Prevenzione delle aderenze dopo la chirurgia

Prevenzione delle Aderenze

Koninckx et al 2010 NEW CONCEPTS IN ADHESION PREVENTION : Click for the complete text of this review

Le ultime relazioni


ESHRE , Stockholm 1 juli 2011
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Le aderenze postoperatorie rappresentano il problema clinico maggiore


Adhaesion over adnexa

Adhaesions over uterus

Bands

Le aderenze postoperatorie occorrono in circa l’805 dei casi in seguito a chirurgia, e sono la causa di dolore cronico, di infertilità e di ostruzione intestinale. Sono responsabili del 30% circa dei casi dolore cronico nelle donne, del 30% dei casi di infertilità e del 100% dei casi di ostruzione intestinale in seguito a chirurgia.

postoperative adhaesions
The peritoneal cavity holte
postoperative adhaesions
Importanza clinica
postoperative adhaesions
Il vecchio modello: un processo locale

A destra: la cavità peritoneale
In mezzo: le conseguenze cliniche

Fisiopatologia

postoperative adhaesions
il vecchio modello: un processo locale
postoperative adhaesions
Il nuovo modello
Il vecchio modello considera che alla base della formazione delle aderenze ci sia una cascata di processi locali. Si può verificare una riparazione rapida in pochi giorni oppure iniziare il processo delle aderenze.
Il nuovo modello che si è sviluppato dal nostro gruppo ha dimostrato che la cavità peritoneale è 20 volte più importante rispetto ai processi locali. La somma di tutti i fattori buoni e cattivi determinerà il grado dell’infiammazione acuta in cavità peritoneale e quindi delle aderenze. In breve:
Durata della chirurgia e il grado della manipolazione, la capacità del chirurgo ( per questa ragione la poca esperienza del chirurgo causerà molte più aderenze).
Desiccation will occur systematically unless specific preventive measurements are taken.
A better gas mixture instead of CO2 that is very irritant
de lower temperatures are better during laparoscopy

If all factors are controlled by conditioning adhaesion formation is reduced by over 70%.

postoperative adhaesions
2001 Jerome Hoffman
price of the aagl
1st Prize
BELGIAN SOCIETY OF
REPRODUCTIVE MEDICINE
2001 Molinas et al
1st Prize ESGE
R. Palmer Prize.
2001 Molinas et al
1st Prize ESHRE
PROMISING YOUNG
SCIENTIST AWARD
2002 ESHRE Molinas et al
1st Prize ESGE
Cagliari
2004 Binda et al
De AAGL Prijs2002 :
Ospan Mynbaev CO2 resorbtion

This work received a series of international prices
and a series of PhD’s were made
M.M. Binda

postoperative adhaesions
the new model
postoperative adhaesions
the new model
postoperative adhaesions
the old model

prevention of adhaesions :
first conditioning
then a barrier

prevention of adhaesions today : with the old model: Maximum 40-50% effective

Flotation agents
Adept : FDA approved
effective ?: unclear
Ringers Lactate : cheap
effective in our mouse model
no clinical evidence
Barriers
maximum 40-50% effective
no demonstrated effect upon
pain, infertility, reintervention
not FDA approved
Prevention : The Old Model

prevention of adhaesions based upon the old model is done by using “barriers” of “Flotation agents” in order to keep the surgical surfaces separated for a few days. All available products have an effectivity of 40 tot 50% at best and this for specific (simple) interventions performed by esperts. In addition, the variability of results is high.
Therefore effectivity has not been demonstrated for any product for a clinical endpoint as infertility, or pain or reintervention. These products are marketed as devices. Only for Adept safety has been extgensively demonstrated . This is the only product approved by the FDA today. Adept can be associated with vulvar oedema

The future of prevention of adhaesions : first conditioning of the peritoneal cavity

postoperative adhaesions
cooling
postoperative adhaesions
is superficial
postoperative adhaesions
cooling is necessary

We do expect that in the very near future we will be able to perform surgery without adhaesions by peritoneal conditioning. This was described first ascombination therapy.

postoperative adhaesions
De Toekomst
postoperative adhaesions
The future
peritoneal conditioning
gas+temperature+humidification
+ barrier
= > 90% adhaesion reduction

Developed clinically in cooperation with eSaturnus NV

Other advantages of Conditioning of the peritoneal cavity

postoperative adhaesions
less tumor metastasis
postoperative adhaesions
less CO2 resorbtion
Peritoneal Conditioning
additional advantages
pain
CO2 resorbtione
tumor metastasis

less postoperative pain , estimated at a 60% decrease.
Less CO2 resorbtion is a major advantage for laparoscopic surgery of longer duration especially in more obese patients
Less tumor metastasis, if confirmed in the human, the importance is obvious in reducing mortality

Important articles of the goup

postoperative adhaesions

2009 Schonman et al : surgical manipulation
2006 Binda :cooling
2004 Elkilani : ringers lactate for adhesion prevention
2003 Binda : ROS and adhaesions
2001 Molinas : effect of hypoxia

Images of adhaesions

postoperative adhaesions
umbilical adhesions
postoperative adhaesions
Velamentous adhaesions
postoperative adhaesions
bands
postoperative adhaesions
after Appendectomy
postoperative adhaesions
Frozen pelvis
postoperative adhaesions
severe adhaesions
postoperative adhaesions
Vascular adhaesions
postoperative adhaesions
Encapsulated ovary
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