Laparoscopic Lysis Of Adhesions Research Articles

Laparoscopic Management of Tubo-Ovarian Abscess Refractory to Percutaneous Drainage

<h3>Study Objective</h3> To demonstrate the feasibility and safety of a laparoscopic approach to a case of tubo-ovarian abscess (TOA) refractory to percutaneous drainage and antibiotic therapy. <h3>Design</h3> Case report. <h3>Setting</h3> Operating room with traditional laparoscopy. <h3>Patients or Participants</h3> 30-year-old female patient with refractory TOA. <h3>Interventions</h3> Laparoscopic lysis of adhesions, bilateral salpingectomy, right oophorectomy, wash out and drain placement. <h3>Measurements and Main Results</h3> The patient is a 30-year-old female who presented with a 16cm TOA, initially managed with parenteral antibiotics and percutaneous drainage. However, despite initial improvement, the abscess continued to re-accumulate, refractory to a total of three percutaneous drain placements over the course of 8 weeks. She was taken to the operating room for laparoscopic resection of the TOA. Four port sites were utilized, three 5mm ports and one 10mm port. Survey of the pelvis revealed dense adhesions, bilateral pyosalpinx, and residual large abscess encompassing the right ovary. Given the patient's prolonged pre-operative course and her consent for loss of future fertility, the decision was made to proceed with bilateral salpingectomy and right oophorectomy. The right adnexal structures were densely adherent to the pelvic side wall and cul de sac; therefore, retroperitoneal dissection was utilized to identify important landmarks including the medial umbilical ligament, uterine artery and ureter in order to safely remove the diseased tissue without injuring the surrounding vital structures. The pelvis was irrigated and a JP drain was placed. She was discharged home on the same day. She had an uncomplicated post-operative course. Final surgical pathology revealed chronic and active salpingitis as well as focal endometriosis. <h3>Conclusion</h3> Laparoscopy is a safe and feasible surgical approach to the management of tubo-ovarian abscess refractory to percutaneous drain placement. The surgeon should be adept and familiar with retroperitoneal dissection to ensure safety of surrounding structures in the setting of dense adhesive disease and inflammation.

Impact of hospital volume on outcomes for laparoscopic adhesiolysis for small bowel obstruction

BackgroundVolume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs. Materials and methodsThe Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant. ResultsA total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017). ConclusionsThis study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.

Will laparoscopic lysis of adhesions become the standard of care? Evaluating trends and outcomes in laparoscopic management of small-bowel obstruction using the American College of Surgeons National Surgical Quality Improvement Project Database.

Small-bowel obstruction (SBO) is a common disorder and constitutes a significant healthcare burden. Laparoscopic lysis of adhesions (LLOA) for SBO is predicted to decrease complications, shorten hospital stay, and cut healthcare costs compared with the open lysis of adhesions (OLOA); however, large comparison studies are lacking.We evaluated the nationwide adoption of LLOA and compared outcomes with OLOA. We retrospectively analyzed data from 9920 OLOA and 3269 LLOA cases from 2005 to 2013 using the American College of Surgeons prospective National Surgical Quality Improvement Program data set. Annual trends were evaluated using linear regression.Surgery outcomes were compared using two-sample t tests or Mann-Whitney tests. Post-surgical complications were compared using multivariable logistic regression adjusting for comorbidities. The proportion of SBO cases treated by LLOA increased nationwide by 1.6 percent per year (R 2 0.87), from 17.2% in 2006 to 28.7% in 2013. Patients undergoing OLOA had longer operations (66 vs 60min, P<0.001), longer hospital stay (8.9 vs 4.2days, P<0.001), and higher post-surgical complication rates (adjusted odds ratio 2.73 95% CI 2.36-3.15, P<0.001) when compared to LLOA. Despite the lack of prospective randomized trials comparing LLOA to OLOA, we found progressive nationwide adoption of LLOA for SBO treatment. Our large retrospective analysis demonstrated clinical benefit and reduced resource utilization for LLOA.

