Two adhesion barriers reduce adhesions after infertility surgery
Two physical barriers reduced adhesions after pelvic surgery in infertility patients, a 1994 review finds. The author concludes clinical studies do not support dextran. Saline-type fluid placed after surgery did not prevent adhesions in clinical observation. In a multicenter study, about 7 out of 10 sites where laparoscopy had cut adhesions showed adhesions again at an early second look.
Key Findings
In a randomized multicenter evaluation of infertility patients, Interceed-covered sidewalls had significantly fewer, smaller and less severe adhesions than uncovered sidewalls; 90% of Interceed-treated patients benefited.
In a randomized paired comparison of 24 patients, one sidewall received Interceed and the other Gore-Tex Surgical Membrane; both barriers markedly reduced adhesions, by 85% and 66% respectively.
After laparoscopic adhesiolysis, 67% of areas where adhesions were lysed contained adhesions at early second-look laparoscopy; new adhesions appeared in 16% of patients, at 25% of the available sites in those patients.
Four early-1980s studies of dextran against crystalloid (n = 204 combined): two found fewer adhesions with dextran, two found no difference, and about 80% of crystalloid patients had adhesion reformation.
Hospital stays for surgery to cut abdominal and pelvic adhesions cost the United States $1,179.9 million in 1988: $254.9 million in hospital costs and $925 million in surgeons' fees.
Interpretation
This 1994 review looked at ways to stop adhesions after pelvic and infertility surgery. The review drew on animal studies, randomized trials and conference reports. Barrier trials checked for adhesions at a second surgery. Doctors call this second-look laparoscopy. The Interceed trials included infertility surgery patients. Among them were 28 patients who had surgery for severe endometriosis in a Japanese study. The author notes it is hard to prove a direct link between stopping adhesions and later problems such as pain, bowel blockage and infertility. The findings support larger trials of barrier methods in pelvic and infertility surgery.
RRM Context
Surgical NaProTechnology, developed by Dr. Thomas W. Hilgers, builds adhesion prevention into reconstructive gynecologic surgery. Excision of endometriosis can leave raw peritoneal surfaces, the tissue whose repair and adhesion formation this review traces. The review names Interceed and Gore-Tex Surgical Membrane as the barriers of its day.
Our editorial summary of this paper, not the article's abstract.
Abstract
Objective
To (1) review the events leading to peritoneal adhesion formation; (2) review traditional adhesion prevention adjuvants; (3) overview studies for adhesion prevention barriers including a perspective for their use; and (4) look toward the future of adhesion prevention.
Results
A great deal of effort has been dedicated to reduce adhesion formation because of the morbidity associated with adhesions and the associated economic burden, which considering only hospital costs and surgeons' fees, was $1,180 million in the United States. To understand the role of adhesion barriers in gynecological surgery, an appreciation of the cellular cascade and temporal nature of peritoneal repair is necessary. Evidence indicates that areas denuded of peritoneum will heal satisfactorily and that suturing of the peritoneum may increase adhesion formation. Physical barriers, including both mechanical and viscous solutions, are widely used to prevent adhesion formation by limiting tissue apposition during the critical stages of mesothelial repair. Clinical studies do not support the use of intraperitoneal, dextran for adhesion prevention. Theoretical considerations of peritoneal fluid dynamics indicate that crystalloid instillates should not prevent adhesion formation because of their short intraperitoneal residence. This prediction is consistent with clinical observation. The availability of Interceed (Johnson and Johnson Medical, Inc., Arlington, TX) and Gore-Tex Surgical Membrane (W.L. Gore, Flagstaff, Arizona) barriers provides substantial progress in postsurgical adhesion prevention.
Conclusions
Although many investigators are incorporating adhesion prevention barriers into their routine clinical situations, physician acceptance is constrained by technical difficulties.
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