Postoperative Adhesion Development Research Articles

Neutrophil Extracellular Traps: A Crucial Factor in Post-Surgical Abdominal Adhesion Formation.

Post-surgical abdominal adhesions, although poorly understood, are highly prevalent. The molecular processes underlying their formation remain elusive. This review aims to assess the relationship between neutrophil extracellular traps (NETs) and the generation of postoperative peritoneal adhesions and to discuss methods for mitigating peritoneal adhesions. A keyword or medical subject heading (MeSH) search for all original articles and reviews was performed in PubMed and Google Scholar. It included studies assessing peritoneal adhesion reformation after abdominal surgery from 2003 to 2023. After assessing for eligibility, the selected articles were evaluated using the Critical Appraisal Skills Programme checklist for qualitative research. The search yielded 127 full-text articles for assessment of eligibility, of which 7 studies met our criteria and were subjected to a detailed quality review using the Critical Appraisal Skills Programme (CASP) checklist. The selected studies offer a comprehensive analysis of adhesion pathogenesis with a special focus on the role of neutrophil extracellular traps (NETs) in the development of peritoneal adhesions. Current interventional strategies are examined, including the use of mechanical barriers, advances in regenerative medicine, and targeted molecular therapies. In particular, this review emphasizes the potential of NET-targeted interventions as promising strategies to mitigate postoperative adhesion development. Evidence suggests that in addition to their role in innate defense against infections and autoimmune diseases, NETs also play a crucial role in the formation of peritoneal adhesions after surgery. Therefore, therapeutic strategies that target NETs are emerging as significant considerations for researchers. Continued research is vital to fully elucidate the relationship between NETs and post-surgical adhesion formation to develop effective treatments.

The effect of natural surfactants on the development of postoperative intraabdominal adhesion.

The development of postoperative adhesion after abdominal surgery is sometimes a severe problem. Our study investigates the effectiveness of exogenous surfactant application in preventing adhesion development in the experimental adhesion model. This randomized-controlled interventional study was carried out in the animal laboratory of Kahramanmaraş Sütçü İmam University between March 1 and March 31, 2020. An experimental intra-abdominal adhesion model was established in 24 adult female rats by cecal abrasion. Rats were randomly divided into four groups. Groups I, II, and III were taken intraperitoneally as beractant, poractant, and calfactant applied groups, respectively. Group IV was the control group. Relaparotomy was performed in all groups on the 15th postoperative day, and intra-abdominal adhesions were scored macroscopically according to the Canbaz scoring system. In addition, the cecal regions were evaluated microscopically and scored according to the Zühlke microscopic classification system. The scores of the groups were compared statistically. The Zühlke adhesion development score was significantly lower in the exogenous surfactant applied groups. In addition, when the surfactant-applied groups were compared among themselves, it was seen that the adhesion score in the beractant group was significantly better than the other surfactant types (p < 0.01). Our study results showed that prophylactic intraperitoneal surfactant application significantly reduced postoperative adhesion development, particularly beractant.

Epigenetics: new insights into postoperative adhesion development.

The link between post-operative adhesion development and epigenetic modifications is important in understanding the mechanism behind their formation. The purpose of this study was to determine whether epigenetic differences exist between primary fibroblasts of normal peritoneum and adhesion tissues isolated from the same patient(s). DNA from fibroblasts isolated from normal peritoneum and adhesion tissues was isolated using Qiagen's EZ1 Advanced Kit. Methylation patterns of genes were quantified and compared in both cell lines using the Infinium Human Methylation 27 Beadchip system. A total of 7364 genes had been found to manifest significantly different DNA methylation levels in adhesion fibroblasts as compared to normal peritoneal fibroblasts (p<0.01). A total of 1685 genes were found to have increased DNA methylation by 50% in adhesion compared to peritoneal fibroblasts, and were enriched in Gene Ontology categories, Glycoprotein, and Defense Response. Furthermore, 1287 genes were found to have decreased DNA methylation patterns with enriched Gene Ontology categories, "Homeobox", and Transcription Factor Activity in adhesion fibroblasts. Epigenetic differences in fibroblasts isolated from normal peritoneum and adhesion tissues were observed. Future studies focusing on the precise role of these genes in the development of post operative adhesions will allow us to more fully appreciate regulatory mechanisms leading to adhesion development, thereby establishing targets for therapeutic interventions to prevent or limit adhesion development.