PWE-268 A systematic review comparing laparoscopic versus open adhesiolysis in patients with adhesional small bowel obstruction

Introduction The objective of this article is to evaluate whether surgical outcomes differ between laparoscopic versus open approach for adhesiolysis in patients presenting with adhesional small bowel obstruction (ASBO). Method A systematic review of literature on published comparative studies reporting the surgical outcomes following laparoscopic versus open adhesiolysis for ASBO was undertaken using the principles of meta-analysis. Results Ten retrospective comparative studies on 37,038 patients evaluating the surgical outcomes in patients undergoing laparoscopic versus open adhesiolysis for ASBO were systematically analysed. There were 31778 patients in open group and 5260 patients in laparoscopic group. Laparoscopic adhesiolysis resulted in the reduced risk of post-operative complications [odds ratio, 0.36 (CI, 0.28–0.46), p < 0.00001], post-operative mortality [odds ratio, 0.31 (CI, 0.23–0.42), p < 0.00001] and surgical site infections [odds ratio, 0.22 (CI, 0.12–0.43), p < 0.00001]. In addition, the risk of respiratory complications, cardiac complications, bowel resection, post-operative ileus, venous thromboembolism [odds ratio, 0.36 (CI, 0.24–0.53), p < 0.00001] and infective complications [odds ratio, 0.41 (CI, 0.34–0.49), p < 0.00001] was also lower in patients undergoing laparoscopic adhesiolysis. Length of hospital stay was statistically shorter in laparoscopic group. However, statistical equivalence was seen in variables of re-operation rate, duration of operation and risk of neurological complications. There was significant heterogeneity among included studies. Conclusion Laparoscopic adhesiolysis for ASBO seems to have clinically proven advantage over open approach in terms of several operative and post-operative outcomes measures in patients whom the procedure was considered feasible. Disclosure of interest None Declared.

A Comparative Analysis between Laparoscopic and Open Adhesiolysis at a Tertiary Care Center

Laparotomy has been the favored approach regarding surgical management of small bowel obstruction (SBO); however, laparoscopy may offer improved outcomes. Patients undergoing laparoscopic lysis of adhesions (LOA) at our institution for SBO will have lower postoperative morbidity and 30-day mortality. Patients undergoing LOA at our institution, from 2000 to 2011, were reviewed. Categorical data were analyzed with χ(2) or Fisher's exact tests. Continuous data were analyzed with Student's t test or Wilcoxon rank sum. One hundred two (38 laparoscopic, 64 open) LOA cases were selected. Perioperative contamination and conservative management were higher in the open group. Open cases had a greater incidence of intensive care unit (ICU) admissions and longer length of stay. Stratified analysis determined a strong association between perioperative contamination and a higher incidence of ICU admission, perioperative contamination and longer LOS, and conservative management and longer LOS. Finally, patient outcome did not differ between those treated by surgeons trained in minimally invasive surgery (MIS) compared with those not trained in MIS. Careful consideration of surgical approach and timing is called for in all patients with SBO; however, whenever possible, laparoscopic preference should be given to most patients in an expeditious fashion irrespective of MIS training.

Laparoscopy and complicated meckel diverticulum in children.

Background and Objectives:Meckel diverticulum can present with a variety of complications but is often found incidentally during other surgical procedures. The role of laparoscopy in the management of Meckel diverticulum is established. We reviewed our experience with complicated cases of Meckel diverticulum in children managed with laparoscopy.Methods:A 15-year retrospective chart review revealed 14 cases of complicated Meckel diverticulum managed with laparoscopy. Incidentally found Meckel diverticulum and cases done by laparotomy were excluded. Ages varied from 2 years to 16 years old. There were 10 males and four females. Eight cases had small bowel obstruction; of those, three had extensive intestinal gangrene. Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum.Results:Eleven cases were treated with laparoscopic Meckel diverticulectomy and three with laparoscopic-assisted bowel resection because of extensive gangrene of the intestine. Two of the three cases with significant intestinal gangrene returned several weeks later with small bowel obstruction secondary to adhesions. They were successfully managed with laparoscopic lysis of adhesions. There were no other complications.Conclusions:Laparoscopy is safe and effective in the management of complicated Meckel diverticulum in children. Most cases can be managed with simple diverticulectomy. Laparoscopy is useful when the diagnosis is uncertain. When extensive gangrene is present, laparoscopy can help to mobilize the intestine and evaluate the degree of damage, irrigate and cleanse the peritoneal cavity, and minimize the incision necessary to accomplish the bowel resection.

