This article was downloaded by: Publisher: KKG Publications Registered office: 18, Jalan Kenanga SD 9/7 Bandar Sri Damansara, 52200 Malaysia Key Knowledge Generation Publication details, including instructions for author and subscription information: http://kkgpublications.com/medical-sciences/ Prophylaxis of Peritoneal Adhesions: Practical Issues to Consider When Using Antiadhesion Agents LUZ ANGELA TORRES-DE LA ROCHE 1, ANJA HER- RMANN 2, CRISTINA CEZAR 3, ANGELIKA LARBIG 4, LASSE LEICHER 5, MAYA SOPHIE DE WILDE 6, RUDY LEON DE WILDE 7 1, 2, 3, 4, 5, 6, 7 Carl Von Ossietzky Universitat Oldenburg, Oldenburg, Germany Published online: 02 March 2017 To cite this article: L. A. T. La Roche, A. Herrmann, C. Cezar, A. Larbig, L. Leicher, M. S. De Wilde and R. L. De Wilde, “Prophylaxis of peritoneal adhesions: Practical issues to consider when using antiadhesion agents,” International Journal of Health and Medical Sciences, vol. 3, no. 1, pp. 01-05, 2017. DOI: https://dx.doi.org/10.20469/ijhms.3.30001-1 To link to this article: http://kkgpublications.com/wp-content/uploads/2017/03/IJHMS-30001-1.pdf PLEASE SCROLL DOWN FOR ARTICLE KKG Publications makes every effort to ascertain the precision of all the information (the “Content”) contained in the publications on our platform. However, KKG Publications, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the content. All opinions and views stated in this publication are not endorsed by KKG Publications. These are purely the opinions and views of authors. The accuracy of the content should not be relied upon and primary sources of information should be considered for any verification. KKG Publications shall not be liable for any costs, expenses, proceedings, loss, actions, demands, damages, expenses and other liabilities directly or indirectly caused in connection with given content. This article may be utilized for research, edifying, and private study purposes. Any substantial or systematic reproduc- tion, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly verboten. International Journal of Health and Medical Sciences 2017, 3:1 01-05 IJHMS PROPHYLAXIS OF PERITONEAL ADHESIONS: PRACTICAL ISSUES TO CONSIDER WHEN USING ANTIADHESION AGENTS LUZ ANGELA TORRES-DE LA ROCHE 1, ANJA HERRMANN 2, CRISTINA CEZAR 3, ANGELIKA LARBIG 4, LASSE LEICHER 5, MAYA SOPHIE DE WILDE 6, RUDY LEON DE WILDE 7∗ 1, 2, 3, 4, 5, 6, 7 Carl Von Ossietzky Universitat Oldenburg, Oldenburg, Germany Keywords: Abstract. As the most frequent complication of abdominal surgery, peritoneal adhesions produce significant morbidity Surgery-Induced and an increased risk of vascular, bowel, and organ injury in subsequent surgeries. Yet, antiadhesion agents are not Tissue Adhesions routinely used in most abdominopelvic surgeries. We present a review on the safety, efficacy, and applicability of available Biocompatible Materials antiadhesion agents to support the surgeons decision-making process and provide accurate counseling to patients regarding the type of agent to be used. Searches were conducted in MEDLINE, Pubmed, Wiley Online Library, Directory of Open Access Journals, and Orbis. Though singular agents have been subjected to randomized controlled trials, few head-to-head Received: 15 September 2016 case-control studies comparing multiply available and in-research antiadhesion agents have been performed as of yet. Accepted: 22 December 2016 Available agents are safe and effective in reducing the incidence of de novo adhesions after abdominopelvic surgery or Published: 02 March 2017 adhesiolysis (up to 89%), but no single agent can fully prevent adhesion formation. The proposed “full conditioning” (86% CO2+ 10% N2O + 4% O2 for the pneumoperitoneum, cooling of the peritoneal cavity, humidification, heparinized rinsing solution and 5 mg of dexamethasone, and hyaluronic acid), showed no adhesion formation (p = 0.0001) in 12/16 women with endometriosis. Surgeons should choose the antiadhesion agent most suitable to the underlying disease, type of surgery, and extent of surgical trauma, although no single available agent or surgical strategy can completely prevent adhesions. Guidelines on adhesion prophylaxis are needed. Future research should focus on comparison and combination of available agents. c 2017 KKG Publications. All rights reserved. INTRODUCTION Adhesions are recognized to be the one of most frequent of different substances capable of reducing the postoperative complications in abdominal surgery [1]. Incidence reports differ formation of adhesions. Then the decision to use these products from 20 to 93 percent [2], according to type of surgery, entry is based on consensus which encourages surgeons to assume techniques, operating