Identifying risk factors for abdominal adhesions: preliminary findings of a prospective study

The objective of this study is to identify relevant risk factors for development of abdominal and pelvic adhesions in women based on their prior medical and surgical history. The primary outcome of this study is the presence and severity of adhesions identified at the time of laparoscopy for benign gynecologic disease. This multi-site prospective study was approved by local IRB board. All laparoscopic cases performed by study staff on adult patients were eligible for inclusion. The anticipated study size is a minimum of 1,000 cases in an effort to account for more rare adhesion-promoting conditions. Cases were performed per standard protocol with entry approach and location per surgeon preference. Intraoperative photo documentation of four abdominal quadrants was obtained at the onset of each case. Following the case, a survey form was completed (Fig 1) to capture data on adhesiogenic events, time spent for adhesiolysis, route of entry, location, and grade of adhesions (Fig 2), if present. Herein we present interval findings from study onset in 2019 until 2021. A total of 490 laparoscopic cases have been collected, with an overall adhesion incidence of 58.98%. The most common prior inflammatory event was presence of endometriosis; among the endometriosis cases with no prior surgeries, the adhesion incidence was 61.29%. The most common preceding abdominal surgical event was a Cesarean section, with 82 patients having one or more prior Cesareans. Adhesions were present in 87.8% of cases with prior Cesarean, predominantly in the lower or midcentral abdomen and requiring on average 18.5 minutes of adhesiolysis; 44.4% of the adhesions were classified as filmy, 33.3% as dense, and 22.2% as cohesive. The second most common laparotomic procedure was abdominal myomectomy (n=22), of which 90.1% had adhesions predominantly in the central lower pelvis. There was a relatively even distribution of adhesion types, requiring an average of 24.4minutes of adhesiolysis. This is in contrast to the cases of laparoscopic myomectomy without prior abdominal surgery (n=10), of which 80% had adhesions noted in the lower or mid pelvis. These adhesions were filmy in 75% of the cases and required an average of 14.8 minutes for adhesiolysis. Our preliminary findings highlight the need for vigilance regarding anticipated intraabdominal adhesions. We anticipate that upon collecting a complete dataset, a model can be established for predicting risk factors for the development of abdominal adhesions. This project has important clinical implications and enables the provider to better counsel patients on rates of postoperative adhesion development, as well as guide operative decision-making for site of abdominal entry.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Genetic and Epidemiological Similarities, and Differences Between Postoperative Intraperitoneal Adhesion Development and Other Benign Fibro-proliferative Disorders.

Intraperitoneal adhesions complicate over half of abdominal-pelvic surgeries with immediate, short, and long-term sequelae of major healthcare concern. The pathogenesis of adhesion development is similar to the pathogenesis of wound healing in all tissues, which if unchecked result in production of fibrotic conditions. Given the similarities, we explore the published literature to highlight the similarities in the pathogenesis of intra-abdominal adhesion development (IPAD) and other fibrotic diseases such as keloids, endometriosis, uterine fibroids, bronchopulmonary dysplasia, and pulmonary, intraperitoneal, and retroperitoneal fibrosis. Following a literature search using PubMed database for all relevant English language articles up to November 2020, we reviewed relevant articles addressing the genetic and epidemiological similarities and differences in the pathogenesis and pathobiology of fibrotic diseases. We found genetic and epidemiological similarities and differences between the pathobiology of postoperative IPAD and other diseases that involve altered fibroblast-derived cells. We also found several genes and single nucleotide polymorphisms that are up- or downregulated and whose products directly or indirectly increase the propensity for postoperative adhesion development and other fibrotic diseases. An understanding of the similarities in pathophysiology of adhesion development and other fibrotic diseases contributes to a greater understanding of IPAD and these disease processes. At a very fundamental level, blocking changes in the expression or function of genes necessary for the transformation of normal to altered fibroblasts may curtail adhesion formation and other fibrotic disease since this is a prerequisite for their development. Similarly, applying measures to induce apoptosis of altered fibroblast may do the same; however, apoptosis should be at a desired level to simultaneously ameliorate development of fibrotic diseases while allowing for normal healing. Scientists may use such information to develop pharmacologic interventions for those most at risk for developing these fibrotic conditions.

