; it was relieved by conservative treatment.

CONCLUSION

Time to completion of colpotomy was influenced by adhesiolysis of the posterior uterus and specimen extraction time by weight of the uterus. Alternative methods for decreasing the time required to extract a large uterus and for approaching posterior adhesion of the uterus are needed for LESS-TLH.

Abdominal adhesions: A practical review of an often overlooked entity

Formation of intra-abdominal adhesions is a common consequence of abdomino-pelvic surgery, radiation therapy, and inflammatory processes. In a small but clinically significant proportion of patients, adhesive disease may develop, wherein adhesions lead to a variety of chronic symptoms such as abdominal distension, pain, nausea, and abnormal bowel movement pattern which can be daily, intermittent, or episodic. Due to the chronic and troublesome nature of these symptoms, adhesive disease may be life-altering in many patients, particularly when not recognized and appropriately addressed, as is the case not infrequently. In addition, there is a paucity of literature regarding the evaluation and management of patients with suspected abdominal adhesive disease. Therefore, in this concise review, we provide a clinically practical synopsis of the etiopathogenesis, symptoms, differential diagnosis, evaluation, and treatment of abdominal adhesive disease.

Randomized Controlled Trial of Hyalobarrier® Versus No Hyalobarrier® on the Ovulatory Status of Women with Periovarian Adhesions: A Pilot Study

Introduction

Periadnexal adhesions are known to contribute to subfertility. The restoration of the tubo-ovarian anatomy is one the key principles in reproductive surgery, and this involves adhesiolysis. However, adhesion formation/reformation is very common after periovarian adhesiolysis. It is not known if the application of Hyalobarrier^®, an anti-adhesion gel, around the adnexal region postsurgery influences ovulatory status. The study is a pilot randomized controlled trial (RCT) randomizing women into the application of Hyalobarrier^® versus no Hyalobarrier^® at the time of laparoscopy, where postsurgical ovulatory status and pregnancy rates were evaluated.

Methods

This was a pilot RCT where women were recruited from the gynecological and subfertility clinic who were deemed to require an operative laparoscopy. If intraoperatively they were found to have periovarian adhesions, they were randomized into having adhesiolysis with and without usage of Hyalobarrier^®. Demographic details and intraoperative details including the severity, extent, and the ease of use of Hyalobarrier^® were recorded. Prior to the surgery and postoperatively, the participants had their serum hormonal status (day 2 FSH, LH and day 21 progesterone) evaluated. Postoperatively, they underwent a follicular tracking cycle at 3 months.

Results

Fifteen women were randomized into use of Hyalobarrier^® (study group) and 15 into the no Hyalobarrier^® group (control group) between December 2011 and January 2014. There was no difference in the patient characteristics in terms of age, BMI, the number of previous pregnancies, or the extent, site, and severity of adhesions between the two groups. There was no significant difference between the study versus control groups in terms of the hormonal profile (day 2 FSH and day 21 progesterone) before or after surgery. The 3-month postoperative day 10–12 follicular tracking findings and endometrial thickness were similar between the study and control groups. Four women were pregnant in the study group (24%) and one in the control group (7%) cumulatively over 2 years.

Conclusion

The use of Hyalobarrier^® post salpingo-ovariolysis did not influence follicular development as inferred from the results of the day 21 progesterone and folliculogram on day 10–12 3-month postsurgery.

Trial Registration

ISRCTN number, ISRCTN1833588.

Funding

Nordic Pharma.

A systematic review comparing laparoscopic vs open adhesiolysis in patients with adhesional small bowel obstruction

BACKGROUND AND OBJECTIVE

To evaluate whether surgical outcomes differ between laparoscopic vs open approach for adhesiolysis in patients presenting with adhesional small bowel obstruction (ASBO).

DATA SOURCE

A systematic review of literature on published studies reporting the surgical outcomes after laparoscopic vs open adhesiolysis for ASBO was undertaken using the principles of meta-analysis.

