Adhäsionen: Fortschritte im Bereich der Adhäsionsprophylaxe und Therapie bei Laparotomie und Laparoskopie

Zusammenfassung

Adhäsionen entstehen bei allen chirurgischen Interventionen, wenn eine lokalisierte Hypoxie die Fibrinolyse unterdrückt und sich Fibrin auf die traumatisierte Oberfläche anlagert. Eine Prävention peritonealer Adhäsionen bei operativen Eingriffen ist sinnvoll. Dies zeigen die klinischen Konsequenzen von Adhäsionen, wie chronische Unterleibsbeschwerden, Sterilität und Infertilität, Darmverschluss und Infektionen. Die Erfassung der wirtschaftlichen Bedeutung von Adhäsionen und ihre Therapie, die Aufzählung der bekannten Prävention von Adhäsionen und letztlich die Analyse einer klinischen Studie eines neuen Adhäsionsprophylaktikums und Beschreibung einer geplanten randomisierten Studie weisen auf die Bedeutung der Prävention von peritonealen Adhäsionen hin. Die Applikation von Ringer-Lösung allein bringt weder bei Laparotomie noch bei Laparoskopie den gewünschten Erfolg. Daher kommt dem beschriebenen SprayGel® (Confluent Surgical Inc.) als Barrieresubstanz sowie der Applikation von Adept® als Spül- und Instillationsmittel am Ende der Operation eine große Bedeutung zu. Wahrscheinlich erbringt die Applikation einer Barrieresubstanz wie SprayGel® mit einer Spül- und Präventionsflüssigkeit für Adhäsionen wie Adept® in der Kombination einen echten Fortschritt in der Adhäsionsprophylaxe. Die randomisierte Studie von SprayGel® zeigte deutlich eine Reduktion neu entstandener Adhäsionen in der postoperativen Phase bei der Technik der Laparotomie und Laparoskopie bei Myomenukleationen. Kliniker sollten ein offenes Ohr für Fortschritte im Bereich der Adhäsionsprophylaxe haben.

Abstract

Adhesions are a frequent consequence of methothelial repair at sites traumatised by surgical procedures, such as laparoscopy or laparotomy, where localised hypoxia suppresses fibriolysis enabling fibrin to be deposited between adjacent tissue surfaces. Prevention of peritoneal adhesions at surgical procedures is essential as shown by the clinical consequences of adhesions: chronic abdominal pain, infertility, bowel occlusion and infections. The economic significance of adhesions and their therapy, as evaluated by known adhesion preventive measures, the analysis of a clinical study of a new adhesion prophylaxis and the description of a randomised study illustrate the importance of the prevention of peritoneal adhesions. The application of Ringers lactate does not bring the desired results. Therefore, the use of SprayGel® (Confluent Surgical Inc.) as a barrier substance and the application of Adept® as an instillation medium at the end of the operation are of significance.

Adhäsionsprophylaxe - gute chirurgische Technik - SprayGel® - Adept® - Laparotomie - Laparoskopie

Adhesion prophylaxis - good surgical technique - SprayGel® - Adept® - laparotomy - laparoscopy

