Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial.

OBJECTIVE: The objective of the study was to determine the long-term effect of the use of a hyaluronic acid-carboxymethylcellulose membrane (Seprafilm) on the incidence of adhesions and subsequent small-bowel obstruction and chronic abdominal complaints after colorectal surgery (Hartmann's procedure). BACKGROUND: Adhesions occur frequently after abdominal surgery and are the most common cause of bowel obstruction, chronic abdominal pain, and infertility. The risk for adhesion-related readmission in the first 10 years after colorectal surgery is as high as 30%. To reduce the formation of adhesions, a mechanical barrier composed of hyaluronic acid and carboxymethylcellulose was developed, to prevent adherence of tissues after abdominal surgery. Long-term results concerning the incidence of small-bowel obstruction and chronic abdominal pain are lacking. METHODS: Between April 1996 and September 1998, 71 patients requiring Hartmann's procedure for sigmoid diverticulitis or obstructed rectosigmoid were randomized to either intraperitoneal placement of Seprafilm under the midline and in the pelvis or as a control. Direct visual evaluation of the incidence and severity of adhesions was performed laparoscopically in 42 patients at second-stage surgery for restoration of the continuity of the colon. The results of this study were published in 2002. In 2006, the patients' general practitioners were interviewed by means of a questionnaire concerning their patients' health. The patients who were still alive were interviewed and asked to fill out 2 questionnaires concerning pain and quality of life (VAS-pain score, EQ-5D, and SF-36). In 2009, the medical records of the patients were evaluated for adhesion-related hospital re-admissions. RESULTS: Of the 42 evaluated patients, 35 (16 in the Seprafilm group, 19 in the control group) could be enrolled in the long-term follow-up. Median follow-up was 126 months (range 41-148) for the Seprafilm group and 128 months (range 49-149) months for the control group. Incidence of chronic (3 months or longer existing) abdominal complaints was significantly lower in the Seprafilm group compared with controls (35.3% vs. 77.8%, respectively; P = 0.018). Incidence of small-bowel obstruction showed no significant difference in favor of the Seprafilm group; no small-bowel obstructions occurred in the Seprafilm group, whereas in the control group 2 cases of small-bowel obstruction were found to have occurred. Evaluation of the quality of life questionnaires did not reveal significant differences between the 2 groups. CONCLUSIONS: In Hartmann's procedure, Seprafilm placement does not provide protection against small-bowel obstruction. Incidence of chronic abdominal complaints is significantly lower after use of Seprafilm.

Laparoscopic kidney donation: The impact of adhesions.

BACKGROUND: Adhesion formation following abdominal surgery causes substantial burden to society. Laparoscopic donor nephrectomy (LDN) offers an opportunity to study the prevalence of adhesions in healthy individuals. Furthermore we evaluated whether or not adhesions hindered LDN. METHODS: Data of 161 LDNs were prospectively collected. The presence of adhesions was documented. Parameters influenced by the presence of adhesions such as operation time, blood loss, and intraoperative complications were documented. RESULTS: Twenty-eight of 44 donors (64%) who had had prior abdominal surgery presented with adhesions at laparoscopy versus 61 of 107 donors (52%) who had no history of abdominal surgery (P = 0.22). Conversion and complication rate, operation times, and blood loss did not differ between those with and without a previous history of abdominal surgery. Blood loss and operation time did not differ between donors with and without adhesions. The number of conversions to open was significantly higher in donors with adhesions (9 versus 0, P = 0.005). Three conversions were due to adhesions. CONCLUSION: Adhesions are present in a significant number of healthy individuals regardless of a history of previous abdominal operations. As these operations are of no predictive value for the number and complexity of adhesion formation, we advocate starting live kidney donation laparoscopically as the procedure can be most probably conducted successfully by this approach.

What patients and surgeons should know about the consequences of appendectomy for acute appendicitis after long-term follow-up: factors influencing the incidence of chronic abdominal complaints.

