Abstract
Today, 40–66% of elective procedures in general surgery are reoperations. During reoperations, the need for adhesiolysis results in increased operative time and a more complicated convalescence. In pre-clinical evaluation, adhesion barriers are tested for their efficacy in preventing ‘de novo’ adhesion formation, However, it is unknown to which extent barriers are tested for prevention of adhesion reformation. The aim of this systematic review and meta-analysis is to assess the efficacy of commercially available adhesion barriers and laparoscopic adhesiolysis in preventing adhesion reformation in animal models. Pubmed and EMBASE were searched for studies which assessed peritoneal adhesion reformation after a standardized peritoneal injury (in the absence of an intra-peritoneal mesh), and reported the incidence of adhesions, or an adhesion score as outcome. Ninety-three studies were included. No study met the criteria for low risk of bias. None of the commercially available adhesion barriers significantly reduced the incidence of adhesion reformation. Three commercially available adhesion barriers reduced the adhesion score of reformed adhesions, namely Seprafilm (SMD 1.38[95% CI]; p < 0.01), PEG (SMD 2.08[95% CI]; p < 0.01) and Icodextrin (SMD 1.85[95% CI]; p < 0.01). There was no difference between laparoscopic or open adhesiolysis with regard to the incidence of adhesion reformation (RR 1.14[95% CI]; p ≥ 0.05) or the adhesion score (SMD 0.92[95% CI]; p ≥ 0.05). Neither currently commercially available adhesion barriers, nor laparoscopic adhesiolysis without using an adhesion barrier, reduces the incidence of adhesion reformation in animal models. The methodological quality of animal studies is poor.
Highlights
Today, 40–66% of elective procedures in general surgery are reoperations
All other studies were excluded since they assessed de novo adhesion formation, either in the presence of absence an intra-peritoneal mesh (Fig. 1)
There was no difference between laparoscopic or open adhesiolysis with regard to the incidence of adhesion reformation (RR 1.14 [95% CI 0.39, 1.89]; Fig. 7) or adhesion score (SMD 0.92 [−0.04, 1.87]; Supplement Fig S3)
Summary
40–66% of elective procedures in general surgery are reoperations. During reoperations, the need for adhesiolysis results in increased operative time and a more complicated convalescence. The aim of this systematic review and meta-analysis is to assess the efficacy of commercially available adhesion barriers and laparoscopic adhesiolysis in preventing adhesion reformation in animal models. Adhesion barriers may be less efficacious in preventing adhesion reformation This is supported by a clinical study in which icodextrin 4% did significantly reduced formation of de novo adhesions but not adhesion reformation[15]. It is unknown to which extent barriers are tested with regards to their ability to prevent of adhesion reformation It is unclear which experimental animal models are most valid for translation to clinical efficacy. In this systematic review and meta-analysis we assess the efficacy of five commercially available adhesion barriers and laparoscopic adhesiolysis in preventing adhesion reformation in animal models. The impact of different study characteristics on the incidence of adhesion reformation and severity of adhesions was investigated to provide guidance on the design and execution of future animal studies
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