Minimally Invasive Surgery in the Management of Adhesive Small Bowel Obstruction: A Rare Case

Introduction: We present the management of a patient who failed conservative management of adhesive small bowel obstruction (ASBO), which was treated with laparoscopic lysis of adhesions. Presentation of Case: A 66 year old, hypertensive, diabetic patient with previous gynaecological surgery presents with symptoms of intestinal obstruction for 2 days. Clinical & radiological features are consistent with the diagnosis of SBO. Conservative treatment was started but the patient failed to show any signs of resolution. Laparoscopic adhesiolysis was successfully performed on thin adhesions between the liver and the anterior abdominal wall (possible Fitz-Hugh Curtis syndrome), which trapped the small bowel. The patient was discharged on day 4 of admission. Discussion: ASBO is a very common and actual disease and its management deserves great attention. Although surgeons are hesitant to perform laparoscopy in patients with distended small bowel due to adhesive obstruction, laparoscopic surgery performed by experienced surgeons offers the opportunity of shorter hospital stay, quick recovery and less morbidity, including wound sepsis and incisional hernia when compared with laparotomy. Conclusion: Minimally invasive surgery (MIS) in ASBO is not standard of care, however, selected patients may benefit from the advantages of this approach. Once the necessary expertises are available, an attempt to treat these patients with MIS may be safe, and as such, should be entertained.

The first nationwide evaluation of robotic general surgery: a regionalized, small but safe start

The purpose of this study was to evaluate the outcomes of the most commonly performed robotic-assisted general surgery (RAGS) procedures in a nationwide database and compare them with their laparoscopic counterparts. The Nationwide Inpatient Sample was queried from October 2008 to December 2010 for patients undergoing elective, abdominal RAGS procedures. The two most common, robotic-assisted fundoplication (RF) and gastroenterostomy without gastrectomy (RG), were individually compared with the laparoscopic counterparts (LF and LG, respectively). During the study, 297,335 patients underwent abdominal general surgery procedures, in which 1,809 (0.6 %) utilized robotic-assistance. From 2009 to 2010, the incidence of RAGS nearly doubled from 573 to 1128 cases. The top five RAGS procedures by frequency were LG, LF, laparoscopic lysis of adhesions, other anterior resection of rectum, and laparoscopic sigmoidectomy. Eight of the top ten RAGS were colorectal or foregut operations. RG was performed in 282 patients (0.9 %) and LG in 29,677 patients (99.1 %). When comparing RG with LG there was no difference in age, gender, race, Charlson comorbidity index (CCI), postoperative complications, or mortality; however, length of stay (LOS) was longer in RG (2.5 ± 2.4 vs. 2.2 ± 1.5 days; p < 0.0001). Total cost for RG was substantially higher ($60,837 ± 28,887 vs. $42,743 ± 23,366; p < 0.0001), and more often performed at teaching hospitals (87.2 vs. 50.9 %; p < 0.0001) in urban areas (100 vs. 93.0 %; p < 0.0001). RF was performed in 272 patients (3.5 %) and LF in 7,484 patients (96.5 %). RF patients were more often male compared with LF (38.2 vs. 32.3 %; p < 0.05); however, there was no difference in age, race, CCI, LOS, or postoperative complications. RF was more expensive than LF ($37,638 ± 21,134 vs. $32,947 ± 24,052; p < 0.0001), and more often performed at teaching hospitals (72.4 vs. 54.9 %; p < 0.0001) in urban areas (98.5 vs. 88.7 %; p < 0.0001). This nationwide study of RAGS exemplifies its low but increasing incidence across the country. RAGS is regionalized to urban teaching centers compared with conventional laparoscopic techniques. Despite similar postoperative outcomes, there is significantly increased cost associated with RAGS.

