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Prevention of peritoneal adhesions after gynecological surgery: a systematic review
Sebastian D Schaefer1, Ibrahim Alkatout2, Nadja Dornhoefer3
1Department of Gynecology and Obstetrics, Clemenshospital Muenster, Münster, Germany. seb.schaefer@alexianer.de.
Insights
Adhesion barriers can reduce post-gynecological surgery adhesions, with hyaluronic acid and modified starch showing significant promise. Further research should standardize scoring and focus on patient outcomes like pain and infertility.
Area of Science:
- Reproductive Medicine
- Surgical Innovation
- Biomaterials Science
Background:
- Post-gynecological surgery adhesions cause pain, infertility, and obstruction.
- Adhesions represent a significant economic burden on healthcare systems globally.
Approach:
- Systematic review of randomized controlled trials (RCTs) evaluating adhesion barriers in gynecological surgery.
- Included RCTs with second-look surgery to assess adhesion formation in the pelvic/abdominal cavity.
Key Points:
- 45 RCTs involving 4,120 patients examined 10 unique barrier types.
- Hyaluronic acid, modified starch, and expanded polytetrafluoroethylene demonstrated notable adhesion reduction.
- 4DryField® showed the greatest improvement in adhesion scores (85%).
Conclusions:
- While findings are inconsistent across barrier types, hyaluronic acid, modified starch, and Gore-Tex Surgical Membrane show potential.
- Nonabsorbable barriers like Gore-Tex may increase risks; 4DryField® offers the highest efficacy.
- Future studies need standardized scores and patient-reported outcomes (pain, infertility) for better comparability.
Importance:
The formation of adhesions after gynecological surgery not only has detrimental impacts on those affected, including pain, obstruction, and infertility, but also imposes a high economic burden on healthcare systems worldwide.
Objective:
The aim of this review was to evaluate the adhesion prevention potential of all currently available adhesion barriers for gynecological surgery.
Evidence Acquisition:
We systematically searched MEDLINE and CENTRAL databases for randomized controlled trials (RCTs) on the use of adhesion barriers as compared with peritoneal irrigation or no treatment in gynecological surgery. Only RCTs with second-look surgery to evaluate adhesions in the pelvic/abdominal (but not intrauterine) cavity were included.
Results:
We included 45 RCTs with a total of 4,120 patients examining a total of 10 unique types of barriers in second-look gynecological surgery. While RCTs on oxidized regenerated cellulose (significant improvement in 6 of 14 trials), polyethylene glycol with/without other agents (4/10), hyaluronic acid and hyaluronate + carboxymethylcellulose (7/10), icodextrin (1/3), dextran (0/3), fibrin-containing agents (1/2), expanded polytetrafluoroethylene (1/1), N,O-carboxymethylchitosan (0/1), and modified starch (1/1) overall showed inconsistent findings, results for expanded polytetrafluoroethylene, hyaluronic acid, and modified starch yielded the greatest improvements regarding adhesion reduction at 75%, 0-67%, and 85%, respectively.
Conclusions And Relevance:
Best results for adhesion prevention were reported after applying Gore-Tex Surgical Membrane, hyaluronic acid, and 4DryField®. As Gore-Tex Surgical Membrane is nonabsorbable, it is associated with a greater risk of new adhesion formation due to second-look surgery to remove the product. 4DryField® yielded the greatest improvement in adhesion score compared to all other barrier agents (85%). For better comparability, future studies should use standardized scores and put more emphasis on patient-reported outcome measures, such as pain and infertility.
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