Professional Documents
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Jurnal Adhesion Prevent
Jurnal Adhesion Prevent
Jurnal Adhesion Prevent
Review
A R T I C L E I N F O A B S T R A C T
Article history: Adhesions are bands of tissue that connect organs together. It is frequently reported after surgery and
Received 31 August 2009 remains a major problem for health and society. Efforts to prevent or reduce peritoneal adhesions mostly
Received in revised form 15 December 2009 have been unsuccessful, hindered by their empirical basis, lack of good predictive animal models and
Accepted 1 February 2010
complexity of adhesion pathogenesis. Although a good surgical technique is a crucial part of adhesion
prevention, the technique alone cannot effectively eliminate the adhesions. Thus, there remains a room
Keywords: for further research. A comprehensive literature review of published experimental and clinical studies of
Peritoneal adhesions
adhesion prevention was carried out at the University of Bristol electronic library (MetaLib1) with cross-
Postoperative adhesions
Prevention
search of seven different medical databases (AMED—Allied and Complementary Medicine Database,
BIOSIS Previews on Web of Knowledge, Cochrane Library, Embase and Medline on Web of Knowledge,
OvidSP and PubMed) by using key words (peritoneal adhesions, postoperative adhesions, prevention) to
explore the progress in different surgical strategies and adjuvant materials used to prevent adhesions
formation and reformation. By the end of the study, recommendations formulated for surgeons to be
followed during the operations to prevent, as much as possible, the postoperative adhesions.
ß 2010 Elsevier Ireland Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
2. The peritoneum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
3. Peritoneal healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
4. Etiology and risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
5. Clinical presentation and complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
6. Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
7. Staging of adhesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
8. Prevention of peritoneal adhesions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
8.1. Surgical approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
8.2. Surgical technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
8.3. Surgical adjuvants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.3.1. Fibrinolytic agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.3.2. Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.3.3. Anti-inflammatory agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.3.4. Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
8.3.5. Mechanical separation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
8.3.6. New agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
8.3.7. Agents under research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
9. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
10. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
* Correspondence address: 4 Tyndall’s Park Road, Clifton, Bristol BS8 1PG, United Kingdom.
E-mail addresses: remah.kamel.07@bristol.ac.uk, remahmoustafa@hotmail.com.
0301-2115/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2010.02.003
112 R.M. Kamel / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 111–118
positive and false negative predictions make them unreliable for Laboratory plasma levels of tumor necrosis factor-alpha (TNF-
routine use. a) and interleukin-6 (IL-6) are correlated with adhesion formation
A plain abdominal X-ray film, small-bowel follow-through, and could be used as diagnostic markers [13].
ultrasound scanning and a computed tomography (CT) are well-
known diagnostic procedures in patients with a suspicion of bowel 7. Staging of adhesions
obstruction. A peritoneal CT, peritoneal magnetic resonance
imaging (MRI) and isotope imaging are more recent techniques. Staging or classification is the cornerstone for comparing
Sigel et al. [11] have described a technique of using ultrasound results of different studies. Although several clinical scoring
to examine the sliding motion of abdominal viscera. Normal systems have been considered since 1982, none of them is
motion was termed ‘‘visceral slide’’ and occurred spontaneously accepted today as universal.
during respiratory movements or was induced by manual Hulka [14] published a prognostic classification after 5 years of
palpation of the abdomen [12]. Restricted visceral slide was surgery for infertile women in his institute. The classification was
shown as a clue of intra-abdominal adhesions. It is a promising based upon two main factors: the extent of the ovarian involvement
non-invasive diagnostic technique that may be useful in identify- and the nature of the adhesions whether filmy or dense.
ing and mapping abdominal adhesions prior to laparoscopic or The French distal tube operability score (Table 1) [15] and the
open surgery. American Fertility Society (AFS) score (Table 2) [16] have great
114 R.M. Kamel / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 111–118
Table 1
The French distal tube operability score [15].
0 2 5 10
acceptability and were in common use for years. In AFS score, four However, the reported disadvantages of laparoscopic surgery
anatomic sites are evaluated per woman: the right ovary, right compared to laparotomy include:
tube, left ovary and left tube. For each of these, a score is given
according to the extent and aspect of adhesions. The higher score 1. Improper choice and use of laparoscopic instruments may cause
represents the side with the higher adhesion. A modified AFS score more tissue injury [6].
was then developed where 24 anatomical sites are to be evaluated 2. Laparoscopy, by itself, does not eliminate adhesions completely
[17]. [27].
In 1994, the Adhesion Scoring Group [18] published their more 3. Adhesion reformation still occurs after laparoscopy [28].
comprehensive scoring system based on the evaluation of 23 sites. 4. Pneumoperitoneum with a non-humidified CO2 gas is a cofactor
Although the AFS scoring method generated a significant for adhesion [29].
agreement between surgeons, the use of this comprehensive 5. Adhesion formation is related to the time and duration of
scoring system produces a marked increase in reproducibility. pneumoperitoneum [30].
6. Subserosal ischemia is a consequence of high intra-peritoneal
8. Prevention of peritoneal adhesions gas pressure [28].
In animal models, adhesion formation has been reduced by In fact, the above-listed risks are mostly related to improper
three different strategies: laparoscopic technique and could be minimized when guidelines
for laparoscopic surgery are respected.