Gastro-jejunal Obstruction Caused by Clotting after Gastric Bypass Surgery: A Case Series

Purpose: One of the most frequent surgical modalities for the treatment of obesity is the Roux-en-Y gastric bypass (RYGB). Previously described complications of RYGB include stomal stenosis, gastric staple line dehiscence, leaks, jejunal and gastric wall necrosis, and loculated fluid collections. Another reported complication is post-operative intraluminal bleeding, which is usually self-limiting. However, it is uncommon to encounter early gastric outlet obstruction secondary to intraluminal blood clots. Intraluminal blood clot formation causing obstruction post RYGB has been reported in only a few case reports, where management predominantly included laparotomy and surgical revision. We report a case series of three patients who developed intraluminal blood clots at the gastro-jejunal anastomosis following robotically-assisted RYGB occurring within 72 hours of surgery. Our first case involves a 63-year-old woman with morbid obesity (BMI 42) who presented with persistent nausea and vomiting for 3 days after an elective, robotically-assisted RYGB and laparoscopic lysis of adhesions. After the procedure, the patient underwent a routine upper GI series without evidence of leakage from the visualized pouch; however, there was no evidence of emptying into the alimentary limb. Physical exam revealed a distended abdomen which was appropriately tender to palpation at the surgical site. EGD was performed and a large blood clot was visualized at the anastomotic site, causing a gastric outlet obstruction. After unsuccessful attempts at irrigation of the clot, biopsy forceps were utilized to fragment the clot. Thereafter, an 8-mm balloon was advanced twice through the clot and inflated to successfully create a lumen. Case 2 and Case 3 include a 53-year old woman (BMI 46) and a 29-year old woman (BMI 43), respectively, who were both admitted for elective RYGB. Both patients experienced persistent nausea for 3 days after surgery. Upper GI series revealed retention of contrast in the gastric pouch, concerning for a gastro-jejunal anastomotic stricture. A subsequent EGD revealed friable, ulcerated, and granulated clot tissue at the gastro-jejunal anastomosis. Thus, a 10-mm gastroscope was passed across the surgical anastomosis to break the clot and relieve the obstruction allowing for passage into the alimenatary limb. Endoscopic dilation has become the elected treatment for gastrojejunal anastomotic stricture after RYGB, due to the low morbidity of this procedure. We highlight three cases of obstructing blood clots at the gastro-jejunal anastomosis managed endoscopically. Endoscopic evaluation and evacuation of clot and fibrinous material should be pursued prior to proceeding straight to laparotomy.

Surgical Failures: Is it the Surgeon or the Patient? The all too often Missed Diagnosis of Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) is a closely related group of disorders caused by a heritable defect in collagen synthesis, which leads to marked healing difficulties. It has been estimated to occur in between one in 2500 and one in 5000 individuals but likely occurs more frequently than reported. EDS has probably been seen by all general surgeons several times over the course of a career. The purpose of this report is to describe the findings that should raise the index of suspicion, to aid in the diagnosis, and to characterize the general surgical procedures seen in patients with EDS by reviewing a single surgeon's experience in managing such patients with a review of the literature. Recommendations for treatment are given. A retrospective review of the experience of a single surgeon of 25 procedures in 15 patients with EDS is being reported. This is believed to be the largest series by one surgeon as yet reported. There was a wide variety of procedures performed, including ventral hernia repair (n = 6), inguinal hernia repair (n = 4), colectomy (n = 3), anal fistula (n = 3), and one each of an exploratory laparotomy, an appendectomy, a closure of a dehiscence, a Hickman catheter placement, an open lysis of adhesions for small bowel obstruction (SBO), a laparoscopic lysis of adhesions for SBO, an open cholecystectomy, a laparoscopic cholecystectomy, and an excision of a round ligament endometrioma. There was only one death, which was in a patient with Type IV EDS who was the first patient in this series. He presented with a spontaneous sigmoid perforation treated by Hartmann procedure and went on to develop two more colon perforations and to die of sepsis. The morbidity included only two recurrent ventral hernias, a wound dehiscence, a wound hematoma, and recurrence of the anal fistula. Although patients with EDS pose significant healing problems, successful general surgical procedures can be performed in most patients. Among other recommendations, total avoidance of colon anastomoses and colostomies in favor of total abdominal colectomy and ileostomy and routine closure of the abdominal wall with mesh or retention sutures is advocated. Making the diagnosis is the key to having successful outcomes. Further recommendations on avoiding operation and on the conduct of the operation, if needed, are given.

