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Peritoneal Adhesions and Their Prevention - Current Trends

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Peritoneal Adhesions and Their Prevention - Current Trends #1385 Krämer FINAL Gynecology SURGICAL TECHNOLOGY INTERNATIONAL Volume 38 Peritoneal Adhesions and their Prevention - Current Trends BERNHARD KRÄMER , P HD STEFAN KOMMOSS , P HD DEPUTY MEDICAL DIRECTOR & S ENIOR CONSULTANT OF CONSULTANT OF OPERATIVE GYNECOLOGY OPERATIVE GYNECOLOGY FELIX NEIS , MD JÜRGEN ANDRESS , MD CONSULTANT OF OPERATIVE GYNECOLOGY CONSULTANT OF OPERATIVE GYNECOLOGY SARA Y B RUCKER , P HD MEDICAL DIRECTOR SASCHA HOFFMANN , MD PROFESSOR OF WOMEN ’S HEALTH AND GYNECOLOGY CONSULTANT OF OPERATIVE GYNECOLOGY DEPARTMENT FOR WOMEN ’S HEALTH , U NIVERSITY HOSPITAL TÜBINGEN , T ÜBINGEN , G ERMANY ABSTRACT he development of adhesions after gynecologic surgery is a severe problem with ramifications that go Tbeyond the medical complications patients suffer (which most often include pain, obstruction and infer - tility), since they also impose a huge financial burden on the health care system and increase the workload of surgeons and all personnel involved in surgical follow-up care. Surgical techniques to avoid adhesion forma - tion have not proven to be sufficient and pharmaceutical approaches for their prevention are even less effec - tive, which means that the use of adhesion prevention devices is essential for achieving decent prophylaxis. This review explores the wide range of adhesion prevention products currently available on the market. Par - ticular emphasis is put on prospective randomized controlled clinical trials that include second-look inter - ventions, as these offer the most solid evidence of efficacy. We focused on adhesion scores, which are the most common way to quantify adhesion formation. This enables a direct comparison of the efficacies of dif - ferent devices. While the greatest amount of data are available for oxidized regenerated cellulose, the out - comes with this adhesion barrier are mediocre and several studies have shown little efficacy. The best results have been achieved using adhesion barriers based on either modified starch, i.e., 4DryField ® PH (PlantTec Medical GmbH, Lüneburg, Germany), or expanded polytetrafluoroethylene, i.e., GoreTex (W.L. Gore & Asso - ciates, Inc., Medical Products Division, Flagstaff, AZ), albeit the latter, as a non-resorbable barrier, has a huge disadvantage of having to be surgically removed again. Therefore, 4DryField ® PH currently appears to be a promising approach and further studies are recommended. - 1- Copyright © 2021 Surgical Technology International ™ #1385 Krämer FINAL Peritoneal Adhesions and their Prevention - Current Trends KRÄMER/NEIS/BRUCKER/KOMMOSS/ANDRESS/HOFFMANN BACKGROUND a decline in fibrinolytic capacity. 13 Inhibi - tinuous pain when they retract the vis - tion of tPA can be triggered by plasmino - cera without obstructing them. 37 The Peritoneal healing and adhesion gen-activator-inhibitor (PAI). actual effect of adhesions on pain is diffi - formation Inflammatory reactions lead to an cult to estimate since the pathophysiolo - Following surgical trauma, the time increased release of PAI and, thus, can gy of chronic abdominal pain is still required for regeneration of the peri - also lead to an inhibition of the fibri - poorly understood. 38 Seventy-four to toneum and its mesothelial layer is 5-6 nolytic system. 15 Once fibrin bridges 86% of all cases of small bowel obstruc - days. 1-3 The cellular sequence of this have formed between neighboring tissues tion can be ascribed to post-surgical repair starts with polymorphonuclear or organs that are not normally connect - adhesions, 39,40 which are also the only leukocytes (PMN) attaching to fibrin ed to one another , these mature into factor causing female infertility in 15% strands , followed by infiltration of adhesions. 16 A multitude of growth fac - of cases. 41 Infertility can be caused by macrophages , which form a single-cell tors, cytokines and signaling molecules either peri-tubal adhesions affecting tubal layer to cover the wound surface by day are involved in this process. 16,17 The mat - motility and ovum transport or adhe - 2. During the following days, primitive uration of adhesions includes vasculariza - sions around the ovaries inhibiting follic - mesenchymal cells and first mesothelial tion , which is highly dependent on ular growth. 24 Although adhesiolysis cells, followed by proliferating fibrob - VEGF expression. 17 As in fibrosis, con - surgery may increase the fertility of pre - lasts , can be observed until a single layer nective tissue formation is mediated by viously infertile women, the surgery of mesothelial cells , interconnected by connective tissue growth factors , as well itself imposes a risk of (re-)formation of desmosomes and tight junctions , is pre - as TGF-betas. 