Adhesiolysis Surgery Research Articles

Spontaneous unscarred uterine rupture at 34 weeks of gestation in a primigravid women: A case report

Spontaneous unscarred uterine rupture (SUUR) is a catastrophic obstetric complication. We presented a case of the woman at 34 weeks of gestation without apparent causes of SUUR.: A 28-year-old primigravid woman in her third trimester came to the hospital because of abdominal pain. She had a history of endoscopic surgery for adhesiolysis of bilateral fallopian tubes and untreated thyroid disease. Out of the typical vital signs, preeclampsia was diagnosed. After considering the results of ultrasound images with massive free fluid in the abdomen, the emergency exploratory laparotomy was conducted. We delivered an alive baby and repaired the uterine rupture site. The patient was discharged on the 5 postoperative day in a stable condition.: The endoscopic surgery for adhesion separation of the fallopian tube could be a risk factor for SUUR. Timely diagnosis and management plays a crucial role in the prognosis of women suspected of SUUR.

Reduction of adhesion formation after gynaecological adhesiolysis surgery with 4DryField PH – a retrospective, controlled study with second look laparoscopies

Adhesions are a common consequence of abdomino-pelvic surgery. Efficacy of available adhesion prevention agents is discussed controversially. Here, we used the adhesion barrier 4DryField PH: a powder, which is transformed into a barrier gel with saline solution. The study includes 40 consecutive patients with surgeries for adhesiolysis, endometriosis and other gynaecological pathologies and subsequent second look interventions. The intervention group (n = 17) received 4DryField PH gel while control patients (n = 23) did not receive any adhesion prevention. Severity and extent of adhesion formation were scored during both interventions using an established score. Direct comparison between first and second interventions showed that extent and severity of adhesions could be reduced significantly using 4DryField PH gel. In contrast, in the control group, extent was not reduced and severity was even significantly higher. Direct comparison of second look laparoscopies revealed that adhesion extent and severity were significantly lower in the 4DryField PH than in the control group. Impact Statement What is already known on this subject? Adhesion formation after gynaecologic surgeries is known to be frequent and highly problematic as it directly induces complications and additionally makes subsequent surgeries more difficult. The effectiveness of established adhesion barriers is not sufficient to tackle these problems adequately. What the results of this study add? This is the first controlled study using the relatively new adhesion barrier 4DryField PH. It yields a significant reduction of extent as well as severity of adhesions, while adhesiolysis surgery alone does not solve the problem. What the implications are of these findings for clinical practice and/or further research? Usage of 4DryField PH gel seems to be a good approach to solve the adhesion problem of gynaecologic surgery in general and the reformation problem of adhesiolysis surgery specifically. The results should be confirmed in a larger prospective randomised controlled trial.

Dynamic Hydrogels for Prevention of Post‐Operative Peritoneal Adhesions

AbstractPost‐operative adhesions are fibrous bands of scar tissue formed between internal tissues and organs causing clinical morbidity and their prevention represents a critical unmet need. Over 20 million Americans undergo invasive surgery each year and 95% of those patients develop post‐operative adhesions. More specifically, peritoneal adhesions forming as a result of abdominal surgery can result in severe complications such as chronic pain or adhesive small bowel obstruction requiring secondary adhesiolysis surgery. Additionally, adhesiolysis increases operation times during reoperative procedures and increases the risk of hemorrhage and organ injury upon reentry. This work reports the use of a dynamically crosslinked polymer‐nanoparticle (PNP) hydrogel adhesion barrier comprised of hydrophobically modified hydroxypropylmethylcellulose and biodegradable PEG‐PLA nanoparticles. These materials have desirable viscoelastic and flow properties, long‐term physical stability during storage, permit administration via spraying, enable local retention in the abdominal cavity for 2 weeks, and definitively reduce peritoneal adhesion formation. Using a rodent ischemic button model to generate peritoneal adhesions (n > 4), the PNP hydrogel significantly reduced peritoneal adhesion severity compared to commercial control products when assessed by a standardized 5‐point scale (3.18 ± 1.07 versus 1.35 ± 0.63; p = 0.0014). These results suggest that the PNP hydrogel adhesion barrier is a simple and effective solution for the prevention of peritoneal adhesions.

