Более 100 лет хирурги ищут ответы на вопрос, чем является спаечный процесс: компенсаторно-приспособительной реакцией, генетически детерминированной склонностью к спайкообразованию или отдельной нозологической единицей? В МКБ-10 представлены непосредственно брюшинные спайки (K66.0). Острая спаечная кишечная непроходимость (K56.5) встречается в 13,9%, хронические тазовые боли (N73.6) — в 25—30% случаев после акушерско-гинекологических операций. Все чаще стали выполняться повторные операции, в том числе по поводу спаечной болезни. Поиск способов предотвращения и уменьшения спайкообразования проводится одновременно в нескольких направлениях; четко сформулированы современные пути профилактики спаек, направленные на снижение травматического воздействия на брюшину, предотвращение явлений воспаления в зоне операции, снижение выпадения фибрина в брюшную полость, создание защитных барьеров на мезотелии. Тактика общего хирурга при обнаружении спаек в брюшной полости однозначно требует борьбы с ними, однако отношение торакальных хирургов к спайкам в плевральной полости различно. Ряд авторов считают, что спайки препятствуют экскурсии легких, а пневмолиз увеличивает эффективность лечения деструктивного туберкулеза легких. Отношение к спайкообразованию в плевральной полости не может рассматриваться как к отрицательному явлению, так как в ряде случаев (травма грудной клетки, остаточная плевральная полость, спонтанный пневмоторакс и др.) стимуляция адгезиогенеза может быть необходимым компонентом лечения. Цель обзора — сравнительный анализ плевральных и перитонеальных сращений и оценка клинической значимости спайкообразования в плевральной и брюшной полостях.

Current views on the problem of abdominal and pleural adhesions: etiology, pathologic manifestations, similarity and differences, disputable issues of prevention

We conducted a prospective randomized single blind – subject study in the University Clinic of Gynecology of Pius-Hospital Oldenburg. The primary objective of the ADBEE study was to assess the safety and manageability of ADBLOCK when used as an adjunct to laparoscopic surgery for the primary of myomas in women wishing to improve pregnancy outcomes. The study population included 32 women aged between 18–45 years, in good general health condition, who have not completed their family planning and who are undergoing primary (‘virgin’) laparoscopic myomectomy with an aim to improve pregnancy outcomes. The patients were randomized in 2 groups, ADBLOCK arm with 21 patients and surgery only arm with 11 patients. The study was single blind – subject and the investigators were blinded to treatment group assignment until completion of uterine suturing and prior to removal of the endoscope. A vigorous follow-up of subjects was organized, focusing on its two critical characteristics: completeness and duration. Completeness represented the percentage of subjects who returned to every planed follow – up appointments. The patients were evaluated in a specific period of time, which defined the duration of follow-up. Safety of the ADBLOCK was estimated after analyzing and documentation of any adverse events occurred, clinical and physical examination of patients as well as evaluation of laboratory measures. There were 25 adverse events reported in ADBLOCK treatment group and 12 events in NO-ADBLOCK group over the 24-months treatment. All adverse events in both treatment arms were not anticipated, with all events in the ADBLOCK group being resolved. At 28 days, there was no significant difference in proportion of events between the two treatments (p = 0.440). Overall, the number of events reported was low and the severity of events was generally mild with an unlikely or no relationship to treatment. There were no unanticipated device related adverse events seen in both treatment groups over the immediate post-operative period or during the 24 months follow up period. By 12 weeks all patients reported their wound as healing well or healed and at 6 months all wounds were reported as healed. There were no differences between both treatment groups regarding the use of painkillers over 24 months follow up period. This clinical first – in – human study, sustained by a rigorous follow-up of the subjects has demonstrated that ADBLOCK is a safe product, presenting no additional safety risk or burden to the patients over surgery alone. The device was relatively easy to use, with a low device failure rate that had no impact on the surgical procedures.

Long term follow-up concerning safety and efficacy of novel adhesion prophylactic agent for laparoscopic myomectomy in the prospective randomized ADBEE study

Postoperative adhesion is a natural phenomenon that occurs in damaged tissue cells. Several anti-adhesion agents are currently used, but there is no leading-edge product with excellent adhesion-preventive effects. The purpose of this study was to develop ideal anti-adhesive agents using human-derived acellular dermal matrix (ADM). We developed 5 new biocompatible thermosensitive anti-adhesion barriers (AABs) using micronized human-derived ADM, hyaluronic acid, and temperature-sensitive and biocompatible synthesized polymers. The biocompatibility, anti-adhesion effect, and biodegradability of these AABs were compared with those of commercial thermosensitive anti-adhesion agents. No cytotoxic effects were observed in vitro and in vivo. Animal testing of adhesion resistance confirmed that the adhesion area, strength, and grade of AAB03 were statistically superior to those of the control group. Factors related to adhesion formation, such as lymphocytes, macrophages, microvessels, and collagen fiber density, were observed using specific staining methods; the results confirmed that AAB03 group exhibited significantly lower macrophage counts, microvessel density, and collagen fiber density than the control groups. Furthermore, AAB03 was completely absorbed by 6 weeks. Thus, AAB03 has the potential to be used as a high-performance anti-adhesion agent.

