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Clinical Update FINAL:Layout 1 3/4/10 6:59 PM Page 1 Ethicon Clinical Update FINAL:Layout 1 3/4/10 6:59 PM Page 1 A Supplement to ® CLINICAL UPDATE Faculty Disclosure The Latest Techniques for Preventing Adhesions in Dr Chapa has received clinical grant funding from Johnson & Johnson Cesarean Delivery Medical Affairs for clinical trials of Both nonmodifiable and modifiable morbidities are Interceed® in cesarean section, is a associated with increased CDs. Chief among the medical consultant for ETHICON nonmodifiable morbidities is the rise in abnormal pla- Women’s Health & Urology, and Hector Chapa, MD, FACOG centation that results from multiple CDs, which will serves as a speaker for Adhesion Medical Director and not be the focus of this review. Chief among the mod- Prevention in Surgery. Outreach Coordinator ifiable morbidities is adhesion formation and its Women's Specialty Center Clinical Faculty related morbidities. This review will address the Obstetrics and Gynecology pathophysiology, morbidity, and prevention tools Residency Program relevant to abdominopelvic adhesive syndromes. Methodist Medical Center Adhesiogenesis Dallas, Texas PRESIDENT, ELSEVIER/IMNG Central to adhesion formation is peritoneal trauma Alan J. Imhoff ccording to the Centers for Disease Control and injury. Devascularization and mesenchymal SALES DIRECTOR and Prevention (CDC), cesarean delivery ischemia initiate the reparative process leading to reep- 9 Mark Altier (CD) remains one of the most common sur- ithelialization (Figure 1). Mesothelial cells migrate A across areas of injury and lay a supportive matrix to NATIONAL ACCOUNT MANAGER geries in women of reproductive age. The US national Kathleen Hiltz cesarean delivery rate was 4.5% in 1965, when first allow for regeneration. The first 5 to 7 days are most 1 influential for adhesion formation, and it is ques- SENIOR PROGRAM MANAGER tracked and reported. The cesarean rate has increased tionable whether any new adhesions form after that Malika Wicks over the last few decades and currently has reached period. However, complete organization and remod- ART DIRECTOR an all-time high of 31%, which represents a doubling 2,3 eling may occur up to 3 to 4 weeks after formation. The HUME Group of the rate since 1996. By extrapolation of trends, it is projected that “cesarean deliveries will make up PRODUCTION SPECIALIST Rebecca Slebodnik approximately 50% of the more than 4 million annual deliveries by 2020.”4 This trend is global. In FIGURE 1. Pathogenesis of Postoperative Peritoneal Adhesions Brazil, local area hospitals report cesarean rates of 5 100%, with health districts reporting rates of 85%. Surgical tissue trauma Two main factors help explain this change in obstetric practice. The first is the litigious climate in This supplement was produced by which physicians practice. According to The Amer- Increased vascular permeability INTERNATIONAL MEDICAL NEWS GROUP, ican College of Obstetricians and Gynecologists a division of ELSEVIER MEDICAL (ACOG) 2009 Medical Liability Survey of 5,644 INFORMATION, LLC. Neither the editor Release of vasoactive substances of OB.GYN. NEWS, the Editorial Advi- obstetricians-gynecologists, 29% reported perform- and inflammatory exudate sory Board, nor the reporting staff con- ing more CDs, and 25.9% stopped offering or per- tributed to its content. forming vaginal births after cesareans (VBACs) Copyright © 2010 Elsevier Inc. All rights specifically because of liability concerns.6 Not sur- Fibrinolysis and mesothelial reaction reserved. No part of this publication may be reproduced or transmitted in any form, prisingly, this is not a new occurrence. Another sur- by any means, without prior written per- vey in 1999 found that 82% of physician survey mission of the Publisher. Elsevier Inc. participants in Ireland had decided to perform a CD Decreased fibrinolytic activity will not assume responsibility for damages, 7 loss, or claims of any kind arising from or specifically to avoid a malpractice claim. It is this related to the information contained in decrease in VBAC allowance that has fueled the over- Fibrin deposition/Capillary development this publication, including any claims all rate of cesarean births since 1996. related to the products, drugs, or services mentioned herein. The second factor is the advent of CDs upon mater- nal request. Although traditionally not recognized, Adhesion formation CD “on demand” has established a foothold in cur- rent practice. Though difficult to track, current esti- INTERNATIONAL Source: The Practice Committee of the American Society for mates place the rate of CD “on demand” at 4% to Reproductive Medicine.9 MEDICAL NEWS Used with permission. GROUP 18% in the United States.8 This supplement was sponsored by Ethicon Clinical Update FINAL:Layout 1 2/24/10 4:51 PM Page 2 2 CLINICAL UPDATE The pregnant patient possesses additional TABLE 1. Adhesions Following Cesarean Section Delivery factors favoring adhesion