Encapsulating Peritoneal Sclerosis: A Rare Devastating Peritoneal Disease: Case Series and Literature Review

Background: Encapsulating peritoneal sclerosis is a rare but life-threatening condition in peritoneal dialysis. It is associated with extensive thickening and fibrosis of the peritoneum resulting in recurrent small bowel obstructions and malnutrition. Herein we present case series of encapsulating peritoneal sclerosis diagnosed and treated in a large center of peritoneal dialysis in the State of Qatar followed by literature review to increase the awareness of physicians to it. Case Presentation: The data were collected retrospectively from 180 peritoneal dialysis patients at Hamad General Hospital, Doha, Qatar, between 2008 and 2016. The diagnosis of encapsulating peritoneal sclerosis was based on clinical and radiological features. Seven patients (3.8%) were diagnosed with encapsulating peritoneal sclerosis. The mean age of the patients was 49 years (range, 23 to 65 years). The mean duration of peritoneal dialysis was 6 years (range, 3 to 7 years). The mean peritonitis episodes were 1.8 (range 1 to 4 episodes). Five patients were diagnosed with encapsulating peritoneal sclerosis after stopping peritoneal dialysis, and two patients diagnosed while they were on peritoneal dialysis treatment. Five patients are still alive and were treated with oral prednisolone and tamoxifen. Two patients underwent adhesiolysis surgery, one of them died due to recurrent sepsis and malnutrition. Another patient died because of cardiac arrest during hemodialysis. The overall mortality rate was 28.5% in our series. Conclusions: Encapsulating peritoneal sclerosis is a rare and life-threatening peritoneal disease in chronic peritoneal dialysis patients. It requires high index of suspicion for early diagnosis and treatment.

Allogeneic cell therapy using umbilical cord MSCs on collagen scaffolds for patients with recurrent uterine adhesion: a phase I clinical trial

BackgroundIntrauterine adhesions (IUA) are the most common cause of uterine infertility and are caused by endometrium fibrotic regeneration following severe damage to the endometrium. Although current stem cell treatment options using different types of autologous stem cells have exhibited some beneficial outcomes in IUA patients, the reported drawbacks include variable therapeutic efficacies, invasiveness and treatment unavailability. Therefore, the development of new therapeutic stem cell treatments is critical to improving clinical outcomes.MethodsTwenty-six patients who suffered from infertility caused by recurrent IUA were enrolled in this prospective, non-controlled, phase I clinical trial with a 30-month follow-up. During the procedure, 1 × 107 umbilical cord-derived mesenchymal stromal cells (UC-MSCs), loaded onto a collagen scaffold, were transplanted into the uterine cavity following an adhesion separation procedure. Medical history, physical examination, endometrial thickness, intrauterine adhesion score and the biological molecules related to endometrial proliferation and differentiation were assessed both before and 3 months after cell therapy.ResultsNo treatment-related serious adverse events were found. Three months after the operation, the average maximum endometrial thickness in patients increased, and the intrauterine adhesion score decreased compared to those before the treatment. A histological study showed the upregulation of ERα (estrogen receptor α), vimentin, Ki67 and vWF (von Willebrand factor) expression levels and the downregulation of ΔNP63 expression level, which indicates an improvement in endometrial proliferation, differentiation and neovascularization following treatment. DNA short tandem repeat (STR) analysis showed that the regenerated endometrium contained patient DNA only. By the end of the 30-month follow-up period, ten of the 26 patients had become pregnant, and eight of them had delivered live babies with no obvious birth defects and without placental complications, one patient in the third trimester of pregnancy, and one had a spontaneous abortion at 7 weeks.ConclusionsTransplanting clinical-grade UC-MSCs loaded onto a degradable collagen scaffold into the uterine cavity of patients with recurrent IUA following adhesiolysis surgery is a safety and effective therapeutic method.Trial registrationClinicaltrials.gov. NCT02313415, Registered December 6, 2014.