RESULTS

Fourteen comparative studies on 38,057 patients, evaluating the surgical outcomes in patients undergoing laparoscopic vs open adhesiolysis for ASBO were analyzed. Laparoscopic adhesiolysis resulted in the reduced risk of morbidity (P < .00001), mortality (P < .0001), and surgical infections (P = .003). In addition, the risk of respiratory complications, cardiac complications, bowel resection, and venous thromboembolism was lower with shorter hospitalization in laparoscopic adhesiolysis group. However, statistical equivalence was seen in variables of duration of operation and iatrogenic enterotomies.

CONCLUSIONS

Laparoscopic adhesiolysis for ASBO seems to have clinically proven advantage over open approach.

Laparoscopic versus open surgical management of small bowel obstruction: an analysis of clinical outcomes

BACKGROUND

Laparotomy is the standard surgical approach for treatment of small bowel obstruction (SBO). Laparoscopic management could be beneficial in terms of less complications and shorter hospital stay. As the minimal invasive approach is gaining more acceptances in the treatment of SBO, there is an increased need of studies to analyze outcomes. The aim of the present study was to compare the short-term clinical outcomes of laparoscopy versus laparotomy in the surgical management of non-bariatric, non-malignant SBO.

METHODS

A retrospective analysis of patients treated for SBO during 2010-2015 was made by a comprehensive search of medical records. A matched-pair review was performed on patients managed surgically for non-bariatric, non-malignant SBO at Danderyd University Hospital, Stockholm, Sweden. Completed laparoscopic surgeries were matched against patients treated with open surgery.

RESULTS

Laparoscopy for SBO was initiated in 71 patients. Conversion to open surgery was performed in 42 %. Results from the matched-pair analysis showed that post-operative length of stay was reduced by 60 % (P < 0.001) in the laparoscopic cohort. Additionally, less major complications were reported and duration of surgery was reduced by 50 % (P < 0.001).

CONCLUSIONS

Laparoscopic management is a safe and feasible alternative to laparotomy. Hospital length of stay was significantly shorter and morbidity rate acceptable.

Percutaneous Adhesiolysis Versus Transforaminal Epidural Steroid Injection for the Treatment of Chronic Radicular Pain Caused by Lumbar Foraminal Spinal Stenosis: A Retrospective Comparative Study

OBJECTIVE

To investigate the efficacy of percutaneous adhesiolysis (PA) compared to fluoroscopy (FL)-guided transforaminal epidural steroid injection (TFESI) in patients with radicular pain caused by lumbar foraminal spinal stenosis (LFSS) by assessing pain relief and functional improvement at 4 and 12 weeks post-procedure.

METHODS

This retrospective study included 45 patients who underwent PA or FL-guided TFSEI for radicular pain caused by LFSS of at least 3 months' duration. Outcomes were assessed with the Oswestry Disability Index (ODI) and Verbal Numeric Pain Scale (VNS) before the procedure and at 4 and 12 weeks post-procedure. A successful outcome was defined by >50% improvement in the VNS score and >40% improvement in the ODI score.

RESULTS

ODI and VNS scores improved 4 and 12 weeks post-procedure in both groups. Statistically significant differences between groups were observed in ODI and VNS at 12 weeks (p<0.05). The proportion of patients with successful outcomes was significantly different between the two groups only at the 12-week time point.

CONCLUSION

Our study suggests that PA is effective for pain reduction and functional improvement in patients with chronic radicular pain caused by LFSS. Therefore, PA can be considered for patients with previous ineffective responses to conservative treatment. Although PA seems to be more effective than TFEFI according to the results of our study, in order to fully elucidate the difference in effectiveness, a prospective study with a larger sample size is necessary.

Novel use of a flowable collagen-glycosaminoglycan matrix (Integra™ Flowable Wound Matrix) combined with percutaneous cannula scar tissue release in treatment of post-burn malfunction of the hand--A preliminary 6 month follow-up

INTRODUCTION

Long-term function following severe burns to the hand may be poor secondary to scar adhesions to the underlying tendons, webspaces, and joints. In this pilot study, we report the feasibility of applying a pasty dermal matrix combined with percutaneous cannula teno- and adhesiolysis.

