Prevenzione delle aderenze dopo chirurgia

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

Le ulteme relazione

ESHRE , Stockholm 1 juli 2011
Click per initiare

Postoperative Adhesions are a major clinical problem

Adhaesion over adnexa

Adhaesions over uterus

Bands

Postoperative adhesions occur in 80% after surgery and cause chronic pain, infertility and bowel obstruction. Thus 30% van alle chronic pain in women, 30% of infertilities 100% of all bowel obstructions are caused by postoperative adhaesions

The peritoneal cavity holte

Clinical importance

The old model : a local process

Right : the peritoneal cavity
Middle : the clinical consequences

Pathophysiology

the old model : a local process

The new model

The old model (above and to the right) considers beschouwt adhaesion formation as a cascade of local processes between denuded areas. Either repair is rapid within a few days or adhesion formation starts
The new model developed by our group has demonstrated that the peritoneal cavity is 20 times more important than this local process . The sum of all the good and bad factors will determine the degree of acute inflammation of the peritoneal cavity and thus of adhesions. In summery these are :
Duration of surgery and the degree of manipulation (For this reason a slow or less experienced surgeon will have more adhaesions )
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%.

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

2002 : Ospan Mynbaev CO2 resorbtion

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

the new model

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

cooling

is superficial

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.

De Toekomst

The future
peritoneal conditioning
gas+temperature+humidification
+ barrier
= > 90% adhaesion reduction

Developed clinically in cooperation with eSaturnus NV

Clinical trials

Other advantages of Conditioning of the peritoneal cavity

less tumor metastasis

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