Use of methylene blue in the prevention of recurrent intra-abdominal postoperative adhesions.

ObjectiveTo evaluate the efficacy of methylene blue in preventing recurrent symptomatic postoperative adhesions.MethodsPatients with a history of >2 surgeries for intra-abdominal adhesion-related complications were selected for this study. Adhesiolysis surgery was subsequently performed using administration of 1% methylene blue. The follow-up period was 28.5 ± 11.1 months.ResultsData were available from 20 patients (seven men and 13 women) whose mean ± SD age was 51.2 ± 11.4 years. Adhesions took longer to become symptomatic after the first abdominal surgery when the initial pathology was malignant compared with benign. However, the recurrence of adhesions after a previous adhesiolysis surgery had a similar time onset regardless of the initial disease. Following adhesiolysis surgery with methylene blue, the majority of patients did not present with symptoms associated with adhesion complications (i.e., chronic abdominal pain, bowel obstruction) for the length of the follow-up period.ConclusionsThe use of methylene blue during adhesiolysis surgery appears to reduce the recurrence of adhesion-related symptoms, suggesting a beneficial effect in the prevention of adhesion formation.

Single Port Robotic Assisted Sacrocolpopexy: Our Experience With the First 25 Cases.

In single-port surgery, the surgeon operates almost exclusively through a single entry point, typically the patient's navel, leaving only a single small scar. The aims of this study were to share some tips and tricks of single-port robotic-assisted sacrocolpopexy and to evaluate the learning curve of mastering the skills to operate this procedure. This is a retrospective study of the first 25 single-port; robotic-assisted sacrocolpopexy surgeries performed during July to December 2015 at Rambam Health Care Campus by a single surgeon.Primary points of interest included intraoperative bleeding, length of surgery, length of hospitalization, and surgical complications. The median age was 59 years (range, 35-74); the median "pelvic organ prolapse quantification" stage was 3 (range, 2-4). The median total operative time was 190 minutes (range, 114-308), and console time was 130 minutes (85-261). Comparisons between the first 15 cases and the following 10 cases demonstrated significant decreases in median total operative and console times: 226 minutes (range, 142-308) versus 156 minutes (range, 114-180), and 170 minutes (range, 85-261) versus 115 minutes (range, 90-270), respectively (P < 0.008). There were no intraoperative adverse events. Postoperative adverse events were also rare, including 1 case of small bowel adhesions that required a second laparoscopic surgery for adhesiolysis. After this incident, we peritonalized the mesh in all 13 successive cases; median time was 8 minutes (range, 5-15 minutes). Single-port robotic-assisted sacrocolpopexy is a feasible procedure with low complication rates, minimal blood loss and postsurgical pain, fast recovery, short hospitalization, and virtually scar-free results. Outcomes of long-term follow-up should be investigated.

Adhesion-related readmissions after surgery for deep endometriosis with the use of icodextrin—long-term results