Literatur

• 1 Ellis H. Intraabdominal adhesions: a historical viewpoint.  Adhesions News Views. 2002;  1 4-5
• 2 Diamond M P, Daniell J F, Feste J, Surrey M W, McLaughlin D S, Friedman S, Vaughn W K, Martin D C. Adhesion reformation and de novo adhesion formation after reproductive pelvic surgery.  Fertil Steril. 1987;  47 864-866
• 3 DeCherney A H, diZerega G S. Clinical problem of intraperitoneal postsurgical adhesion formation following general surgery and the use of adhesion prevention barriers.  Surg Clin North Am. 1997;  77 671-688
• 4 Monk B J, Berman M L, Montz F J. Adhesions after extensive gynecologic surgery: clinical significance, etiology and prevention.  Am J Obstet Gynecol. 1994;  170 1396-1403
• 5 Holmdahl L. Making and covering of surgical footprints.  Lancet. 1999;  353 1456-1457
• 6 Mathias S D, Kuppermann M, Liberman R F, Lipschutz R C, Steege J F. Chronic pelvic pain: prevalence, health-related quality of life and economic correlates.  Obstet Gynecol. 1996;  87 321-327
• 7 Szigetvari I, Feinman M, Barad D, Bartfai G, Kaali S G. Association of previous abdominal surgery and significant adhesions in laparoscopic sterilization patients.  J Reprod Med. 1989;  34 465-466
• 8 Lower A M, Hawthorn R J, Ellis H, O'Brien F, Buchan S, Crowe A M. The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: an assessment from the Surgical and Clinical Adhesions Research Study.  Br J Obstet Gynaecol. 2000;  107 855-862
• 9 Menzies D, Ellis H. Intestinal obstruction from adhesions - how big is the problem?.  Ann R Coll Surg Engl. 1990;  72 60-63
• 10 Stovall T G, Elder R F, Ling F W. Predictors of pelvic adhesions.  J Reprod Med. 1989;  34 345-348
• 11 Weiner J. Chronic pelvic pain.  Practitioner. 1994;  238 352-357
• 12 Porpora M G, Koninckx P R, Piazze J, Natili M, Colagrande S, Cosmi E V. Correlation between endometriosis and pelvic pain.  J Am Assoc Gynecol Laparosc. 1999;  6 429-434
• 13 Stout A L, Steege J F, Dodson W C, Hughes C L. Relationship of laparoscopic findings to self-report of pelvic pain.  Am J Obstet Gynecol. 1991;  164 73-79
• 14 Duffy D M, diZerega G S. Adhesion controversies: pelvic pain as a cause of adhesions, crystalloids in preventing them.  J Reprod Med. 1996;  41 19-26
• 15 Malik E, Berg C, Meyhofer-Malik A, Haider S, Rossmanith W G. Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis: a retrospective analysis.  Surg Endosc. 2000;  14 79-81
• 16 Peters A A, Trimbos-Kemper G C, Admiraal C, Trimbos J B, Hermans J. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain.  Br J Obstet Gynaecol. 1992;  99 59-62
• 17 Stephen E H. Projections of impaired fecundity among women in the United States: 1995 to 2020.  Fertil Steril. 1996;  66 205-209
• 18 Mettler L. Immunologic problems in fertility disturbances from the gynecologic point of view.  Fortschr Androl. 1974;  3 35-40
• 19 Mettler L, Semm K, Gebhardt J H, Schollmeyer Th, Schollmeyer M, Meyer D, Ternamian A. Endoskopische Abdominalchirurgie in der Gynäkologie. Stuttgart, New York; Schattauer 2002
• 20 Caspi E, Halperin Y, Bukovsky I. The importance of periadnexal adhesions in tubal reconstructive surgery for infertility.  Fertil Steril. 1979;  31 296-300
• 21 Milingos S, Kallipolitis G, Loutradis D, Liapi A, Mavrommatis K, Drakakis P, Tourikis J, Creatsas G, Michalas S. Adhesions: laparoscopic surgery versus laparotomy.  Ann NY Acad Sci. 2000;  900 272-285
• 22 DeCherney A H. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Operative Laparoscopy Study Group.  Fertil Steril. 1991;  55 700-704
• 23 Maruyama M, Osuga Y, Momoeda M, Yano T, Tsutsumi O, Taketani Y. Pregnancy rates after laparoscopic treatment. Differences related to tubal status and presence of endometriosis.  J Reprod Med. 2000;  45 89-93
• 24 Ellis H. The clinical significance of adhesion: focus on intestinal obstruction.  Eur J Surg. 1997;  163 (Suppl 577) 5-9
• 25 Wilson M S, Hawkswell J, McCloy R F. Natural history of adhesional small bowel obstruction: counting the cost.  Br J Surg. 1998;  85 1294-1298
• 26 Melody G F. Intestinal obstruction following gynecologic surgery.  Obstet Gynecol. 1958;  11 139-147
• 27 Stricker B, Blanco J, Fox H E. The gynecologic contribution to intestinal obstruction in females.  J Am Coll Surg. 1994;  178 617-620
• 28 Al-Took S, Platt R, Tulandi T. Adhesion-related small-bowel obstruction in patients with gynecologic disease: a review of 368 patients.  Am J Obstet Gynecol. 1999;  180 313-315
• 29 Krebs H B, Gopelrund D R. Mechanical intestinal obstruction in patients with gynecologic disease: a review of 368 patients.  Am J Obstet Gynecol. 1987;  157 577-583
• 30 Ellis H, Moran B J, Thompson J N, Parker M C, Wilson M S, Menzies D, McGuire A, Lower A M, Hawthorn R J, O'Brien F, Buchan S, Crowe A M. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study.  Lancet. 1999;  353 1476-1480