Is There a Genetic Predisposition to Postoperative Adhesion Development?

Adhesions are permanent fibrovascular bands between peritoneal surfaces, which develop following virtually all body cavity surgeries. The susceptibility to develop, and the severity, of adhesions following intra-abdominal surgery varies within and between individuals, suggesting that heritable factors influence adhesion development. In this manuscript, we discuss the pathophysiology of adhesion development from the perspective of genetic susceptibility. We restrict our discussion to genes and single-nucleotide polymorphisms (SNPs) that are specifically involved in, or that cause modification of, the adhesion development process. We performed a literature search using the PubMed database for all relevant English language articles up to March 2020 (n = 186). We identified and carefully reviewed all relevant articles addressing genetic mutations or single-nucleotide polymorphisms (SNPs) that impact the risk for adhesion development. We also reviewed references from these articles for additional information. We found several reported SNPs, genetic mutations, and upregulation of messenger RNAs that directly or indirectly increase the propensity for postoperative adhesion development, namely in genes for transforming growth factor beta, vascular endothelial growth factor, interferon-gamma, matrix metalloproteinase, plasminogen activator inhibitor-1, and the interleukins. An understanding of genetic variants could provide insight into the pathophysiology of adhesion development. The information presented in this review contributes to a greater understanding of adhesion development at the genetic level and may allow modification of these genetic risks, which may subsequently guide management in preventing and treating this challenging complication of abdominal surgery. In particular, the information could help identify patients at greater risk for adhesion development, which would make them candidates for anti-adhesion prophylaxis. Currently, agents to reduce postoperative adhesion development exist, and in the future, development of agents, which specifically target individual genetic profile, would be more specific in preventing intraperitoneal adhesion development.

Safety and Efficacy of Two Techniques of Temporary Ovarian Suspension to the Anterior Abdominal Wall after Operative Laparoscopy

Background This retrospective study compares the safety and efficacy of temporary ovarian suspension (TOS) to the anterior abdominal wall using absorbable versus non-absorbable suture after operative laparoscopy to elevate the ovaries away from the ovarian fossa to reduce postoperative adhesion development. Methods Patients (n=152) underwent TOS to the anterior abdominal wall at the conclusion of surgery between 1998 and 2017. One hundred forty-two patients underwent operative laparoscopy for advanced stages of endometriosis (93.4%) and 10 patients for other indications (6.6%). In 78 patients the ovaries were suspended to the fascia using absorbable 3-0 plain catgut sutures (Group 1). In 74 earlier patients non-absorbable 3-0 mono-lamentous nylon was used to suspend the ovaries to the anterior abdominal (Group 2). Results In both groups there was no reported incidence of any major intra-operative complications such as bleeding, or late complications such as infection, hematoma or bowel herniation through the suture loop and its sequalae (bowel obstruction or strangulation). In all patients in both groups the ovaries were present in its anatomical location on transvaginal ultrasound scan, one week after surgery following absorption or removal of the TOS suture. There was no significant difference in clinical pregnancy (34.3% vs 44.2%) and delivery (31.3% vs 36.5%) rates in patients who conceived with non-IVF methods between Group 1 and Group 2 respectively. Conclusions TOS to the anterior abdominal wall, using absorbable or non-absorbable sutures, in an attempt to reduce postoperative adhesion development between the ovary and ovarian fossa, is simple, safe, easy to learn, and has potential effectiveness.

Attenuation of postoperative adhesions using a modeled manual therapy.