18,19 adhesion and, thereby, persistence or sent on the wound surface on day 5 . By The main intra-operative factor pro - even aggravation of the problems caused then, PMNs have vanished and the moting adhesion formation is injury to by the adhesions. Adhesions or adhesion- amount of fibrin has decreased signifi - the peritoneum. 20,21 Other factors related complications are also some of cantly. The amount of macrophages also include the complexity of the the main reasons for readmission. It was begins to decrease from day 5 onwards ; a procedure, 22 tissue necrosis through found that 33% to 44% of patients with continuous basement membrane forms heavy coagulation 23 and bacterial inflam - extensive open surgery were readmitted beneath the mesothelial coverage and mation. 24 For laparoscopic procedures , either directly or likely due to adhesion- blood vessels begin to develop. 4,5 The desiccation through dry insufflation gas , related complications within 10 most probable origin of the new as well as high insufflation pressure (also years. 35,42,43 With 48% and 41% of mesothelial cells is mesenchymal stem leading to the compression of capillary women being readmitted, respectively, cells within the connective tissue. 6 The flow) 25-27 and mesothelial hypoxia surgical procedures on the ovary and fal - 28 mesothelial cells are attracted to the through CO 2 have to be considered as lopian tube have been shown to have the injury site chemotactically , where they possible contributors to adhesion forma - highest risk of adhesion-related readmis - initially form islands and then proliferate tion. For laparotomies, these possible sion. 35 Furthermore, adhesions are one to complete the re-epithelialization. 5,7 contributors include desiccation as a of the main reasons for conversion dur - Healing of the visceral peritoneum does result of heat and/or light 23 and ing subsequent surgeries. 44,45 Adhesioly - not seem to differ significantly from that mesothelial desiccation/abrasion from sis prolongs surgery and post-surgical of the parietal peritoneum , apart from dry swabs. 20,21 recovery and increases the risk of intra- different time intervals of some healing Foreign bodies can also provoke adhe - operative accidental damage of neighbor - stages. 5,8,9 sions; possible sources include suture ing tissues and organs and post-surgical The pathophysiology of adhesiogene - materials ,2,10,29 surgical glove dusting complications. 46-48 A meta-analysis found sis after surgical injury generally depends powders, 30 material extruded from the that the overall incidence of adhesiolysis- on exudation, 10 inflammation and fibrin digestive tract , and hernia mesh - related enterotomy in gynecologic surg - deposition. Inflammatory responses are es. 24,29,31,32 . The likelihood of adhesion eries was 4.8% (95%CI: 0.6-9.1 %). 49 triggered by ischemia in the damaged tis - formation is also influenced by the pro - Another meta study found that the inci - sue through the release of inflammatory cedure performed, and ovarian cystecto - dence rate correlates with the number of mediators from mesothelial cells , as well my, endometriosis, myomectomy, previous laparotomies and the presence as pro-coagulatory and anti-fibrinolytic adhesiolysis, tubal surgery including of bowel fistula. 50 While the incidence reactions. 11 An imbalance between fibri - ectopic pregnancies , and surgical treat - rate of ureteral injuries was considerably nolytic and pro -coagulatory factors leads ment of pelvic inflammatory disease are lower , and regularly below 1%, adhe - to the persistence of the formed polyfib - associated with relatively high adhesio - sions were considered to be a predispos - rin, which under normal physiological genicity. 33 ing factor .51,52 conditions would be degraded by the fib - rinolytic activity of the mesothelium. 12-14 THE AFTETHREM AAFTEHRMATH Economic impact The fibrinolytic system is activated While the possible medical impact of through tPA (tissue-type plasminogen Medical complications adhesions is well known among surgeons , activator), which cleaves plasminogen to Adhesions are the main cause of the extent of the economic ramifications yield active plasmin. The protease plas - chronic abdominal pain, 34 small bowel of adhesions is often neglected . Several min then cleaves fibrin and , therefore , obstructions, 34-36 and secondary female studies have examined the economic can dissolve polyfibrin strands. 12 Howev - infertility. 34-36 Chronic abdominal pain impact of adhesions and adhesion-related er, reduced tPA activity has been found can be divided into continuous and col - complications . The costs associated with in peritoneal tissue as a local response to icky pain. While adhesions more often hos pital stays due to adhesive small surgical trauma , causing (at least in part) cause the latter
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