INTRODUCTION: Abscess formation and perforation are complications of acute appendicitis that lead to localized or generalized peritonitis. The long-term implications of complicated appendectomy remain largely unknown. MATERIALS AND METHODS: In the present study, it was investigated whether patients with complicated appendicitis experienced more abdominal complaints after long-term follow-up when compared to uncomplicated cases. In addition, the influence of operation technique (open versus laparoscopic) was studied. A retrospective analysis of 1,481 appendectomies for acute appendicitis was performed in two centers from January 2000 until January 2006. Demographic data, operative reports, intraoperatively adhesions and complications, abdominal pain, and satisfaction were monitored. In total, 1,433 patients were invited to fill out a questionnaire with a median follow-up of 7.1 years. Questionnaires of 526 (37 %) patients were suitable for analysis. RESULTS: Perforation, abdominal abscesses, or adhesions at initial operation did not result in more abdominal complaints when compared to appendectomy for uncomplicated acute appendicitis. Additionally, no significant differences in abdominal complaints were seen between laparoscopic and open techniques. CONCLUSION: In conclusion, the results of our study show that after follow-up of 7 years, the incidence of abdominal complaints was not influenced by operative technique or whether acute appendicitis was complicated or not. This finding does not support a causative role for adhesions with regard to chronic abdominal complaints. Our data enables surgeons to inform their patients about the long-term results of appendectomy, whether it was complicated or not.

Biology of the peritoneum in normal homeostasis and after surgical trauma.

The peritoneum is a serous membrane, which has a protective function for the contents of the abdominal cavity. It maintains homeostasis by allowing exchange of molecules and production of peritoneal fluid, thus providing an environment in which intra-abdominal organs can function properly. When traumatized, whether by surgery or due to inflammatory processes, a series of responses come into action to regenerate the injured part of the peritoneum. The inflammatory reaction causes influx of inflammatory cells but also activates resident mesothelial cells, ultimately leading to a fibrinous exudate. Depending on the severity of the trauma this exudate is transient due to fibrinolysis, or becomes more dense as a result of fibroblasts persisting, leading to fibrinous adhesions. A pivotal role is taken by the enzyme plasmin and its promotors and inhibitors; it is mainly the tissue-type plasminogen activator/plasminogen activator inhibitor ratio which determines the rate of fibrinolysis and therefore the rate of adhesion formation. The rate of injury determines the rate and extent of the inflammatory response to that injury; in its turn the inflammatory reaction determines the extent of adhesion formation. One should realize this when performing intra-abdominal surgery, which is in fact operating inside the peritoneal organ.

The role of superoxide anions in the development of distant tumour recurrence.

We hypothesise that reactive oxygen species (ROS) released from activated polymorphonuclear leucocytes during surgery play a crucial role in enhanced tumour recurrence seen after surgery. Therefore, the effect of ROS on adhesion of tumour cells to microvascular endothelium in a reproducible human in vitro model was studied. Preincubation of microvascular endothelial cells with the superoxide anion producing xanthine-xanthine oxidase complex significantly increased adhesion of the human colon carcinoma cells HT29 (167% vs control, P < 0.01), Caco2 (164% vs control, P < 0.01) and of the pancreas carcinoma cells PanC1 (180% vs control, P < 0.01). Addition of the antioxidant enzymes superoxide dismutase or catalase significantly decreased tumour cell adhesion (P < 0.01). Exposure of endothelial cells to superoxide anions increased the apoptotic rate to 7.9 times the normal rate. Additionally, exposure increased expression of the endothelial adhesion molecules E-Selectin, ICAM-1, and VCAM-1 of maximally 170% vs control (P < 0.01). In conclusion, this study shows that superoxide anions promote the adherence of tumour cells to the microvasculature by inducing endothelial apoptosis that subsequently induces the expression of various adhesion molecules for tumour cells. This indicates that by tackling the production of ROS preventing tumour recurrence at distant sites might be feasible.