Postoperative adhesions are pathological attachments that develop between abdominopelvic structures following surgery. Considered unavoidable and ubiquitous, postoperative adhesions lead to bowel obstructions, infertility, pain, and reoperations. As such, they represent a substantial health care challenge. Despite over a century of research, no preventive treatment exists. We hypothesized that postoperative adhesions develop from a lack of movement of the abdominopelvic organs in the immediate postoperative period while rendered immobile by surgery and opiates, and tested whether manual therapy would prevent their development. In a modified rat cecal abrasion model, rats were allocated to receive treatment with manual therapy or not, and their resulting adhesions were quantified. We also characterized macrophage phenotype. In separate experiments we tested the safety of the treatment on a strictureplasty model, and also the efficacy of the treatment following adhesiolysis. We show that the treatment led to reduced frequency and size of cohesive adhesions, but not other types of adhesions, such as those involving intraperitoneal fatty structures. This effect was associated with a delay in the appearance of trophic macrophages. The treatment did not inhibit healing or induce undesirable complications following strictureplasty. Our results support that that maintained movements of damaged structures in the immediate postoperative period has potential to act as an effective preventive for attenuating cohesive postoperative adhesion development. Our findings lay the groundwork for further research, including mechanical and pharmacologic approaches to maintain movements during healing.

A first-in-human, randomized, controlled, subject- and reviewer-blinded multicenter study of Actamax\u2122 Adhesion Barrier

PurposePost-surgical adhesions remain a significant concern following abdominopelvic surgery. This study was to assess safety, manageability and explore preliminary efficacy of applying a degradable hydrogel adhesion barrier to areas of surgical trauma following gynecologic laparoscopic abdominopelvic surgery.MethodsThis first-in-human, prospective, randomized, multicenter, subject- and reviewer-blinded clinical study was conducted in 78 premenopausal women (18–46 years) wishing to maintain fertility and undergoing gynecologic laparoscopic abdominopelvic surgery with planned clinically indicated second-look laparoscopy (SLL) at 4–12 weeks. The first two patients of each surgeon received hydrogel, up to 30 mL sprayed over all sites of surgical trauma, and were assessed for safety and application only (n = 12). Subsequent subjects (n = 66) were randomized 1:1 to receive either hydrogel (Treatment, n = 35) or not (Control, n = 31); 63 completed the SLL.ResultsNo adverse event was assessed as serious, or possibly device related. None was severe or fatal. Adverse events were reported for 17 treated subjects (17/47, 36.2%) and 13 Controls (13/31, 41.9%). For 95.7% of treated subjects, surgeons found the device “easy” or “very easy” to use; in 54.5%, some residual material was evident at SLL. For 63 randomized subjects who completed the SLL, adjusted between-group difference in the change from baseline adhesion score demonstrated a 41.4% reduction for Treatment compared with Controls (p = 0.017), with a 49.5% reduction (p = 0.008) among myomectomy subjects (n = 34).ConclusionSpray application of a degradable hydrogel adhesion barrier during gynecologic laparoscopic abdominopelvic surgery was performed easily and safely, without evidence of clinically significant adverse outcomes. Data suggest the hydrogel was effective in reducing postoperative adhesion development, particularly following myomectomy.

Hypoxia-Induced Genotype Switch in Nicotinamide Adenine Dinucleotide Phosphate (NADPH) Oxidase Through the Up-Regulation of Cytidine Deaminase Regulates Postoperative Adhesion Development

Hypoxia-Induced Genotype Switch in Nicotinamide Adenine Dinucleotide Phosphate (NADPH) Oxidase Through the Up-Regulation of Cytidine Deaminase Regulates Postoperative Adhesion Development

Predisposing factors to post-operative adhesion development

Adhesion development is the most common sequelae of intra-abdominal and pelvic surgery and represents a significant, yet poorly understood, cause of morbidity among post-operative patients. It remains unclear, for example, exactly why adhesions form more frequently in certain tissues and/or patients, or at specific locations within them, as opposed to others. This review contributes to the growing knowledge pool by elucidating factors that potentially predispose to the development of adhesions. Given the strong correlation between a hypofibrinolytic state and adhesion formation, this review article will examine not only those factors that have been shown to directly predispose to adhesion development, but also those that are likely do so indirectly by means of altering the coagulation/fibrinolytic profile. A literature search was performed using the PubMed database for all relevant English language articles up to February 2014. All of the identified articles were reviewed with particular attention to predisposing factors to post-operative adhesion development. In addition, the reference lists of each article were reviewed to identify additional relevant articles. Various factors have been shown to directly increase the risk of post-operative adhesion development; namely, certain genetic polymorphisms in the interleukin-1 receptor antagonist, increased estrogen exposure, and endometriosis. In addition, numerous factors are known to increase the risk of fibrosis, therefore likely increasing the risk of adhesion development indirectly. These factors include genetic polymorphisms in plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor, diabetes mellitus, metabolic syndrome, hyperglycemia, obesity, depression, binge alcohol consumption, anti-Parkinsonian medications, oral hormone therapy, pregnancy, and cancer. The literature reviewed in this paper will help to direct future research aimed at understanding the mechanisms that underlie the association of certain factors with adhesion development. This information will be crucial in the creation of adequate preventative and treatment strategies.

