Prevention of peritoneal adhesions after gynecological surgery: a systematic review.

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.

Abdominal Instillation of Crystalloid Fluid Decreases the Recurrence of Adhesive Small Bowel Obstruction.

Peritoneal adhesion is a common cause of small bowel obstruction (SBO). In this study, we included 40 adult patients who had SBO, or partial obstructive symptoms. In the abdominal instillation of crystalloid fluid (AICF) cohort, 16 patients underwent lysis of adhesions and abdominal crystalloid fluid instillation at the end of the procedure. In the control (CO) group, 24 patients received lysis of adhesions without fluid instillation. AICF was achieved by the abdominal instillation of 1864 ± 97.5 mL of crystalloid fluid. We analyzed the recurrence of peritoneal adhesions resulting in reoperation for SBO within the 64.3 ± 9.15 months of follow-up time for the CO and the 70.5 ± 13.16-month follow-up for the AICF group. The AICF group had a lower SBO recurrence rate of 12.5% compared to the CO group's 41.6% rate (P = .049). Taken together, AICF decreased the recurrence of SBO requiring reoperation secondary to adhesion formation compared to the lysis of adhesions alone, as seen in the CO group.

D-limonene inhibits peritoneal adhesion formation in rats via anti-inflammatory, anti-angiogenic, and antioxidative effects.

The aim of this research was to investigate the effects of D-limonene on decreasing post-operative adhesion in rats and to understand the mechanisms involved. Peritoneal adhesions were induced by creating different incisions and excising a 1 × 1 cm section of the peritoneum. The experimental groups included a sham group, a control group in which peritoneal adhesions were induced without any treatment, and two treatment groups in which animals received D-limonene with dosages of 25 and 50 mg/kg after inducing peritoneal adhesions. Macroscopic examination of adhesions showed that both treatment groups had reduced adhesion bands in comparison to the control group. Immunohistochemical assessment of TGF-ß1, TNF-α, and VEGF on day 14 revealed a significant increment in the level of immunopositive cells for the mentioned markers in the control group, whereas administration of limonene in both doses significantly reduced levels of TGF-ß1, TNF-α, and VEGF (P < 0.05). Induction of peritoneal adhesions in the control group significantly increased TGF-ß1, TNF-α, and VEGF on days 3 and 14 in western blot evaluation, while treatment with limonene significantly reduced TNF-α level on day 14 (P < 0.05). Moreover, VEGF levels in both treatment groups significantly reduced on days 3 and 14. In the control group, a significant increment in the levels of MDA and NO and a notable decline in the levels of GPX, CAT was observed (P < 0.05). Limonene 50 group significantly reduced MDA level and increased GPx and CAT levels on day 14 (P < 0.05). In summary, D-limonene reduced adhesion bands, inflammatory cytokines, angiogenesis, and oxidative stress.

Effects of linalool on postoperative peritoneal adhesions in rats.

The current study examines the effects of linalool in preventing postoperative abdominal adhesions. Twenty male Wistar rats were randomly divided into four groups. (1) Sham: in this group, the abdomen was approached, and without any manipulations, it was sutured. (2) Control: rats in this group underwent a surgical procedure to induce adhesions. This involved making three incisions on the right abdominal side and removing a 1×1-cm piece of the peritoneum on the left abdominal side. (3) Treatment groups: these groups underwent the same surgical procedure as the control group to induce adhesions. Animals in these groups received linalool orally with doses of 50 and 100 mg/kg, respectively, for a period of 14 days. Moreover, rats in the sham and control groups received normal saline via gavage for 14 days. The evaluation of TNF-α, TGF-ß, VEGF, and caspase 3 was performed using western blot and IHC methods. Furthermore, oxidative stress biomarkers such as MDA, TAC, GSH, and NO were assessed in the peritoneal adhesion tissue. The findings revealed that linalool significantly reduced peritoneal adhesions by reducing TNF-α, TGF-ß, VEGF, and caspase 3 levels. Moreover, MDA concentration was significantly decreased, while NO, TAC, and GSH levels were notably increased. Overall, linalool was effective in preventing adhesion formation and reduced inflammation, angiogenesis, apoptosis, and oxidative stress. Therefore, linalool as a potent antioxidant is suggested for reducing postoperative adhesions in rats.