Surgical Management of Pediatric Adhesive Bowel Obstruction

The objective of this study was to analyze a population-based database for recent trends in surgical management of pediatric adhesive bowel obstruction and compare open versus laparoscopic lysis of adhesions (LOA). Pediatric adhesive bowel obstruction cases were identified in the Kids' Inpatients Database from 1997, 2000, 2003, 2006, and 2009. Data analysis included patients' demographics, hospital variables, length of stay (LOS), and total hospital charges (THC). Complications analysis included postoperative shock, hemorrhage, hematoma, seroma, wound complications, infection, fistula, and pulmonary complications. In total, 20,679 pediatric adhesive bowel obstruction cases were identified during the study period. These were characterized by a median age of 11 years old, with 59.0% of the population female. Overall treatment included 88.6% open and 11.4% laparoscopic LOA. A more than twofold increase in utilization of laparoscopy was observed from 7.2% in 1997 to 17.2% in 2009 (P<.001). Complication rates were lower for laparoscopic LOA versus open (5.6% versus 10.4%; odds ratio 0.512; 95% confidence interval 0.394-0.667; P<.001), especially accidental puncture or laceration rate (2.2% versus 3.9%; odds ratio 0.566; 95% confidence interval 0.375-0.854; P=.006). Conversion to open LOA occurred in 1.9%. Laparoscopy was associated with a shorter median LOS (6 versus 8 days; P<.001) and a lower mean THC ($38,241.11 versus $48,552.51; P<.001) compared with open LOA. Multivariate regression analysis did not find hospital bed size, location, teaching status, and regions to be statistically significant predictors for utilization of laparoscopy. Laparoscopic LOA is a safe option for pediatric adhesive bowel obstruction with lower complication rates and a reduced economic burden. Despite the increase in utilization of laparoscopy in recent years, only a minority of patients underwent laparoscopic LOA. Further studies are needed to identify and characterize the subgroup of patients who benefit from laparoscopic LOA.

Laparoscopic Lysis of Adhesions for Small Bowel Obstruction is an Uncommon but Safe Procedure

Laparoscopic Lysis of Adhesions for Small Bowel Obstruction is an Uncommon but Safe Procedure

Survey of opinions on operative management of adhesive small bowel obstruction: laparoscopy versus laparotomy in the state of connecticut

This study sought to know the opinions of general surgeons registered in the state of Connecticut about their use of laparoscopic lysis of adhesions (LLA) to manage adhesive small bowel obstruction (SBO) compared with open lysis of adhesions (OLA) in terms of safety, contraindications, and outcomes. A questionnaire was designed to gather the opinions of general surgeons registered in Connecticut on this topic. The questionnaire was administered electronically and through the mail. Of the 205 general surgeons to whom the questionnaire was sent, 87 completed it (42% response). The respondents were evenly distributed throughout Connecticut. Of these respondents, 9% were university teaching hospital faculty, 55% were community teaching hospital based, and 36% were community nonteaching hospital based. The answers to the questions were expressed as percentages and differences between groups tested using Fisher's exact test, with the significance level set at a P value less than 0.05. According to their self-reports, 60% of the respondents used LLA in their practice, with 38% of this group using LLA for less than 15% of their adhesive SBO cases. Compared with surgeons out of training less than 15 years, a greater number of surgeons out of training more than 15 years considered LLA to be safer (P = 0.03) and to have better outcomes (P = 0.04) than OLA. More surgeons in academic/teaching settings considered LLA to be safe than did surgeons in nonacademic/nonteaching settings (P = 0.04), and more members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)/Society of Laparoendoscopic Surgeons (SLS) considered LLA to be safe than nonmembers (P = 0.001). Many surgeons do not perform LLA for reasons that differ from those in the surgical literature, which supports LLA. Surgeons recently trained or with membership in minimally invasive surgery (MIS) societies are more likely to use LLA. These data suggest that recent training and interest or membership in MIS associations influence surgeons' choice for LLA. This survey demonstrated that an opportunity exists to improve patient outcomes with education about the merits of LLA in the state of Connecticut.