The in-vivo effects of superoxide dismutase on the incidence and severity of post-operative adhesion development

The sequels of intra-abdominal adhesions following surgery are a cause of significant morbidity. Superoxide dismutase (SOD) protects against toxic effects of superoxide anions, which plays a fundamental role in adhesion development. We have previously showed that SOD treatment effectively reduces the adhesion phenotype biomarkers in fibroblasts isolated from adhesion tissues. The objective of this study is to evaluate the in vivo effects of SOD on the incidence and severity of post-operative adhesion development after cecal abrasion.

Nicotinamide Adenine Dinucleotide Phosphate Oxidase Expression Is Differentially Regulated to Favor a Pro-oxidant State That Contributes to Postoperative Adhesion Development

We have previously reported that superoxide (O2•-) contributes to the development of postoperative adhesions. In this study, we determined whether O2•- generating nicotinamide adenine dinucleotide phosphate oxidase (NOX) is differentially expressed in normal peritoneal and adhesion fibroblasts and tissues. The NOX isoforms were measured utilizing Western blot, immunohistochemistry, high-performance liquid chromatography, and real-time reverse transcription polymerase chain reaction. Expression and activity of NOX were found to be significantly higher in adhesion tissues and cells than that in normal peritoneal tissues and cells (P < .05). Levels of NOX2, NOX4, NOX activating protein 1, DUOX1, p47phox, and p22phox messenger RNA increased in adhesion fibroblasts when compared to normal peritoneal and increased in response to hypoxia in normal peritoneal fibroblasts. Thus, adhesion fibroblasts are characterized by a unique NOX expression profile, which maintains a pro-oxidant state that may be responsible for the persistence of the adhesion phenotype. Decreasing the activity of NOX by targeting these isoforms may be beneficial for future therapeutic interventions of postoperative adhesions.

Lycopene, a powerful antioxidant, significantly reduces the development of the adhesion phenotype

Postoperative adhesions are a common medical complication of gynecologic and other pelvic surgeries resulting in persistent pelvic pain, obstruction of the intestines, and even infertility. The molecular mechanisms of postoperative adhesion development remain to be elucidated. We have recently described a role for reactive oxygen species, specifically superoxide, in the development of postoperative adhesions. In this study, we sought to determine whether lycopene, a potent antioxidant, reduces markers characteristic of the adhesion phenotype. Primary fibroblast cultures from normal peritoneum and adhesion tissues were utilized to determine mRNA levels of adhesion phenotype markers type I collagen, transforming growth factor-beta 1 (TGF-β1), and vascular endothelial growth factor (VEGF) in response to lycopene (24 hours, 10 μM) treatment. There was a 2 (p < 0.003), 4.7 (p < 0.004), and 1.6 fold (p < 0.004) increase in mRNA levels of type I collagen, TGF-β1, and VEGF, respectively, in adhesion as compared to normal peritoneal fibroblasts. Lycopene treatment led to a 6.8 and a 12.4 fold decrease in type I collagen mRNA levels, in normal peritoneal and adhesion fibroblasts, respectively (p < 0.005). Lycopene treatment led to a 4.2 (p < 0.03) and a 4.6 (p < 0.05) fold decrease in VEGF mRNA levels, in normal peritoneal and adhesion fibroblasts, respectively. Lycopene treatment led to a 7.0 fold decrease in TGF-β1 mRNA levels, in adhesion fibroblasts (p < 0.03). A 1.9 fold decrease in TGF-β1 mRNA was observed in normal peritoneal fibroblasts in response to treatment, although it was not significant. Lycopene substantially reduced levels of adhesion phenotype markers in normal peritoneal and adhesion fibroblasts and whether it will reduce postoperative adhesions needs to be further investigated.