Adhesive small-bowel obstruction as a challenging complication of familial Mediterranean fever: A case-based review.

Familial Mediterranean fever (FMF) is the most common inherited autoinflammatory disorder, characterized by recurrent and self-limiting episodes of fever and serosal inflammation. Recurrent serositis may rarely lead to the formation of adhesions in the peritoneum, which may result in mechanical bowel obstruction. The symptoms, such as abdominal pain and vomiting, may mimic typical FMF attacks, resulting in misdiagnosis and severe morbidity, including strangulation and intestinal necrosis. Physicians are generally aware of other complications associated with FMF but reports on peritoneal adhesions and intestinal obstruction in English-language literature are inadequate to increase clinicians' awareness. Therefore, it is crucial to meticulously evaluate FMF patients presenting with abdominal pain and ileus because these symptoms could be due to adhesive small-bowel obstruction (ASBO). Furthermore, patients presenting with ASBO without a history of abdominal surgery should also be thoroughly evaluated, especially as it could be an initial presentation for an autoinflammatory disease. Herein, we present a pediatric case of FMF with the M694V homozygous mutation, complicated by ASBO while under colchicine treatment. Additionally, we provide a comprehensive review of the available literature on ASBO in FMF.

Can we predict peritoneal adhesions formation after cesarean delivery?

OBJECTIVE: To examine demographic and obstetrical factors that are associated with adhesion formation following cesarean delivery. METHODS: We conducted a population-based study that included all women over 18 years og age who underwent two cesarean deliveries between the years 1988 and 2016 in a large tertiary medical center. We excluded women with adhesions already diagnosed during the first cesarean delivery, history of other abdominal or pelvic surgery, history of pelvic infection or pelvic inflammatory disease, history of endometriosis and history of uterine Müllerian anomalies. In addition, women with a classical or T-shaped uterine incision, non-singleton pregnancies, and fetal chromosomal or structural abnormalities were excluded. RESULTS: During the study period, 32.6% (n = 2283) of women were diagnosed with peritoneal adhesions during the second cesarean delivery. Factors found to be significantly associated with peritoneal adhesions were maternal age 35 years or older at the first cesarean delivery, Bedouin Arab ethnicity, composite of intrapartum and postpartum infectious morbidity, and cesarean deliveries that were performed after the onset of labor. In contrast, having a previous vaginal birth was found to be protective. CONCLUSIONS: Our results suggest that a woman's characteristics at her first cesarean delivery and her obstetrical history may be predictive of the likelihood of adhesion formation.

Farnesol remodels the peritoneal cavity immune environment influencing Candida albicans pathogenesis during intra-abdominal infection.

Candida albicans is a lifelong member of the mycobiome causing mucosal candidiasis and life-threatening, systemic, and intra-abdominal disease in immunocompromised and transplant patients. Despite the clinical importance of intra-abdominal candidiasis with mortality rates between 40% and 70%, the contribution of fungal virulence factors and host immune responses to disease has not been extensively studied. Secretion of the quorum-sensing molecule, farnesol, acts as a virulence factor for C. albicans during systemic infection, while inducing local, protective innate immune responses in oral models of infection. Previously, we reported that farnesol recruits macrophages to the peritoneal cavity in mice, suggesting a role for farnesol in innate immune responses. Here, we expand on our initial findings, showing that farnesol profoundly alters the peritoneal cavity microenvironment promoting innate inflammation. Intra-peritoneal injection of farnesol stimulates rapid local death of resident peritoneal cells followed by recruitment of neutrophils and inflammatory macrophages into the peritoneal cavity and peritoneal mesothelium associated with an early increase in chemokines followed by proinflammatory cytokines. These rapid inflammatory responses to farnesol significantly increase morbidity and mortality of mice with intra-abdominal candidiasis associated with increased formation of peritoneal adhesions, despite similar rates of fungal clearance from the peritoneal cavity and retro-peritoneal organs. C. albicans ddp3Δ/ddp3Δ knockout and reconstituted strains recapitulate these findings. This indicates that farnesol may be detrimental to the host during intra-abdominal infections. Importantly, our results highlight a need to understand how C. albicans virulence factors modulate the host immune response within the peritoneum, an exceedingly common site of Candida infection.