Is Operative Conversion Necessary for Patients Diagnosed With Dense Adhesions During an Elective Laparoscopic Colectomy?

Laparoscopic colectomy is often complicated by adhesions. Studies examining the morbidity of laparoscopic lysis of adhesions (LOA) combined with colectomy are sparse. The goal of this study was to prospectively evaluate the results of using the harmonic scalpel to lyse adhesions in patients undergoing laparoscopic colectomy. Laparoscopic colectomy was performed in 83 patients between November 2003 and April 2007. A total of 20 patients underwent laparoscopic colectomy with LOA and 53 patients underwent laparoscopic colectomy alone. Patients were prospectively followed to determine operative time (OT), blood loss, operative conversion, length of stay (LOS), and 30-day morbidity. Operative conversion was 2%, mean estimated blood loss (EBL) was 95+/-84 mL, and mean OT was 220+/-64 minutes. There were no anastomotic leaks or perioperative mortalities. There were 9 major complications (11%). Patients undergoing laparoscopic colectomy with LOA (n=20) compared with patients undergoing laparoscopic colectomy alone (n=63) had similar conversion rates (5% vs 2%), EBL (115+/-108 vs 88+/-74 mL), and major complications (15% vs 10%), but prolonged minor complications (25% vs 6%) and LOS (6.0+/-3.0 vs 4.6+/-1.5 days). Laparoscopic LOA combined with colectomy leads to similar conversion rates and major morbidity compared to laparoscopic colectomy alone.

Nationwide Impact of Laparoscopic Lysis of Adhesions in the Management of Intestinal Obstruction in the US

Treatment of adhesion-related complications is cost intensive and presents a considerable burden to the health care system. The objective of this study was to compare open (OLA) and laparoscopic lysis of adhesions (LLA) in the treatment of intestinal obstruction, based on a nationwide representative sample. Patients with intestinal obstruction undergoing OLA, LLA, and conversion were identified from the 2002 National Inpatient Sample. After propensity methods were used to adjust for covariates including patient demographics, hospital characteristics, and comorbidities, the impact of OLA and LLA was analyzed concerning in-hospital mortality, postoperative complications, length of stay (LOS), and in-hospital costs. Of 6,165 patients, 88.6% underwent OLA and 11.4% had LLA. Conversion was required in 17.2% of LLA patients. Unadjusted mortality was equal between LLA and conversion (1.7%) and half the rate compared with OLA (3.4%) (p = 0.014). After adjusting with propensity methods, the odds of complications in the LLA group (intention to treat) were 25% less than in the OLA (p = 0.008). The LLA group had a 27% shorter LOS (p = 0.0001) and was 9% less expensive than the OLA group (p = 0.0003). There was no statistical significant difference for LOS, complications, and costs between the conversion and OLA groups. Results from this study suggest that when LLA is applied to selected patients with intestinal obstruction, there are reductions in postoperative complications, LOS, and costs. Prospective studies are needed to confirm these data and better identify the subgroup of patients who have improved outcomes with LLA.