PATIENTS AND METHODS

In this 6 month follow-up pilot study, we included eight hands in five patients with hand burns undergoing minimal-invasive, percutaneous cannula adhesiolysis and injection of INTEGRA™ Flowable Wound Matrix for a pilot study of this new concept. The flowable collagen-glycosaminoglycan wound matrix (FCGWM) was applied with a buttoned 2mm cannula to induce formation of a neo-gliding plane. Post treatment follow-up was performed to assess active range of motion (AROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, Vancouver Scar Scale (VSS) and quality of life Short-Form (SF)-36 questionnaire.

RESULTS

No complications were detected associated with the treatment of FCGWM injection. The mean improvement (AROM) at 6 months was 30.6° for digits 2-5. The improvement in the DASH score was a mean of 9 points out of 100. The VSS improved by a mean of 2 points out of 14.

DISCUSSION

The study demonstrates the feasibility and safety of percutaneous FCGWM for dermal augmentation after burn. Results from this pilot study show improvements in AROM for digits 2-5, functional scores from the patient's perspective (DASH) and scar quality (VSS). The flowable form of established INTEGRA™ wound matrix offers the advantage of minimal-invasive injection after scar release in the post-burned hand with a reduction in the risk of postsurgical re-scarring.

open adhesiolysis]

OBJECTIVE

To compare the results of laparoscopic versus open adhesiolysis in children affected by postoperative bowel obstruction.

METHODS

Retrospective study reviewing charts of all patients who were operated on due to postoperative adhesions in our Department. Demographic data, clinical characteristics and postoperative data were collected.

RESULTS

During the last 8 years, 37 patients were operated on for postoperative intestinal obstructions. 40.5% were operated by laparoscopy and 59.5% by laparotomy. Mean ages were 6.31 and 4.32 years in laparoscopic and open groups, respectively. There were no differences in days of evolution of the occlusion, neither in their medical history. Patients in laparoscopic group had better outcomes in the need of central lines (15% vs 61.90% p= 0.012), use of parenteral nutrition (38.46% vs 83.33% p= 0.005), beginning of the enteral nutrition (4.04 vs 8.17 days p= 0.004) and hospital stay (7.77 vs 13.05 days p= 0.027).

CONCLUSIONS

Open and laparoscopic adhesiolysis are effective to treat adhesive cases. Laparoscopic adhesiolysis has some advantages over open surgery: less need of central lines and parenteral nutrition, earlier start of enteral nutrition, less rate of complications and shorter hospital stay.

Reproductive Outcome of Patients with Asherman's Syndrome: A SAIMS Experience

BACKGROUND

The purpose of the study was to evaluate menstrual and reproductive outcome in patients diagnosed with Asherman's syndrome on hysteroscopy and to assess the role of hysteroscopic adhesiolysis.

METHODS

A prospective study was performed for patients having intrauterine adhesion at a tertiary care teaching hospital, Indore, India for a period of 2 years. Findings at hysteroscopy, details of adhesiolysis, changes in menstrual pattern following adhesiolysis, need for repeat procedure and fertility outcome were prospectively collected. Data was analysed using SPSS software. A p-value of <0.05 was considered significant.

RESULTS

A total of 60 patients with a mean age of 30.1±5.5 years with Asherman's syndrome were included. In 53.3% of them, no factors like post-partum curettage, uterine surgery or history of tuberculosis could be found in which the present intrauterine adhesions could be attributed to. Hypomenorrhoea was the most common (53.3%) menstrual pattern in patients diagnosed with Asherman's syndrome. Thirty eight out of 60 (63.33%) required second look hysteroscopy. There was a significant change in endometrial lining and echo pattern after adhesiolysis (p<0.05). 45% of patients started having normal menstrual flow after adhesiolysis which was statistically significant. A total of 16 conceptions and 10 live births were reported in the present cohort. Pregnancy rate was higher in patients having mild Asherman's syndrome (53.3%) as compared to moderate (26.9%) or severe type (9.5%), (p=0.0049). It was also higher in patients having normal endometrial pattern after adhesiolysis (p=0.0005).

CONCLUSION

Women who underwent hysteroscopic adhesiolysis showed significant improvement in the menstrual pattern. Pregnancy rates were improved after hysteroscopic adhesiolysis.