Multifunctional Oxidized Dextran-Metformin as a Tissue-Adhesive Hydrogel to Prevent Postoperative Peritoneal Adhesions in Patients with Metabolic Syndrome.

Patients with metabolic syndrome (MetS) undergoing surgery are at high risk of developing peritoneal adhesions and other severe postoperative complications. However, the single shielding function and absence of physiological activity render conventional methods less useful in preventing adhesions in patients with MetS. To address this challenge, a convenient method is introduced for developing a novel tissue-adhesive hydrogel called oxidized dextran-metformin (ODE-ME) via Schiff base linkages. This injectable ODE-ME hydrogel exhibits excellent tissue-adhesive properties and various physiological functions, particularly enhanced antibacterial effects. Furthermore, in vivo experiments demonstrate that the hydrogel can effectively alleviate hyperglycemia, reduce excessive inflammation, and improve fibrinolytic activity in MetS mice, thereby preventing adhesions and promoting incisional healing. The hydrogel concurrently isolates injured tissues and lowers the blood glucose levels immediately after surgery in mice. Therefore, the ODE-ME hydrogel functions as a multifunctional barrier material and has potential for preventing postoperative peritoneal adhesions in patients with MetS in clinical settings.

Smart hydrogels delivered by high pressure aerosolization can prevent peritoneal adhesions.

Postoperative peritoneal adhesions occur in the majority of patients undergoing intra-abdominal surgery and are one of the leading causes of hospital re-admission. There is an unmet clinical need for effective anti-adhesive biomaterials, which can be applied evenly across the damaged tissues. We examined three different responsive hydrogel types, i.e. a thermosensitive PLGA-PEG-PLGA, a pH responsive UPy-PEG and a shear-thinning hexapeptide for this purpose. More specifically, their potential to be homogeneously distributed in the peritoneal cavity by high pressure nebulization and prevent peritoneal adhesions was evaluated. Solutions of each polymer type could be successfully nebulized while retaining their responsive gelation behavior in vitro and in vivo. Furthermore, none of the polymers caused in vitro toxicity on SKOV3-IP2 cells. Following intraperitoneal administration, both the PLGA-PEG-PLGA and the hexapeptide hydrogels resulted in local inflammation and fibrosis and failed in preventing peritoneal adhesions 7 days after adhesion induction. In contrast, the pH sensitive UPy-PEG formulation was well tolerated and could significantly reduce the formation of peritoneal adhesions, even outperforming the commercially available Hyalobarrier® as positive control. To conclude, local nebulization of the bioresponsive UPy-PEG hydrogel can be considered as a promising approach to prevent postsurgical peritoneal adhesions.

Practice of Peritoneal Adhesions in Osteopathic Medicine: Part 2.

Peritoneal adhesions are an unwanted and frequent event following abdominal surgery, with a response rate that can reach 100%. The adhesions can be symptomatic, becoming a source of pain and discomfort for the patient, or asymptomatic, with possible chronic or acute visceral dysfunction. The article reviews what the diagnostic strategies are and discusses what could be the causes that lead to chronic pain in the presence of adhesions. The text reports the knowledge of the literature on the manual treatment of adhesions and illustrates possible symptoms that are not easily recognized by the clinician. To conclude, the article proposes osteopathic manual approaches derived from clinical experience and from what has been explained about the formation of peritoneal adhesions. Research must make further efforts to identify not only the causes triggering the formation of peritoneal neogenesis but also seek the most appropriate non-invasive treatments to help the patient.

Melt electrowriting-printed peritoneal scaffold prevents peritoneal adhesion and facilitates peritoneal repair.

