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Expert Panel: Techniques and tools to prevent pelvic adhesions


 

References

DECHERNEY: In my opinion, that is its major drawback.

PAGIDAS: In cardiac surgery, Seprafilm appears to work quite effectively.

SANFILIPPO: The manufacturer initially focused on surgeons in the context of sigmoid colon surgery, and it seems to work well in that setting.

Intergel

DECHERNEY: That brings us to the current state of the art: gels. I’m sure you all are familiar with Intergel (Lifecore Biomedical, Chaska, Minn), which is a ferrous derivative of hyaluronic acid that works by coating the raw surface areas. It also has the theoretical advantage of ease of use. Have any of you used Intergel?

HURD: As you know it was only recently approved by the US Food and Drug Administration, but not for laparoscopic use. It may work best on abraded bowel, which is avoided by laparoscopic surgery.

As you are probably also aware, the manufacturer recently took it off the market because of unusual side effects, namely a chemical peritonitis. Although peritonitis was cited as being rare, we encountered it in probably half the patients we operated on.

PAGIDAS: When we used it on hospitalized patients, the peritonitis wasn’t that obvious, since there was an expectation of significant pain. However, when we used Intergel on short-stay patients, we had to readmit them and do a full workup because we were concerned about bowel perforations. I’m surprised the manufacturer didn’t take it off the market sooner.

DECHERNEY: It seems strange, since Intergel has been used in Europe for a while now. I’ve used it in only 1 case and didn’t have adverse effects. It seemed to work well.

SANFILIPPO: It had all the right ingredients for success. It is unfortunate that these side effects have prohibited its use.

There is no question that adhesion prevention is one of the unmet challenges in all surgeries, especially reproductive surgery.

Gels and the cost factor

DECHERNEY: Other gels are in the pipeline. I’m reminded of plasminogen activator, which is a powerful antiadhesive agent that lyses fibrin effectively. Unfortunately, it is prohibitively expensive.

The next phase likely will involve the so-called polymers. If you spray them on your hand, they are activated by light or another chemical and become a cellophane-like substance. The problem is viscosity. If sprayed on the sidewall, for instance, they run halfway down before they are activated, so the entire surface does not get covered.

PAGIDAS: One concern with polymers is that they could actually bring surfaces together when they polymerize. We still have a lot to learn.

DECHERNEY: Let’s say a new gel comes on the market that takes reformation adhesions from 90% to 10%, as opposed to 40% recurrence. Would you use it in all 4 of the cases we discuss here?

HURD: If it was that effective and had no adverse effects, it would be wonderful.

The cesarean-delivery case is different, as healing in a pregnant patient is 1 concern; the size of the uterus also has an effect. If the patient is breastfeeding, you would want to make sure the gel didn’t interfere.

PAGIDAS: We desperately need a product that can minimize adhesions regardless of the route of access or type of procedure. Even though we lack data on outcomes, I predict wide use of such a product, assuming it is nontoxic and effective.

DECHERNEY: What if it costs $1,000 a case?

SANFILIPPO: If it prevents 1 bowel obstruction, it still would be cost-effective.

DECHERNEY: The incidence of bowel obstruction for total abdominal hysterectomy is 2%, and 5% for radical hysterectomy.

HURD: We must be careful of the cost-benefit ratio. Bowel obstruction after gynecologic surgery is uncommon.

Is the gel worth $100? $1,000? $3,000? It’s difficult to say, but the more expensive it is, the less likely it will find widespread use.

PAGIDAS: I agree. We should remember that we still need to maintain microsurgical techniques and appropriate tissue handling, as well as avoid ischemia and infection.

Looking for the magic bullet

DECHERNEY: What is the future of adjunctive therapy?

SANFILIPPO: I would focus on noxythiolin; it has potential. Calcium channel blockers for adhesion prevention have also been studied.20 In 1 investigation involving a rat model, the calcium channel blocker verapamil as well as several other agents—including vitamin E, carboxymethylcellulose, cyclosporin, aprotinin, and tenoxicam—were compared with respect to tissue effects. A beneficial effect was noted with all agents except cyclosporin and carboxymethylcellulose.

Whoever succeeds in manufacturing an effective preventive will be a winner.

HURD: There is no question that adhesion prevention is one of the unmet challenges in all surgeries, especially reproductive surgery. The most effective agent would be applied intraabdominally, since any systemic agent that stops adhesion formation would probably decrease wound healing as well.

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