/pdf/development-of-novel-biocompatible-thermosensitive-anti-1dawk3qd1x.pdf

Development of novel biocompatible thermosensitive anti-adhesive agents using human-derived acellular dermal matrix.

The recurrence, metastasis and poor prognosis are important characteristics of ovarian carcinoma (OC), which are associated with exfoliation of cells from the primary tumor and colonization of the cells in pelvic cavity. On the other hand, the life quality of the patients undergoing surgical resection of OC was influenced by postoperative adhesions. Therefore, preventing postoperative implant tumor and adhesion may be effective methods to improve OC treatment. HyaRegen Gel, a cross-linked hyaluronan gel (CHAG), has been widely used as an anti-adhesive agent following pelvic operation in clinic. However, whether it can affect the implantation and growth of OC cells or not is still not clear. Migration and invasion assays were applied to detect the effect of CHAG on migration and invasion of OC cells. Western blotting was performed to detect the phosphorylation/activation of EGFR and ERK, and the expression of PCNA and MMP7. Pull down assay was used to analyze the effect of CHAG on the activation of small G protein Rac1. Nude mice implantation tumor model was applied to observe the effect of CHAG on implantation tumor of OC cells. The results of in vitro experiments showed that CHAG suppressed both basic and EGF-induced migration and invasion of OC cells, blocked the activation of EGF-initiated EGFR activation, inhibited downstream signal transduction of EGFR, and decreased expression of proliferation and migration/invasion related proteins. Meanwhile, results of in vivo experiments showed that CHAG not only inhibited the formation of implantation tumor of OC cells but also delayed the of the growth of the tumors. CHAG inhibited migration, invasion and proliferation of OC cells in vitro, and suppressed development of implantation tumor of OC in vivo. This made it as both anti-tumor and anti-adhesion agents.

/pdf/cross-linked-hyaluronan-gel-inhibits-the-growth-and-2yktkeh58g.pdf

Cross-linked hyaluronan gel inhibits the growth and metastasis of ovarian carcinoma.

The aim of this study was to assess the effect of ovarian suspension to the round ipsilateral ligament with a resorbable suture, performed during laparoscopic surgery for endometrioma, on postoperative ovarian adhesion formation. The tool used to assess this effect was not conventional laparoscopy but outpatient transvaginal hydrolaparoscopy. Fifty women with single ovarian endometrioma were divided in two groups (group A, 24 and group B, 26). All patients underwent laparoscopic ovarian cystectomy for endometriosis. In group A, the ovary was suspended to the ipsilateral round ligament. In group B, ovarian suspension was not performed. All patients underwent transvaginal outpatient hydrolaparoscopy as follow-up. A significantly lower rate of postsurgical ovarian adhesion in group A in comparison with group B (33.3 vs 80.8 %—p = 0.001) was observed. Operative time and postoperative pain were similar in both groups. Ovarian suspension to the ipsilateral round ligament with a resorbable suture during surgery for endometrioma is associated with a lower rate of postoperative ovarian adhesion formation.

/pdf/efficacy-of-ovarian-suspension-to-round-ligament-with-a-jbuqx8wnxm.pdf

Efficacy of ovarian suspension to round ligament with a resorbable suture to prevent postoperative adhesions in women with ovarian endometrioma: follow-up by transvaginal hydrolaparoscopy

Adhesions are the most frequent complication of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with considerable morbidity and expense, and an important mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in most patients. There is rising evidence, however, that surgeons can take important steps to reduce the impact of adhesions. A task force of Italian gynecologists with a specialist interest in adhesions having reviewed the current evidence on adhesions and considered the opportunities to reduce adhesions in Italy, have approved a collective consensus position. This consensus paper provides a comprehensive overview of adhesions and their consequences and practical proposals for actions that gynecological surgeons in Italy should take. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be adopted particularly in high risk surgery and in patients with adhesiogenic conditions. Patients also need to be better informed of the risks of adhesions.

[Prevention of postoperative abdominal adhesions in gynecological surgery. Consensus paper of an Italian gynecologists' task force on adhesions]

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[Prevention of postoperative abdominal adhesions in gynecological surgery. Consensus paper of an Italian gynecologists' task force on adhesions]

[Prevention of postoperative abdominal adhesions in gynecological surgery. Consensus paper of an Italian gynecologists' task force on adhesions]