Peritoneal adhesion is a critical issue after abdominal surgery. Cell-based methods for preventing peritoneal adhesion have not yet been fully investigated. Here, we constructed a highly biomimetic peritoneal scaffold by seeding mesothelial cells, the natural physiological barrier of the peritoneum, onto a melt electrowriting-printed scaffold. The scaffolds with the microfibers crossed at different angles (30°, 60°, and 90°) were screened based on mesothelial cell proliferation and orientation. Thirty degrees were more suitable for improving proliferation of mesothelial cells and cell growth in a single direction; therefore, the 30° peritoneal scaffold could better mimic the physiological structure of native peritoneum. Mechanistically, such a peritoneal scaffold was able to act as a barrier to prevent peritoneal resident macrophages from migrating to the site of the peritoneal lesion. In vivo mesothelial cell tracking using lentivirus technology confirmed that the peritoneal scaffold, compared to the scaffold without mesothelial cells, could prevent peritoneal adhesion and was directly involved in the repair of injured peritoneum. This study suggests that the peritoneal scaffolds can potentially prevent peritoneal adhesion, offering a new approach for clinical treatment.

Multifunctional Fluorinated Lubricant-Infused Poly(4-Hydroxybutyrate) (P4HB) Membranes for Full-Thickness Abdominal Wall Defect Repair.

Abdominal wall defect caused by surgical trauma, congenital rupture, or tumor resection may result in hernia formation or even death. Tension-free abdominal wall defect repair by using patches is the gold standard to solve such problems. However, adhesions following patch implantation remain one of the most challenging issues in surgical practice. The development of new kinds of barriers is key to addressing peritoneal adhesions and repairing abdominal wall defects. It is already well recognized that ideal barrier materials need to have good resistance to nonspecific protein adsorption, cell adhesion, and bacterial colonization for preventing the initial development of adhesion. Herein, electrospun poly(4-hydroxybutyrate) (P4HB) membranes infused with perfluorocarbon oil are used as physical barriers. The oil-infused P4HB membranes can greatly prevent protein attachment and reduce blood cell adhesion in vitro. It is further shown that the perfluorocarbon oil-infused P4HB membranes can reduce bacterial colonization. The in vivo study reveals that perfluoro(decahydronaphthalene)-infused P4HB membranes can significantly prevent peritoneal adhesions in the classic abdominal wall defects' model and accelerate defect repair, as evidenced by gross examination and histological evaluation. This work provides a safe fluorinated lubricant-impregnated P4HB physical barrier to inhibit the formation of postoperative peritoneal adhesions and efficiently repair soft-tissue defects.

Endogenously produced hyaluronan contributes to the regulation of peritoneal adhesion development.

Peritoneal adhesions are postsurgical fibrotic complications connected to peritoneal inflammation. The exact mechanism of development is unknown; however, an important role is attributed to activated mesothelial cells (MCs) overproducing macromolecules of extracellular matrix (ECM), including hyaluronic acid (HA). It was suggested that endogenously-produced HA contributes to the regulation of different fibrosis-related pathologies. However, little is known about the role of altered HA production in peritoneal fibrosis. We focused on the consequences of the increased turnover of HA in the murine model of peritoneal adhesions. Changes of HA metabolism were observed in early phases of peritoneal adhesion development in vivo. To study the mechanism, human MCs MeT-5A and murine MCs isolated from the peritoneum of healthy mice were pro-fibrotically activated by transforming growth factor ß (TGFß), and the production of HA was attenuated by two modulators of carbohydrate metabolism, 4-methylumbelliferone (4-MU) and 2-deoxyglucose (2-DG). The attenuation of HA production was mediated by upregulation of HAS2 and downregulation of HYAL2 and connected to the lower expression of pro-fibrotic markers, including fibronectin and α-smooth muscle actin (αSMA). Moreover, the inclination of MCs to form fibrotic clusters was also downregulated, particularly in 2-DG-treated cells. The effects of 2-DG, but not 4-MU, were connected to changes in cellular metabolism. Importantly, the inhibition of AKT phosphorylation was observed after the use of both HA production inhibitors. In summary, we identified endogenous HA as an important regulator of peritoneal fibrosis, not just a passive player during this pathological process.