formation. The post- partum uterus resting against the abdominal Procedure N % with adhesions wall/peritoneum has been postulated to be the 11 reason for cohesive adhesions between the ante- At time of 2nd C-section 217 46% rior abdominal wall and uterine serosa.10 Addi- At time of 3rd C-section11 64 76% tionally, the hypervascularity and tissue At time of 4th C-section11 6 83% inflammation of pregnancy, as well as the sub- 12 sterile nature of the operative field, may fur- At time of 2nd C-section 955 24% ther influence adhesion formation. At time of 3rd C-section12 255 43% Although no formal grading system for At time of 4th+ C-section12 73 48% adhesions currently exists, most adhesions are % Dense (moderate-severe) Adhesions classified as grade 1 (filmy/peritoneal), grade 2 (moderate thickness), or up to grade 3/4 Morales: 55% (2nd C/S), 54% (3rd C/S), 60% (4th C/S) (severe/dense or cohesive). Tulandi: 48% (2nd C/S), 56% (3rd C/S), 56% (≥4th C/S) Adhesion Frequency in Cesarean Sources: Morales et al11; Tulandi et al.12 Deliveries C/S=cesarian section. In one retrospective study, adhesions of all grades were found in 46% of second cesarean skin incision to fetal delivery times of 8.9 min- Where Are Adhesions Most Likely to births, 76% of third cesarean births, and 83% utes for a first CD, 10.7 minutes for a second Develop? of fourth cesarean births.11 Similarly, Tulandi CD, and 12.8 minutes for a third CD. Simi- Adhesions favor two anatomic areas in et al12 documented adhesion frequencies in larly, Morales et al11 reported an 18-minute patients who have had a CD: (1) between the 24% of second cesarean births, 43% of third delay of a fourth CD as a result of adhesions. hysterotomy site/bladder flap and anterior peri- cesarean births, and 48% of fourth cesarean This delay results in economic as well as infec- toneum and (2) between the anterior uterine births. Percent differences between the two tious ramifications for the individual patient. serosa and anterior abdominal wall. The med- studies can be explained by the subjective Additionally, adhesions at CD increase the risk ical literature points to the latter as the more grading scales employed in each cohort. The of bladder injuries, greater blood loss, and lower frequent (Figure 2). It is proposed that the post- percentage of moderate-severe adhesions in umbilical cord potential hydrogen (pH).13, 21-24 partum uterus resting on the traumatized peri- each cohort varied less because of the more In fact, lower umbilical blood pH is twice as toneal edges facilitates junction of the two by reproducible classification of cohesive disease likely during a repeat CD, when compared to the regenerating peritoneal edges (Figure 3). (Table 1). Additionally, Nisenblat et al13 com- a primary nonurgent CD; this is a direct con- The influence that peritoneal suturing may pared 277 women undergoing a third or more sequence of adhesions.25 have on this phenomenon will be discussed later. CDs to 491 women undergoing a second CD. Excessive blood loss (7.9% vs 3.3%; P<0.005), FIGURE 2. Cesarean Section Adhesion Locations difficult delivery of the neonate (5.1% vs 0.2%; Anterior Uterine/ P<0.001), and dense adhesions (46.1% vs Author Abdominal Wall (Fascia) Bladder Flap/Anterior Uterine 25.6%; P<0.001) were significantly more com- Morales et al 77% Not Applicable mon in the group of women undergoing a third Tulandi et al 48%-53% 26%-35% or more CDs, validating what practicing obste- Lyell et al 27%* 12%* tricians have known for years. *Nonperitoneal closure group. Sources: Lyell et al10; Morales et al11; Tulandi et al.12 General and Obstetric Sequelae of Adhesions FIGURE 3. Images Taken at Diagnostic Laparoscopy in Two Separate Patients Following The morbidity associated with abdomino- Low Transverse Cesarean Sections pelvic adhesions is well documented. Published Grade 3 adhesion at time of C/S reports place small bowel obstruction (SBO) as Grade 2 adhesion at time of C/S Exteriorized post-cesarean uterus. Band of adhesion one of the most dreaded complications of adhe- Adhesion is between lower uterine segment and between lower uterine segment and abdominal abdominal wall (peritoneum and rectus muscles) contents (peritoneum/bowel to uterine serosa). sion formation, with a rate of 50% to 75% of all SBOs being related to postoperative adhe- sions.14-16 As related to CD, Al-Sunaidi et al17 documented an SBO rate of 7/6,500 cases. Additionally, infertility,9 chronic pelvic pain,18 and subsequent surgical bowel/bladder injury have all been ascribed to adhesive disease.19-20 CD-related adhesions contribute to longer delivery times and total operating times dur- Photos courtesy of H.O. Chapa, MD ing subsequent CDs. Tulandi et al12 reported Used with permission. Ethicon Clinical Update FINAL:Layout 1 3/8/10 6:02 PM Page 3 ® CLINICAL UPDATE 3 Adhesion propensity also is influenced by FIGURE 4. Gynecare Interceed Absorbable Barrier Effectiveness choice of abdominal entry.
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