Role of laparoscopy in the prevention and in the treatment of adhesions

The formation of adhesions after abdominal surgery can lead to increased morbidity in children, increases the incidence of readmission, and may pose a significant challenge to subsequent surgical care over their lifetime. As the pathophysiology of peritoneal adhesion formation has been better understood, preventive strategies that minimize surgical trauma and contamination have been sought. Laparoscopy, over the past few decades, has become an increasingly utilized approach for many pediatric surgical problems and intuitively should have an advantage over open surgery in reducing adhesion formation. In this review, we examine the utility of laparoscopy in both the prevention and the treatment of intraabdominal adhesive disease in children.

Morbidity related to concomitant adhesions in abdominal surgery

BACKGROUND

We sought to assess the independent effect of concomitant adhesions (CAs) on patient outcome in abdominal surgery.

MATERIALS AND METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program data, we created a uniform data set of all gastrectomies, enterectomies, hepatectomies, and pancreatectomies performed between 2007 and 2012 at our tertiary academic center. American College of Surgeons National Surgical Quality Improvement Program data were supplemented with additional variables (e.g., procedure complexity-relative value unit). The presence of CAs was detected using the Current Procedural Terminology codes for adhesiolysis (44005, 44180, 50715, 58660, and 58740). Cases where adhesiolysis was the primary procedure (e.g., bowel obstruction) were excluded. Multivariable logistic regression analyses were performed to assess the independent effect of CAs on 30-d morbidity and mortality, while controlling for age, comorbidities and the type/complexity/approach/emergency nature of surgery.

RESULTS

Adhesiolysis was performed in 875 of 5940 operations (14.7%). Operations with CAs were longer (median duration 3.2 versus 2.7 h, P < 0.001), more complex (median relative value unit 37.5 versus 33.4, P < 0.001), performed in sicker patients (American Society for Anesthesiologists class ≥3 in 49.9% versus 41.2%, P < 0.001), and harbored higher risk for inadvertent enterotomies (3.0% versus 0.9%, P < 0.001). In multivariable analyses, CAs independently predicted higher morbidity (adjusted odds ratio [OR], 1.35; 95% confidence interval, 1.13-1.61, P = 0.001). Specifically, CAs independently correlated with superficial and deep or organ-space surgical site infections (OR = 1.42 (1.02-1.86), P = 0.036; OR = 1.47 (1.09-1.99), P = 0.013, respectively), and prolonged postoperative hospital stay (≥7 d, OR = 1.34 [1.11-1.61], P = 0.002). No difference in 30-d mortality was detected.

CONCLUSIONS

CAs significantly increase morbidity in abdominal surgery. Risk adjusting for the presence of adhesions is crucial in any efforts aimed at quality assessment and/or benchmarking of abdominal surgery.

[A preliminary experience in the laparoscopic approach to bowel obstruction]

BACKGROUND

The laparoscopic approach to bowel obstruction is still controversial.

OBJECTIVE

To evaluate our initial results in the laparoscopic treatment of bowel obstruction.

MATERIAL AND METHODS

A retrospective study on patients diagnosed with bowel obstruction that underwent laparoscopic surgery within the time frame of January 2008 to June 30, 2012. The variables employed were: age, sex, occlusion etiology, previous surgeries, clinical progression, pneumoperitoneum creation, use of an auxiliary incision, anesthesia duration, conversion rate, postoperative hospital stay, time needed to tolerate liquids, and complications.

RESULTS

Twenty-six patients, 18 women (69.2%) and 8 men (30.8%), with a mean age of 64.35 years (range: 21-92 years) were analyzed. The most frequent obstruction etiology was secondary to adhesions and presented in 12 cases. Nine patients (34.6%) underwent a completely laparoscopic approach and laparoscopy was complemented by an auxiliary incision in another 9 patients (34.6%), resulting in 18 cases (69.2%) of successful laparoscopic approach. Eight patients (30.8%) required conversion to open surgery. The mean anesthesia duration was 95min (range: 55-165min), mean postoperative hospital stay was 6 days (range: 3-72 days), and the mean amount of time needed to tolerate liquids was 3 days (range: 1-10 days). The patients that underwent complete laparoscopic approach presented with shorter hospital stay, they were able to ingest liquids earlier, and they presented with a lower number of postoperative complications; this latter variable was the only one that was statistically significant.