Evaluation of the effectiveness of alginate-based hydrogels in preventing peritoneal adhesions.

Infertility and intestinal blockage are just two examples of the postoperative consequences that can arise from peritoneal damage, which can also result in severe peritoneal fibrosis and peritoneal adhesions. Peritoneal adhesions are still not effectively treated, and both pharmaceutical therapy and biomaterial barriers have only had modest preventative effects. In this work, we looked into the effectiveness of in-place injectable sodium alginate hydrogel for peritoneal adhesion prevention. The findings demonstrated that sodium alginate hydrogel promoted human peritoneal mesothelial cell proliferation and migration, prevented peritoneal fibrosis by suppressing the production of transforming growth factor-ß1, and, most importantly, promoted mesothelium self-repair. These findings imply that this brand-new sodium alginate hydrogel is a good candidate material for peritoneal adhesion prevention.

Peritoneal adhesion findings during laparoscopy: Determinants of occurrence and effect of severity on operative outcomes in a Nigerian Hospital.

Context: Peritoneal adhesions unlike other immediately recognizable complications of the surgery may produce long-term consequences, which include infertility and intestinal obstruction. Aims: The study aimed to determine the prevalence, the determinants, and the outcomes of laparoscopic surgery associated with intraperitoneal adhesion findings. Settings and Design: This was a retrospective observational study. Materials and Methods: The study included all laparoscopic gynecological surgeries done between January 2017 and December 2021. Adhesion severity was graded, using the peritoneal adhesion index (PAI), by Coccolini et al. Statistical Analysis: The data were analyzed using the SPSS version 21.0. Binary logistic regression was used to assess the factors associated with adhesion finding during laparoscopy. Results: There were 158 laparoscopic surgeries with 26.6% prevalence of peritoneal adhesions. The prevalence of adhesions among women with previous surgery was 72.7%. Previous peritoneal surgery was a significant determinant of occurrence of adhesions (odds ratio = 8.291, 95% confidence interval [CI] = 4.464-15.397, P < 0.001), and such patients had significantly (P = 0.025, 95% CI = 0.408-5.704) more severe adhesions (PAI = 11.16 ± 3.94) than those without prior surgery (PAI = 8.10 ± 3.14). Abdominal myomectomy (PAI = 13.09 ± 2.95) was the most important primary surgical determinant of adhesion formation. There was no significant relationship between adhesion occurrence and conversion to laparotomy (P = 0.121) or mean duration of surgery (P = 0.962). Greater adhesion severity was, however, observed in individuals with operative blood loss <100 ml (PAI = 11.73 ± 3.56, P = 0.003) and those hospitalized for ≤2 days (PAI = 11.12 ± 3.81, P = 0.022). Conclusion: The prevalence of postoperative adhesions during laparoscopy in our center is comparable to what has been earlier reported. Abdominal myomectomy is associated with the greatest risk and severity of adhesions. Laparoscopy in patients with more severe adhesions resulted in less blood loss and shorter duration of hospitalization, suggesting an association of better outcomes with a cautious approach to adhesions.