• 31 Ray N F, Denton W G, Thamer M, Henderson S C, Perry S. Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994.  J Am Coll Surg. 1998;  186 1-9
• 32 International Classification of Diseases. 9th Revision. Clinical Modification: ICD-9-CM. Department of Health and Human Services: Health Care Financing Division. DHHS publication no. (PHS) 80 - 1260. Department of Health and Human Services; Washington, DC 1980
• 33 Ray N F, Larsen Jr J W, Stillmann R J, Jacobs R J. Economic impact of hospitalizations for lower abdominal adhesiolysis in the United States in 1988.  Surg Gynecol Obstet. 1993;  176 271-276
• 34 Coleman M G, McLain A D, Moran B J. The impact of previous surgery on the time taken for incision and division of adhesions during laparotomy.  Dis Colon Rectum. 2003;  in press
• 35 Van Der Krabben A A, Dijkstra F R, Nieuwenhuijzen M, Reijnen M M, Schaapveld M, Van Goor H. Morbidity and mortality of inadvertent enterotomy during adhesiotomy.  Br J Surg. 2000;  87 467-471
• 36 Diamond M P, DeCherney A H. Pathogenesis of adhesion formation/reformation: application to reproductive pelvic surgery.  Microsurgery. 1987;  8 103-107
• 37 Ellis H. The magnitude of adhesion related problems.  Ann Chir Gynaecol. 1998;  87 9-11
• 38 Alwan M H, van Rij A M, Greig S F. Postoperative adhesive small bowel obstruction: the resources impacts.  NZ Med J. 1999;  112 421-423
• 39 Holmdahl L, Risberg B. Adhesions: Prevention and complications in general surgery.  Eur J Surg. 1997;  163 169-174
• 40 Soules H, Dennis L, Bosarge A, Moore D E. The prevention of postoperative pelvic adhesions: an animal study comparing barrier methods with dextran 70.  Am J Obstet Gynecol. 1982;  143 829-834
• 41 Kresch A J, Seifer D B, Sachs L B. et al . Laparoscopy in 100 women with CPP.  Obstet Gynecol. 1984;  64 672-674
• 42 Howard F M. The role of laparoscopy in chronic pelvic pain: promise and pitfalls.  Obstet Gynecol Surv. 1993;  48 357-358
• 43 Johns A. Initial feasibility study of a sprayable hydrogel adhesion barrier system in patients undergoing laparoscopic ovarian surgery. ISGE Berlin, 25. - 28. 4. 2002
• 44 Mettler L, Audebert A, Lehmann-Willenbrock E. Prospective clinical trial of SprayGel® as a barrier to adhesion formation: an interim analysis.  J Am Assoc Gynecol Laparosc. 2003;  in press
• 45 Dunn R, Lyman M D, Edelman P G, Campbell P K. Evaluation of the SprayGel® adhesion barrier in the rat cecum abrasion and rabbit uterine horn adhesion models.  Fertil Steril. 2001;  75 411-416
• 46 Ferland R, Mulani D, Campbell P K. Evaluation of a sprayable polyethylene glycol adhesion barrier in a porcine efficacy model.  Hum Reprod. 2001;  16 2718-2723
• 47 Jacobs V R, Melanson D A, Campbell P K, Sawhney A S. Pressure balanced sprayer for use in laparoscopy: new instrument for intraabdominal application of soluble biomaterials. 29th Global Congress for Gynecological Endoscopy of the American Association of Gynecological Laparoscopists (AAGL), Orlando, FL, USA, November 15 - 19. 2000
• 48 Mettler L, Schollmeyer Th, Kotdawala P, Zavala A, Moharram A E. Laparoscopic surgery and adhesiolysis.  Gynaecol Endosc. 2002;  11 189-195
• 49 Wiseman D M, Trout J R, Diamond M P. The rates of adhesion development and the effects of crystalloid solutions on adhesion development in pelvic surgery.  Fertil Steril. 1998;  70 702-711
• 50 Peers E, Gokal R. Icodextrin: overview of clinical experience.  Perit Dial Int. 1977;  17 22-26
• 51 Hosie K, Gilbert J A, Kerr D. et al . Fluid dynamics in man of an intraperitoneal drug delivery solution: 4 % icodextrin.  Drug Delivery. 2001;  8 9-12
• 52 Verco S JS, Peers E M, Brown C B. et al . Development of a novel glucose polymer solution (icodextrin) for adhesion prevention: pre-clinical studies.  Hum Reprod. 2000;  15 1764-1772
• 53 diZerega G S, Verco S JS, Young P, Kettel M, Koback W, Martin D, Sanfilippo J, Peers E M, Schrimgeour A, Brown C B. A randomised, controlled pilot study of the safety and efficacy of 4 % icodextrin solution (Adept®) in the reduction of adhesions following laparoscopic gynaecological surgery.  Hum Reprod. 2002;  17 1031-1038
• 54 Lundorff P, van Geldorp H, Tronstad S E, Lalos O, Larsson B, Johns D B, diZerega G S. Reduction of post-surgical adhesions with ferric hyaluronate gel: a European study.  Hum Reprod. 2001;  16 1982-1988
• 55 Peters A, Bakkum E, Hellebrekers B. Debate: Do adhesions cause pain? A debate for and against.  Adhesions News Views. 2002;  2 24-38
• 56 Becker S, Schauf B, Wallwiener D. Gynäkologisches Operieren - quo vadis?.  Geburtsh Frauenheilk. 2002;  62 708-710
• 57 Schauf B. Interview. Congress of Gynaecological Endoscopy and Innovative Surgery.  Geburtsh Frauenheilk. 2002;  62 86-87
• 58 Sutton C. Adept: clinical evaluation by the ARIEL Registry.  Adhesions News Views. 2002;  2 4-9