Effects of hypoxia on the expression of inflammatory markers IL-6 and TNF-a in human normal peritoneal and adhesion fibroblasts

Inflammation is known to be involved in the postoperative adhesion development. Interleukin (IL)-6 and tumor necrosis factor (TNF)-α are cytokines that stimulate the acute-phase reaction, which leads to a systemic reaction including inflammation, fever, and activation of the complement and clotting cascades. The goal of this study was to examine the expression of these inflammatory markers, under normal and hypoxic conditions, in normal and adhesion fibroblasts. Primary cultures of fibroblasts were established from normal peritoneum and adhesion tissues from the same patient(s) and cultured under 20% O2 or hypoxic 2% O2 conditions for 24 hours. Cells were harvested and total RNA was isolated. Complimentary DNA was generated by reverse transcription and subjected to real-time RT-PCR using specific primers for IL-6 and TNF-α. Both normal peritoneal and adhesion fibroblasts expressed IL-6 and TNF-α. Adhesion fibroblasts exhibited significantly higher levels of IL-6 and TNF-α mRNA as compared to normal peritoneal fibroblasts (p < 0.05). Both IL-6 and TNF-α mRNA levels were upregulated in response to hypoxia in both normal peritoneal and adhesion fibroblasts. The increase in IL-6 and TNF-α mRNA levels of normal fibroblasts reached the levels observed in adhesion fibroblasts. Our results suggest that hypoxia promotes the development of the adhesion phenotype by the induction of inflammatory markers, which may contribute to the development of postoperative adhesions. The inhibition of inflammation may be a potential therapeutic approach in the prevention and/or reduction of postoperative adhesion development.

Pelvic Adhesion and Gonadotropin-Releasing Hormone Analogue: Effects of Triptorelin Acetate Depot on Coagulation and Fibrinolytic Activities

The study investigated the impact of gonadotropin-releasing hormone analogue (GnRH-a) on coagulation and fibrinolytic activities and its effectiveness in the prevention of pelvic adhesion after myomectomy. Thirty-two infertile women underwent myomectomy followed by adhesion evaluation surgery with a second-look laparoscopy. Before myomectomy, 15 women were treated with triptorelin acetate for 3 months and 17 received no treatment. Plasminogen activator inhibitor (PAI), thrombin activatable fibrinolysis inhibitor (TAFI), protein C (PC), plasminogen, α2-antiplasmin were determined by enzyme-linked immunosorbent assays and the activity of coagulation factors V and VIII by coagulometric methods. Patients treated with GnRH-a showed significant decrease in PAI, TAFI, factors V, and VIII (P < .05) and increased PC (P < .05), but no significant change in plasminogen and α2-antiplasmin levels compared with control group. The incidence, extent, and severity of adhesions were significantly lower in GnRH-a-treated patients compared with control group (P < .05), suggesting a possible critical role of the GnRH-a therapy in preventing postoperative adhesion development.

Rapamycin and a hyaluronic acid-carboxymethylcellulose membrane did not lead to reduced adhesion formations in a rat abdominal adhesion model

Rapamycin, an immunosuppressive in transplant surgery, has an additional antiproliferative effect. The aim of this study was to investigate the potential protective effects of rapamycin on postoperative adhesion development. Ten rats per group underwent midline incision laparotomy and adhesion induction including bowel sutures. Therapy groups received daily intraperitoneal rapamycin injections (1.5 mg/kg body weight) for 3 weeks postoperatively. Controls were rats without any postoperative treatment, rats receiving the rapamycin solvent or a hyaluronic acid-carboxymethylcellulose membrane (Seprafilm(™)). Postoperative rapamycin application led to enhanced adhesion development and there was a higher rate of wound infections. In addition, Seprafilm(™) did not reduce adhesions, in subgroups there were even more. Rapamycin is not recommendable for perioperative immunosuppression, it enhances adhesion development and leads to a higher rate of wound infections. Surprisingly, the established Seprafilm(™) membrane led to more adhesions in our experimental setting.