Résumé Contexte: Les adhérences péritonéales, contrairement aux autres complications chirurgicales immédiatement reconnaissables, peuvent avoir des conséquences à long terme, notamment la stérilité et l'occlusion intestinale. Objectifs: L'étude visait à déterminer la prévalence, les déterminants et les résultats de la chirurgie laparoscopique associée aux résultats des adhérences intrapéritonéales. Paramètres et conception: Il s'agissait d'une étude d'observation rétrospective. Matériaux et méthodes: L'étude a inclus toutes les chirurgies gynécologiques laparoscopiques réalisées entre janvier 2017 et décembre 2021.La gravité des adhérences a été évaluée, en utilisant l'indice d'adhérence péritonéale (PAI), de Coccolini et al. Analyse statistique: Les données ont été analysées à l'aide de SPSS version 21.0. Une régression logistique binaire a été utilisée pour évaluer les facteurs associés à la recherche d'adhérences pendant la laparoscopie. Résultats: Il y a eu 158 chirurgies laparoscopiques avec une prévalence de 26,6 % d'adhérences péritonéales. La prévalence des adhérences chez les femmes avec une chirurgie antérieure était de 72,7 %. La chirurgie péritonéale antérieure était un déterminant important de l'apparition d'adhérences (rapport de cotes = 8,291, Intervalle de confiance [IC] à 95 % = 4,464-15,397, P < 0, 001), et ces patientes avaient significativement (P = 0,025, IC à 95 % = 0,408-5,704) des adhérences plus sévères (PAI = 11,16 ± 3,94) que celles sans chirurgie préalable (PAI = 8,10 ± 3,14). La myomectomie abdominale (PAI = 13,09 ± 2,95) était le déterminant chirurgical primaire le plus important de la formation de l'adhérence. Il n'y avait pas de relation significative entre l'occurrence de l'adhérence et la conversion en laparotomie (P = 0,121) ou la durée moyenne de la chirurgie (P = 0,962). Cependant, une plus grande sévérité de l'adhérence a été observée chez les personnes ayant une perte de sang opératoire <100 ml (PAI = 11,73 ± 3,56, P = 0,003) et celles hospitalisées pendant ≤2 jours (PAI = 11,12 ± 3,81,P=0,022). Conclusion: La prévalence des adhérences postopératoires lors d'une laparoscopie dans notre centre est comparable à ce qui a été précédemmentRapporté. La myomectomie abdominale est associée au plus grand risque et à la plus grande sévérité des adhérences. La laparoscopie chez les patients souffrant d'adhérences plus sévères a entraîné une perte de sang moins importante et un séjour hospitalier plus court, ce qui suggère une association de meilleurs résultats avec une approche prudente des adhérences. Mots-clés: Fertilité, laparoscopie, myomectomie, adhrérences péritonéales.

Method of prevention of post-operative peritoneal adhesions.

OBJECTIVE: The purpose of the research was to assess the performance of the method of prevention of post-operative peritoneal adhesions (PAs) (author's method) in patients of different age groups. METHODS: Two hundred eighty-five patients were in total enrolled in the study. The patients of two age groups were divided into two groups: Group 1 (treatment group), where the author's method was used on 143 patients, and Group 2 (control group) 142 patients, where was used the standard approach of prevention of intra-abdominal adhesions. All patients were operated in an urgent order on adhesive intestinal obstruction (AIO). The patients previously had surgery on AIO one to 3 times. Within each group, sick children and adults were identified. The gender distribution was comparable in both groups. RESULTS: The recurrence of AIO was significantly less in Group 1 than in Group 2 (1.4% and 6.3%, respectively, p<0.05). A separate study of the results of treatment in the age aspect in groups showed some features. Among children the AIO relapse rate in study Groups 1 and 2: Early AIO-in 1 (0.86%) and 2 (1.8%) patients, respectively; late AIO-in 1 (0.86%) and 4 (3.5%), patients, respectively. Among adults who didn't have relapse AIO during the follow-up period in Group 1. The AIO relapse rate in Group 2: Early AIO - in 1 (3.5%) and late AIO-2 (6.9%) patients, respectively. CONCLUSION: The proposed author's method for preventing AIO recurrence has shown its effectiveness among patients with adhesive AIO. Besides, using this method in children to reduce the AIO relapse rate by more than thrice; in adult patients, to prevent the development of clinically significant signs of PA and normalize the patient's quality of life.

A retrospective study on the association of keloids with underlying health conditions in African-American Women.