times and concomitant diseases. Multiple effective steps to prevent adhesions [6], and are especially rec- adhesiogenic entities have been described, amongst which are ommended in “high-risk of adhesions” procedures, regardless of desiccation, CO2-insufflation, traumatic tissue handling, coagu- open or laparoscopic surgery [7]. Of course, patients should be lation and diseases like endometriosis or pelvic inflammatory informed about the risks of adhesion formation and prevention disease. They arise from an imbalance between fibrin produc- strategies. tion and fibrinolysis during the healing process after the surgical For the purpose to support the surgeon’s decision and to trauma, and their presence implies a high risk of complications give an accurate counselling to patients in regard the type of in further surgeries, affecting the patient’s quality of life and agent to be used, we realized a review on the safety and efficacy the budget of the health system. Affected patients showed an of available Antiadhesion Agents (AA). Again, remembering increased morbidity and mortality [3] with a higher incidence that the first step in adhesions prophylaxis is based on a meticu- of intensive care admission, longer hospital stays and a higher lous surgical technique, and adherence to general microsurgical incidence of bowel resections [4]. Additionally, it is well known rules [3], an issue that is of ultimate interest in gynecology and that adhesions tend to reformate after laparoscopic adhesiolysis fertility surgery. in 55-100% of cases [2]. Nevertheless at this time good evidence about the best Available Antiadhesion Agents option to handle with peritoneal adhesions, and methods to An antiadhesion agent is any natural or synthetic sub- assess their efficacy are lacking. Therefore, prevention of stance capable of interfering the adhesions formation process adhesions is a significant unmet need in surgical therapeutics between adjacent anatomic structures normally not attached to [5]. Investigation in this field had led to the development and use each other [4]. To reach its goal, the agent should act during the ∗Corresponding author: Rudy Leon De Wilde yEmail: [email protected] 2017 Int. J. Heal. Med. Sci. 2 first seven days of peritoneal healing, or staying long enough products that cost e130 or e300 need to demonstrate a 26% or during this critical period of adhesion development, leading to a 60% reduction of adhesion-related readmissions, respectively. minor incidence, extension and severity of adhesions, and their Concluding that healthcare systems could save overall costs by associated disorders. using an AA with a reasonable cost-effectiveness ratio. Factors that need to be considered before using an AA Modern products - films, powder, gels and fluids - are not only safety, usability and clinical outcome but also comply with most of the desirable characteristics required to its cost/effectiveness ratio. In the SCAR study [7], costs of produce an effective barrier between adjacent tissues (Table 1), adhesion-related pathology have been modeled by measur- but surgeons continue using Ringer’s solution, that does not ing adhesion-related readmission within the first 3 years after fulfill the requirements to be a very effective AA [3]. surgery, with or without the use of an AA. To be cost-effective, TABLE 1 DESIRABLE CHARACTERISTICS OF AN ANTIADHESION AGENT Adequate intraperitoneal disposition to stay in the peritoneal cavity for the healing process. Effective surface division. No degradation or loss of efficacy in wet or bloody environment. Being resorbed and metabolized with minimal inflammatory response. Has no negative effect on wound healing. Restriction of bacterial growth. Good cost/effectiveness ratio Nevertheless, evidence of safety and effectivity of AA is In a recent Cochrane review of 18 randomized con- limited as a consequence of paucity and the quality of studies. trolled trials of AA with a total of 1262 women undergoing Most of them are observational, not controlled, and non-head to gynecological surgery [10], it was found that there is no effect of head trials. AA on pain or fertility outcome in women of reproductive age, Other products are no longer used because they show though no adverse effects were reported. They also encountered no clear clinical benefits, like antibiotics, non-steroidal anti- that some AA could have stronger anti adhesion effects than no inflammatory drugs, corticosteroids and fibrinolytic drugs. In treatment after pelvic surgery. case of SurgiWrap R (polylactide: copolymer of 70:30 Poly Agents of oxidized regenerated cellulose (Interceed R ) [L-lactide-co-D,L lactide]), a polymer film designed to be reduce