1. Altering the fibrinolytic pathway by using either recombinant t-
PA [19] or gonadotrophin releasing hormone agonist (GnRHa) 8.2. Surgical technique
[20].
2. Immunomodulation by using transforming growth factor (TGF)- The first use of microsurgery was described by Swolin [31] in
bl antibodies [21], IL-1 and TNF-a antibodies [13], or IL-10 and 1967. The term ‘‘microsurgery’’ implies the use of magnification to
ketorolac (NSAID) [22]. allow close tissue visualization, handling small caliber instru-
3. Disruption of cell interaction with extra-cellular matrix (ECM) ments, and use of fine sutures [32]. Other principles of micro-
[23]. surgery include minimal tissue handling, prevention of tissue
desiccation, avoidance of foreign bodies, precise re-approximation
In humans, progress for prevention of postoperative adhesion of the tissues, and meticulous hemostasis.
formation has passed through the following three main stages with Temporary ovarian suspension appears to be a simple, safe and
controversies: effective method to prevent ovarian adhesions after laparoscopy
for endometriosis [33]. Non-closure of parietal peritoneum during
1. Surgical approach: laparoscopy versus laparotomy. caesarean section is recommended as it results in a significantly
R.M. Kamel / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 111–118 115
shorter operative time, lower febrile morbidity, and lesser use of Table 3
Adjuvants for prevention of postoperative adhesions.
analgesics with a quicker return of bowel activity. The practice of
omitting closure of the peritoneum is well supported in the Fibrinolytic agents
Thrombokinase, fibrinolysin, streptokinase, urokinase, hyaluronidase,
literature [34].
chymotrypsin, trypsin, papain and pepsin.
Laser surgery definitely decreased the adhesion formation and Tissue plasminogen activators [36] and recombinant t-PA [37]
reformation by making a precise incision, achieving a meticulous Thromboxane synthetase inhibitors: imidazole and ridogrel [38]
hemostasis, and by reducing the operative time. Different types of Thrombin inhibitor (rec-Hirudin1) [39]
laser are in a common use now, mostly the ultra-pulse carbon Anti-proliferative medications: Paclitaxel [40] and Camptothecin [41]
Polypeptides: lysozyme, polylysine, and polyglutamate [42]
dioxide [35].
Anticoagulants
Heparin [43,45]
8.3. Surgical adjuvants
Low molecular weight heparin (Enoxaparin-Na) [44,46]
product for prevention of postoperative adhesion in all cases is yet [10] Lower AM, Hawthorn RJ, Ellis H, O’Brien F, Buchan S, Crowe AM. The impact of
adhesions on hospital readmissions over ten years after 8849 open gynaeco-
to be discovered. logical operations: an assessment from the Surgical and Clinical Adhesions
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before surgery? And at which stage of the healing process is it adhesions: a prospective study in 48 patients with surgical correlation. J Clin
proper to interfere with an agent to reduce the adhesion Ultrasound 1995;25:363–6.
[13] Basoglu M, Kiziltunc A, Akcay F, Keles S, Gundogdu C, Ören D. Tumor Necrosis
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10. Recommendations [14] Hulka JF. Adnexal adhesions: a prognostic staging and classification system
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[16] American Fertility Society. The American Fertility Society classification of
1. For laparotomy, follow meticulously the microsurgical princi- adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal
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[20] Sharpe-Timms K, Zimmer R, Jolliff W, et al. Gonadotrophin releasing hormone
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Conflict of interests
[21] Lucas P, Warejcka D, Young H, et al. Formation of abdominal adhesions is
inhibited by antibodies to transforming growth factor-beta 1. J Surg Res
The author hereby declares that there are no competing 1996;65:135–8.
interests. [22] Holschneider CH, Nejad F, Montz FJ. Immunomodulation with interleukin-
10 and interleukin-4 compared with ketorolac tromethamine for preven-
Ethical approval tion of postoperative adhesions in a murine model. Fertil Steril 1999;71(1):
This study was carried out in accordance with the requirements 67–73.
of the University of Auvergne Regulations and Code of Ethics for [23] Rout UK, Saed GM, Diamond MP. Expression pattern and regulation of genes
differ between fibroblasts of adhesion and normal human peritoneum. Reprod
Research Programmes, France. Biol Endocrinol 2005;3(1):1.
Funding [24] Gutt C, Oniu T, Schemmer P, Mehrabi A, Buchler M. Fewer adhesions induced
This work was self-funded. The author did not receive any by laparoscopic surgery. Surg Endosc 2004;18(6):898–906.
[25] Luijendijk RW, de Lange DC, Wauters CC, et al. Foreign material in post-
financial funding or support from any person, company, or operative adhesions. Ann Surg 1996;223.
institution. [26] Schäfer M, Krähenbühl L, Büchler MW. Comparison of adhesion formation in
open and laparoscopic surgery. Dig Surg 1998;15:148–52.
[27] Nappi C, Sardo A, Greco E, Guida M, Bettocchi S, Bifulco G. Prevention of
Acknowledgements
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