Icodextrin (Adept®) has been shown to prevent postoperative adhesions in experimental and laparoscopic adhesiolysis surgery. However, the role of icodextrin in the prevention of adhesions in extensive gynecological surgery is unclear. The present study evaluated the effect of icodextrin on adhesion-related readmissions after extensive gynecological surgery. The hospital readmissions of 140 endometriosis patients operated on at Paijat-Hame Central Hospital in 2004–2008 with the use of icodextrin were retrospectively reviewed. The evaluation of readmissions focused on adhesion-related disorders and reoperations. If an abdominal or pelvic reoperation was performed, the extent of the adhesions was classified. The mean follow-up time was 6.53 years (range 0.21–9.83). After initial surgery, one patient (0.7 %) had adhesive small bowel obstruction. Another directly adhesion-related readmission occurred in two patients (1.4 %). The number of readmissions possibly related to adhesions was 3 (2.1 %). Abdominal or pelvic reoperation was performed on 54 patients (38.6 %): 4 in the open surgery group and 50 in the laparoscopic surgery group. The extent of the adhesions among the 54 reoperated patients was as follows: not mentioned in 16 patients, no adhesions in 14, mild in 18, moderate in 5, and severe in 1. There were two (3.7 %) bowel injuries (one enterotomy and one serosal lesion) in reoperations. The incidence of adhesion-related readmissions after the use of icodextrin is relatively low. This favorable result may be partly related to the laparoscopic technique. Despite the use of an anti-adhesion agent, in some patients, the extent of postoperative adhesions is severe.

Displasia cefaloesquelética (síndrome de Taybi-Linder): presentación de un caso y consideraciones anestésicas

IntroductionMicrocephalic osteodysplasic primordial dwarfism (Taybi -Linder syndrome) is a rare disease characterized by bone and central nervous system malformations and intrauterine growth retardation. Case presentationWe report the case of a 20 years patient who underwent intestinal surgery for adhesiolysis and intestinal pexia because of intestinal obstruction by postoperative flanges. ConclusionAs anesthetic considerations of these patients highlight the possible impairment of airway secondary to facial malformations and neurological complications, primarily seizures.

Minimally Invasive Surgery in Gynecologic Oncology

Minimally invasive surgery has been utilized in the field of obstetrics and gynecology as far back as the 1940s when culdoscopy was first introduced as a visualization tool. Gynecologists then began to employ minimally invasive surgery for adhesiolysis and obtaining biopsies but then expanded its use to include procedures such as tubal sterilization (Clyman (1963), L. E. Smale and M. L. Smale (1973), Thompson and Wheeless (1971), Peterson and Behrman (1971)). With advances in instrumentation, the first laparoscopic hysterectomy was successfully performed in 1989 by Reich et al. At the same time, minimally invasive surgery in gynecologic oncology was being developed alongside its benign counterpart. In the 1975s, Rosenoff et al. reported using peritoneoscopy for pretreatment evaluation in ovarian cancer, and Spinelli et al. reported on using laparoscopy for the staging of ovarian cancer. In 1993, Nichols used operative laparoscopy to perform pelvic lymphadenectomy in cervical cancer patients. The initial goals of minimally invasive surgery, not dissimilar to those of modern medicine, were to decrease the morbidity and mortality associated with surgery and therefore improve patient outcomes and patient satisfaction. This review will summarize the history and use of minimally invasive surgery in gynecologic oncology and also highlight new minimally invasive surgical approaches currently in development.

Awareness and perception of intra-abdominal adhesions and related consequences: survey of gynaecologists in German hospitals

