Page 77 - Postoperative Intra-Abdominal Adhesions- New insights in prevention and consequences

Adhesion barrier and colon anastomoses
separation of the damaged peritoneal surfaces. The adhesion barrier
used in this study, polyvinyl alcohol (PVA), is used in many other medical
fields 28-30, and has a solubility, biocompatibility and inactivation in
body fluids that makes it a suitable adhesion barrier 31. PVA diminishes adhesions in vitro, after spinal surgery, and after tendon surgery 31-33.
To improve quality of adherence of the barrier to the viscera CMC was
added to PVA-gel. Jaenigen et al.14 have shown in a rabbit sidewall
model this PVA-CMC gel effectively diminishes adhesions compared to untreated controls and 4% icodextrin. Lang et al.15 found similar results
in their rabbit sidewall model; significantly fewer adhesions were present 4 in rabbits treated with PVA-CMC gel than in those given 4% icodextrin
and in controls. Good results also were obtained in their re-laparotomy model16.
However, if an adhesion barrier is capable of diminishing fibrin deposition to a sufficient extent to prevent adhesions, it is essential to show that healing, which also relies on fibrin deposition followed by collagen formation, is not impaired. The consequence of impaired healing of a gastrointestinal anastomosis is leakage, leading to abscesses or peritonitis with a mortality rate between 10% and 20%. This life- threatening complication makes the balance between diminishing adhesions and encouraging incision healing crucial in gastrointestinal surgery. Previous studies have emphasized this fragile balance through results showing more anastomotic leakage in patients receiving a hyaluronic acid (HA) and CMC anti-adhesive film. Initial results with this film were promising, with an impressive reduction of 50% in the number of adhesions to the midline incision. Following these results, a randomized safety study was performed by Beck et al.17 with 1791 patients undergoing abdominopelvic surgery. This study showed there were significantly more abscesses, anastomotic leakages, and peritonitis cases in the patients with the HA-CMC film. Subgroup analysis of all patients with anastomoses showed the placement of HA-CMC film directly on the anastomosis increased the risk of anastomotic leakage compared to control subjects, whereas there was not a problem when the HA-CMC film was not placed on the anastomosis. An experimental study with the same anti-adhesive film showed that wrapping it around an
75