394: Laparoscopic Lysis of Adhesions for Severe Endometriosis with a Right Ureteral Stricture

394: Laparoscopic Lysis of Adhesions for Severe Endometriosis with a Right Ureteral Stricture

A neurokinin 1 receptor antagonist decreases adhesion reformation after laparoscopic lysis of adhesions in a rat model of adhesion formation

Up to 94% of patients experience fibrous adhesions after abdominal surgery, and a significant number of these patients require a second operation for open or laparoscopic lysis of adhesions (LOA). The authors have previously shown that inhibition of the binding of tachykinin ligands to the neurokinin 1 receptor (NK-1R) using the neurokinin 1 receptor antagonist (NK-1RA) CJ-12,255 decreases primary adhesion formation and upregulates the peritoneal fibrinolytic system in a rat model. Whereas most studies have focused on the prevention of primary adhesions, few have addressed adhesion reformation after LOA. This study aimed to determine the effects of NK-1RA administration on adhesion reformation and peritoneal fibrinolytic activity after laparoscopic LOA. Adhesions were induced in 31 rats using our previously described ischemic button model. The rats underwent laparoscopy 7 days later, during which adhesions were scored and lysed followed by administration of the NK-1RA or saline. Then 7 days after LOA, 23 rats were killed and adhesions were scored. Eight rats also were killed 24 h after the LOA to obtain peritoneal tissue and fluid, which were analyzed for tissue plasminogen activator (tPA) mRNA expression and peritoneal fibrinolytic activity by reverse transcriptase-polymerase chain reaction (RT-PCR) and bioassay, respectively. At laparoscopy, 79% +/- 3% of the buttons formed adhesions. In the saline-administered control animals, 42% +/- 3.2% of the buttons reformed adhesions after LOA (p < 0.05), whereas in the animals that received the NK-1RA, 18.2% +/- 3.5% of the buttons reformed adhesions (p < 0.05). As compared with control animals, NK-1RA administration increased tPA mRNA levels by 38% and fibrinolytic activity sixfold (p < 0.05; 7.0 +/- 2.1 U/ml vs 1.2 +/- 0.54 U/ml). When administered during laparoscopic LOA, an NK-1RA significantly upregulates peritoneal fibrinolytic activity and decreases adhesion reformation.

30: Open lysis of adhesions decreases adhesion reformation more effectively than laparoscopic lysis of adhesions in a rat model

30: Open lysis of adhesions decreases adhesion reformation more effectively than laparoscopic lysis of adhesions in a rat model

A neurokinin 1 receptor antagonist (NK-1RA) decreases adhesion reformation after laparoscopic lysis of adhesions (LOA) in a rat model

A neurokinin 1 receptor antagonist (NK-1RA) decreases adhesion reformation after laparoscopic lysis of adhesions (LOA) in a rat model

Results after laparoscopic lysis of adhesions and placement of seprafilm for intractable abdominal pain.

The surgical treatment of patients with chronic abdominal pain resulting from intraabdominal adhesions is controversial. We report our experience with treatment of this challenging patient population using laparoscopic lysis of adhesions (LOA) and placement of Seprafilm (Genzyme, Cambridge, MA, USA). The participants in this study were 19 consecutive patients (2 men and 17 women) who underwent laparoscopic LOA and placement of Seprafilm between July 1998 and July 2001. Patients with abdominal pain resulting from irritable bowel syndrome, hernias, or endometriosis were excluded. The patients had undergone a mean of 6.4 previous abdominal procedures (range, 1-14) and 2.3 previous LOAs (range, 0-10). They had experienced chronic, intractable abdominal pain for at least 4 months (range, 4-180). Eight patients had preoperative obstructive symptoms. A completely laparoscopic procedure was used to treat 16 patients, whereas the procedure for 3 patients was converted to open surgery because of dense adhesions. Perioperative complications included two patients in whom enterocutaneous fistulae developed and one patient with intraabdominal hematoma. At follow-up (mean, 9.6 months; range, 1-32 months), 14 patients (73.7%) had completely discontinued all pain medications. At this writing, 12 of these patients are completely symptom free. Two patients are taking nonsteroidal antiinflammatory drugs (NSAIDs) as needed, and three patients require round-the-clock narcotics. Three patients were readmitted with small bowel obstruction, which was managed nonoperatively. One patient had diagnostic laparoscopy for recurrent pain 6 months postoperatively, but had no adhesions. Chronic intractable abdominal pain is relieved in most patients via this approach. Repeat laparoscopy in two patients showed no intraabdominal adhesions. Laparoscopic LOA and placement of Seprafilm is an excellent approach to this challenging patient population with symptoms caused by intraabdominal adhesions.