CONCLUSIONS

The initial results of our experience were good, although more patients are needed in order to standardize and extend the use of this technique.

Results of a laparoscopic approach for the treatment of acute small bowel obstruction due to adhesions and internal hernias

INTRODUCTION

Laparotomy is the standard approach for the surgical treatment of acute small bowel obstruction (ASBO).

PATIENTS AND METHODS

From February 2007 to May 2012 we prospectively recorded all patients operated by laparoscopy in our hospital because of ASBO due to adhesions (27 cases) and/or internal hernia (6 cases). A preoperative abdominal CT was performed in all cases. Patients suffering from peritonitis and/or sepsis were excluded from the laparoscopic approach. It was decided to convert to laparotomy if intestinal resection was required.

RESULTS

The mean age of the 33 patients who underwent surgery was 61.1 ± 17.6 years. 64% had previous history of abdominal surgery. 72% of the cases were operated by surgeons highly skilled in laparoscopy. Conversion rate was 21%. Operative time and postoperative length of stay were 83 ± 44 min. and 7.8 ± 11.2 days, respectively. Operative time (72 ± 30 vs 123 ± 63 min.), tolerance to oral intake (1.8 ± 0.9 vs 5.7 ± 3.3 days) and length of postoperative stay (4.7 ± 2.5 vs 19.4 ± 21 days) were significantly lower in the laparoscopy group compared with the conversion group, although converted patients had greater clinical severity (2 bowel resections). There were two severe complications (Clavien-Dindo III and V) in the conversion group.

CONCLUSIONS

In selected cases of ASBO caused by adhesions and internal hernias and when performed by surgeons highly skilled in laparoscopy, a laparoscopic approach has a high probability of success (low conversion rate, short hospital length of stay and low morbidity); its use would be fully justified in these cases.

A case of corrosive injury-induced pharyngeal stricture treated by endoscopic adhesiolysis using an electrosurgical knife

Here, we report a case of corrosive injury-induced pharyngeal stricture in a 69-year-old female, which was successfully treated with endoscopic adhesiolysis using an electrosurgical knife. The patient had ingested sodium hydroxide in an attempted suicide, and immediate endoscopy revealed corrosive injuries of the pharynx, esophagus, and stomach. When a liquid diet was permitted, she complained of nasal regurgitation of food. Follow-up endoscopy revealed several adhesive bands and a web-like scar that did not allow passage of the endoscope into the hypopharyngeal area. For treatment of the hypopharyngeal stricture, the otolaryngologist attempted to perform an excision of the fibrous bands around the esophageal inlet using microscissors passed through an esophagoscope, but this procedure was not effective. We then dissected the mucosal adhesion and incised the adhesive bands using an electrosurgical knife. After this procedure, nasal regurgitation of food no longer occurred. To our knowledge, this case is the first report of endoscopic adhesiolysis with an electrosurgical knife in a patient with a corrosive injury-induced pharyngeal stricture.

Large bowel injury during total laparoscopic hysterectomy

Large bowel injuries are unfortunate complications of laparoscopic surgery, with an incidence of 0.62 to 1.6 per 1000 laparoscopies. One-third of these injuries can be diagnosed intraoperatively, with the rest going unnoticed and revealed later. Rectal injury, a very rare complication, may be caused during pelvic dissection of dense adhesions. Injury at the rectosigmoid junction due to traction with a rectal probe is extremely rare and highly underreported. We report a case of rectal injury during total laparoscopic hysterectomy in a case with dense pelvic adhesions.

Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon): A report of 5 cases

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick grayish-white fibrotic membrane encasing the small bowel. SEP can be classified as idiopathic, also known as abdominal cocoon, or secondary. It is difficult to make a definite pre-operative diagnosis. We experienced five cases of abdominal cocoon, and the case files were reviewed retrospectively for the clinical presentation, operative findings and outcome. All the patients presented with acute, subacute and chronic intestinal obstruction. Computed tomography (CT) showed characteristic findings of small bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle in four cases. Four cases had an uneventful post-operative period, one case received second adhesiolysis due to persistent ileus. The imaging techniques may facilitate pre-operative diagnosis. Surgery is important in the management of SEP.