Postoperative Adhesion Development Following Cesarean and Open Intra-Abdominal Gynecological Operations

In this review, we discuss the pathophysiology of adhesion development, the impact of physiological changes associated with pregnancy on markers of adhesion development, and the clinical implications of adhesion development following cesarean delivery (CD). Although peritoneal adhesions develop after the overwhelming majority of intra-abdominal and pelvic surgery, there is evidence in the literature that suggests that patients having CD may develop adhesions less frequently. However, adhesions continue to be a concern after CD, and are likely significant, albeit on average less than after gynecological operations, but with potential to cause significant delay in the delivery of the baby with serious, lifelong consequences. Appreciation of the pathophysiology of adhesion development described herein should allow a more informed approach to the rapidly evolving field of intra-abdominal adhesions and should serve as a reference for an evidence-based approach to consideration for the prevention and treatment of adhesions.

Gynecologic use of Sepraspray Adhesion Barrier for reduction of adhesion development after laparoscopic myomectomy: a pilot study

To assess the safety and efficacy of Sepraspray Adhesion Barrier (a modified hyaluronic acid and carboxymethylcellulose powder) after laparoscopic surgery, in view of both the high efficacy of Seprafilm Adhesion Barrier in reducing postoperative adhesions after open surgical procedures and the difficulty with laparoscopic delivery. Multicenter, randomized, reviewer-blinded trial. Reproductive endocrinology and infertility clinics. Women undergoing laparoscopic myomectomy for indications including infertility. Randomization to treatment with (n = 21) or without (n = 20) Sepraspray Adhesion Barrier. Postoperative adhesions development was assessed at early second-look laparoscopy. Adhesions were scored using the modified American Fertility Society scoring system. Surgical procedure duration length was 99 versus 102 minutes in the control versus Sepraspray Adhesion Barrier groups, respectively, with the median number of fibroids removed being two in each group and corresponding fibroid weights of 134 ± 103 versus 113 ± 161 g, respectively. Adhesions scores increased in both the control and Sepraspray Adhesion Barrier groups, with larger although nonstatistically significant increases noted in control subjects when evaluating for the anterior uterus, the posterior uterus, and the entire uterus. Laparoscopic application of Sepraspray Adhesion Barrier after myomectomy in this pilot study was associated with a trend toward a reduction in postoperative adhesion development, as well as an encouraging safety profile. Further evaluation is warranted. Sepraspray Adhesion Barrier #NCT00624930.

A prospective, controlled, randomized, multicenter, exploratory pilot study evaluating the safety and potential trends in efficacy of Adhexil

To present a multicenter, reviewer-blinded pilot study evaluating the safety and trends of efficacy of Adhexil, a novel product using fibrin sealant. Randomized, reviewer-blinded assessment of postoperative adhesion development in women with bilateral ovarian disease. Gynecologic clinics. Women undergoing gynecologic surgery. Patients were assessed for incidence, extent, and severity of ovarian adhesions at the first-look laparoscopy (1LL), followed by standard surgical procedure. Ovaries were randomized for application of Adhexil or untreated. A second-look laparoscopy (2LL) was performed to assess postoperative adhesions. Safety and efficacy of Adhexil. A trend toward improvement in adhesion incidence was found in the treated ovaries, with 50% (8/16) of adhesion free ovaries in the Adhexil group, versus 31% (5/16) of control ovaries. Similarly, the improvement in the mean American Fertility Society (AFS) score in the Adhexil-treated group from 1LL (6.4 ± 6.8) to 2LL (4.6 ± 6.9) was observed, whereas worsening of adhesions was observed on the control side from 1LL (5.6 ± 5.1) to 2LL (7.1 ± 6.9). No adverse events or serious adverse events considered related to the study product were reported. A clear trend of efficacy for Adhexil reducing the incidence, severity, and extend of adhesions in laparoscopic gynecology surgery, despite the small sample size. The use of Adhexil appears safe. Further exploration of its safety and efficacy in preventing/reducing postsurgical adhesions is warranted.