Objective Intra-abdominal adhesion formation after abdominal surgery is the most common postsurgical complication, and the consequences are a considerable burden for patients, surgeons and health systems. Since a wide variety of factors influence adhesion formation, it is difficult to define clear guidelines on how to reduce adhesion formation in daily practice. Given this dilemma, this study assessed the awareness and perception of adhesion formation among gynaecologists in Germany in order to define a baseline for further research and education. Study design The Clinical Adhesion Research and Evaluation (CARE) group of the University of Giessen designed a questionnaire that was sent to the heads of all gynaecological departments in Germany. The director or one of the surgical consultants was asked to complete the questionnaire and return it for evaluation. Results The completed questionnaire was returned by 279 of 833 gynaecological departments. Interviewed surgeons expected adhesions to form in 15% of cases after laparoscopy and 40% after laparotomy. Before surgery, 83.1% of the respondents told their patients about the risk of prior adhesion formation. More than 60% believed that postsurgical adhesion accounts for major morbidity. Infections within the abdomen, previous surgery and extensive tissue trauma were thought to have the most influence on adhesion formation. Risk of adhesion formation was thought to be highest in endometriosis and adhesiolysis surgery. The respondents agreed on performing adhesiolysis in symptomatic but not in all patients. Only 38.4% used adhesion reduction agents regularly. A total of 65.1% of a repertoire of adhesion prevention agents were familiar to the interviewed surgeons. Only 22.0% of them used anti-adhesion products in clinical practice. In general, the respondents were uncertain whether these products play an important role in adhesion reduction, represented by a range of 1.97 ± 0.98% on a scale from 0 to 4. Conclusions Even though postoperative adhesions are recognized as a major cause for morbidity, and it is widely agreed that infections, extensive tissue trauma and surgery lead to adhesion formation, there is uncertainty about the treatment and prophylactic strategies for dealing with adhesions. This dilemma reflects the awareness and perception of gynaecologists in Germany and is an initial point for further research.

The effect of 4% icodextrin solution on adhesiolysis surgery time at the Hartmann’s reversal: a pilot, multicentre, randomized control trial vs lactated Ringer’s solution

A pilot randomized controlled clinical multicentre trail was established to compare intraperitoneal 4% icodextrin (ID) solution with lactated Ringer's solution (LRS) on adhesion formation after Hartmann's procedure. The adhesiolysis surgery time during Hartman's reversal was used as a marker of the severity of adhesions. Patients scheduled for Hartmann's resection were randomized at surgery to either of the two study solutions used as an irrigant during the operation and instilled (1000 ml) at the end of surgery. During the reversal procedure, the time for small bowel adhesiolysis was recorded. On completion of 17 eligible patients, an interim analysis was performed. There were no complications following the use of 4% ID solution. The mean (SD) total adhesiolysis times in patients treated with 4% ID solution and LRS were 30.8 (18.0) min and 47.6 (45.7) min, respectively. The mean reduction of 16.8 min, although greater than expected, was not statistically significant (P = 0.33) because of the large variance in adhesiolysis times. Further statistical analysis showed that to achieve significance for the observed differences and variance, a minimum of 240 patients in each group would be required. Icodextrin treatment resulted in a decreasing trend in adhesiolysis time. The use of 4% ID solution in peritonitis patients seemed to be safe. Because of larger than expected variations in adhesiolysis times, this pilot study was underpowered to meet the study end-point and further statistical modelling estimated that significance cannot be reached within a reasonable time scale. Other models should be used to evaluate the efficacy of anti-adhesive agents.

Water‐Soluble Contrast Medium (Gastrografin) Value in Adhesive Small Intestine Obstruction (Asio): A Prospective, Randomized, Controlled, Clinical Trial

Patients with adhesive small intestine obstruction (ASIO) are difficult to evaluate and to manage and their treatment is still controversial. The diagnostic and therapeutic role of water-soluble contrast medium (Gastrografin) in ASIO is still debated. This study was designed to determine the therapeutic role of Gastrografin in patients with ASIO. The study was a multicenter, prospective, randomized, controlled investigation. The primary end points were the evaluation of the operative rate reduction and shortening the hospital stay after the use of Gastrografin. A total of 76 patients were randomized into two groups: the control group received traditional treatment (TT), whereas the study group (GG) received in addition a Gastrografin meal and follow-through study immediately. Patients with Gastrografin in the colon within 36 hours were considered to be partially obstructed and submitted to nonoperative management. If after 36 hours, the Gastrografin had not entered the colon, the subjects were submitted to laparotomy. No significant differences were found in age, sex, intravenous administration of prokinetics, incidence and characteristics of the previous procedures in surgical history of the patients, previous episodes of ASIO and surgery for adhesiolysis, or duration of symptoms before admission. In the GG group obstruction resolved subsequently in 31 of 38 cases (81.5%) after a mean time of 6.4 hours. The remaining seven patients were submitted to surgery, and one of them needed bowel resection for strangulation. In the control group, 21 patients were not submitted to surgery (55%), whereas 17 showed persistent untreatable obstruction and required laparotomy: 2 of them underwent bowel resection for strangulation. The difference in the operative rate between the two treatment groups reached statistical significance (p = 0.013). The time from the hospital admission for obstruction to resolution of symptoms was significantly lower in the GG group (6.4 vs. 43 hours; p < 0.01). The length of hospital stay revealed a significant reduction in the GG group (4.7 vs. 7.8 days; p < 0.05). This reduction was more evident in the subset of patients who did not require surgery (3 vs. 5.1 days; p < 0.01). No GG-related complications or significant differences in major complications and the relapse rate were found (relapse rate, 34.2% after a mean time to relapse of 6.3 months in the GG group vs. 42.1% after 7.6 months in the TT; p = not significant). Data showed that the use of Gastrografin in ASIO is safe and reduces the operative rate and the time to resolution of obstruction, as well as the hospital stay.

Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study

To evaluate the efficacy and safety of Adept (4% icodextrin solution) in reducing adhesions after laparoscopic gynecological surgery involving adhesiolysis. Multicenter, prospective, randomized, double-blind study comparing Adept with lactated Ringer's solution (LRS). Four hundred two patients randomized intraoperatively to Adept (n = 203) or LRS (n = 199) returned for second laparoscopy within 4-8 weeks. Incidence, severity, and extent of adhesions were determined on both occasions. The primary efficacy measure defined by the Food and Drug Administration was the number of patients achieving clinical success with adhesion treatment. Other measures included incidence and American Fertility Society (AFS) scores. Significantly more Adept patients achieved clinical success than did LRS patients (49% vs. 38%). In infertility patients, Adept demonstrated particular clinical success compared with LRS (55% vs. 33%). This was reflected in the number of patients with a reduced AFS score (53% vs. 30%) and in fewer patients with a moderate/severe AFS category score (43% vs. 14%). Safety was comparable in both groups. Most events were related to the surgery, with an increase in transient labial edema in the Adept group. This is the first randomized, double-blind trial of an adhesion reduction agent. It demonstrated that Adept is a safe and effective adhesion reduction agent in laparoscopy.

Adhesions Caused by Umbilical Piercing

A 31-year-old woman experienced chronic pelvic pain, unresponsive to medical therapy. History, physical examination, and laboratory analyses were noncontributory except for multiple body piercings. Diagnostic laparoscopy revealed an umbilical adhesion from the small bowel to the anterior abdominal wall. The patient removed the umbilical piercing but declined surgery for adhesiolysis.

Laparoscopic surgery and adhesiolysis

Objectives To evaluate the degree of adhesion formation at laparoscopic surgery in different patient groups. Design A retrospective study using the American Fertility Society's Adhesion Scoring Method and the MCASM (More Comprehensive Adhesion Scoring Method). Subjects The 465 patients with adhesions among 2124 patients who underwent laparoscopy. Results Details of the 465 cases of adhesiolysis are given. In subgroup 1 (n = 34) there were no pre-existing adhesions. All 34 patients were assessed for adhesion occurrence at a second-look laparoscopy after 6–8 weeks; 29.4% were found to have no adhesions and 70.6% of patients had significant or mild adhesions. A more comprehensive adhesion scoring method (MCASM) was found to be more objective in the assessment of adhesions; however, it was difficult to record in an easily readable manner. In subgroup 2, 21 patients who had undergone previous surgery for adhesiolysis were operated upon again, and 24% revealed an increased adhesion score, 57% the same adhesion score and 19% a reduced adhesion score at second-look laparoscopy. Conclusions The new data confirmed our previous knowledge: to avoid adhesions one must avoid surgery. If surgery has to be performed, laparoscopic surgery causes fewer adhesions than laparotomy.