Keloids are disfiguring benign scars that develop due to an exaggerated response to cutaneous wound healing, growing beyond the boundaries of the cutaneous insult into normal, previously uninvolved skin. The association of keloids with other underlying health conditions has been postulated, but not well characterized. Objective: This study aims to identify whether there is any association of keloids with underlying health conditions in African-American women. Methods: This study was done via the use of the National Inpatient Sample, a subset of the Healthcare Cost and Utilization Project. African-American women with keloids who had undergone cesarean sections were compared with a control group of African-American women with no history of keloids who had undergone cesarean sections. Results: A total of 301 African-American inpatient encounters with patients with keloids were compared with 37,144 encounters in the control group. The keloid patients had an increased association with peritoneal adhesions compared with the control group. Limitations: results are limited to one race and restricted age range; also, unable to differentiate keloids from hypetrophic scarring with ICD-10 codes. Conclusion: These findings suggest that keloids and peritoneal adhesions may have similar inflammatory processes.

Connexin43 in Post-Surgical Peritoneal Adhesion Formation.

OBJECTIVE: Post-surgical peritoneal adhesions are a serious problem for the quality of life and fertility. Yet there are no effective ways of preventing their occurrence. The gap junction protein Cx43 is known to be involved in fibrosis in several different organs and disease conditions often associated with inflammation. Here we examined the Cx43 dynamic expression in an ischemic button model of surgical adhesions. METHODS: Using the mouse ischemic button model, Cx43 antisense was delivered in Pluronic gel to attenuate Cx43 expression. The severity of button formation and immunofluorescence analysis of Cx43 and TGF-ß1 were performed. The concentration of tissue plasminogen activator via ELISA was also performed. RESULTS: As early as 6 h after button formation, the Cx43 levels were elevated in and around the button and some weak adhesions were formed. By 24 h Cx43 levels had increased further and adhesions were more defined. At 7 days the adhesions were much more robust, opaque, and vascularized, requiring blunt or sharp dissection to break them. Cx43 antisense attenuated its upregulation and, reduced the number and severity of adhesions that formed. CONCLUSION: Targeting Cx43 after surgical procedures may be a potential therapeutic strategy for preventing adhesion formation or at least reducing their severity.

Mechanisms of Peritoneal Mesothelial Cells in Peritoneal Adhesion.

A peritoneal adhesion (PA) is a fibrotic tissue connecting the abdominal or visceral organs to the peritoneum. The formation of PAs can induce a variety of clinical diseases. However, there is currently no effective strategy for the prevention and treatment of PAs. Damage to peritoneal mesothelial cells (PMCs) is believed to cause PAs by promoting inflammation, fibrin deposition, and fibrosis formation. In the early stages of PA formation, PMCs undergo mesothelial-mesenchymal transition and have the ability to produce an extracellular matrix. The PMCs may transdifferentiate into myofibroblasts and accelerate the formation of PAs. Therefore, the aim of this review was to understand the mechanism of action of PMCs in PAs, and to offer a theoretical foundation for the treatment and prevention of PAs.

The Therapeutic Potential of Targeting Key Signaling Pathways as a Novel Approach to Ameliorating Post-Surgical Adhesions.

BACKGROUND: Peritoneal adhesions (PA) are a common complication of abdominal operations. A growing body of evidence shows that inhibition of inflammation and fibrosis at sites of peritoneal damaging could prevent the development of intra-abdominal adhesions. METHODS: A search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords 'postsurgical adhesion', 'post-operative adhesion', 'peritoneal adhesion', 'surgery-induced adhesion' and 'abdominal adhesion'. Studies detailing the use of pharmacological and non-pharmacological agents for peritoneal adhesion prevention were identified, and their bibliographies were thoroughly reviewed to identify further related articles. RESULTS: Several signaling pathways, such as tumor necrosis factor-alpha, tissue plasminogen activator, and type 1 plasminogen activator inhibitor, macrophages, fibroblasts, and mesothelial cells play a key part in the development of plasminogen activator. Several therapeutic approaches based on anti-PA drug barriers and traditional herbal medicines have been developed to prevent and treat adhesion formation. In recent years, the most promising method to prevent PA is treatment using biomaterial-based barriers. CONCLUSION: In this review, we provide an overview of the pathophysiology of adhesion formation and various agents targeting different pathways, including chemical agents, herbal agents, physical barriers, and clinical trials concerning this matter.