Adhesion Prevention: What are my Options in Colorectal/General Surgery?

Surgical adhesions are pathological fibrotic connections that form between organ surfaces and the walls of surrounding body cavities following tissue trauma and ischemia.^5,10

Adhesions can negatively affect surgical outcomes as they occasionally cause complications that lead to readmission. An estimated 9% of patients present with adhesion-related conditions within the first year after abdominal surgery, rising to 19% at 4 years and 35% at 10 years.⁶

Post-surgical adhesion formation is a common complication of any type of surgery, affecting 50–95% of patients regardless of the type of procedure or anatomical location.⁵

Adhesions are especially common after abdominopelvic procedures, developing after 93% of major abdominal operations.¹¹

All patients undergoing surgery are at risk of developing adhesions. However, data suggest that various factors directly or indirectly increase the likelihood of adhesion formation.¹²

Directly predisposing factors: genetic polymorphisms in the interleukin-I receptor antagonist, increased estrogen exposure, and endometriosis.¹²

Indirectly predisposing factors: insufficient fibrinolytic activity has been shown to favor adhesion formation.^12,13 Thus, factors affecting the fibrinolytic system can indirectly put a patient at increased risk of post-surgical adhesions. These determinants include certain genetic polymorphisms (plasminogen activator inhibitor-1, thrombin-activatable fibrinolysis inhibitor), underlying conditions (diabetes mellitus, metabolic syndrome, hyperglycemia, obesity, depression, cancer), medication (anti-Parkinsonian or oral hormone therapy), pregnancy, and high alcohol consumption.¹²

Although many adhesions go unnoticed and do not cause any symptoms, some patients develop severe complications such as small bowel obstruction, chronic pain, and infertility.^1,14

Adhesions can also lead to difficulties in subsequent operations – even if the patient is asymptomatic – as they change the normal anatomy. Obliterated dissection planes and abnormally conjoined organs can increase operation time and complication rates.^6,15 For instance, laparoscopic adhesiolysis carries a 10–25% risk of bowel injury.⁶

Adhesions are the most common etiology for small bowel obstruction in developed world countries and account for approximately 60% of all episodes.¹⁶ In addition, small bowel obstruction is one of the most severe of adhesion-related complications, with a 30-day mortality rate of up to 10%.¹⁷

Currently, no effective targeted pharmacotherapies are available to counter existing adhesions.16 If intervention is necessary, the standard approach is surgical adhesiolysis.¹⁸ However, reoperation can perpetuate the problem by causing new adhesions or reformation of the existing bands due to the traumatic disruption.^6,18-20 Thus, the best strategy against adhesive disease is preventing adhesion formation in the initial surgery.

Current anti-adhesion measures can be classified into the following categories⁴:

1. Surgical technique optimized to minimize tissue damage

2. Adhesion barriers that block physical contact between two injured tissues or organ surfaces

3. Pharmacological agents that counteract inflammation reactions and interfere with adhesion neogenesis

However, although pharmacological agents have shown potential to reduce adhesion formation in clinical studies, off-target and adverse effects limit their use in clinical practice.⁵

Some groups have suggested that the overall risk of post-surgical adhesions should decrease in the wake of the introduction of laparoscopic surgery.⁵ However, although some preclinical and clinical data support this hypothesis, conclusive proof that this is the case in clinical practice is currently lacking. A systematic review and meta-analysis of the effect of surgical approach on the incidence of adhesion-related complications found no indication that minimally invasive techniques (e.g., laparoscopy) could improve outcomes.^11,25

Despite its limited impact on adhesion-related outcomes, meticulous surgical technique is central to an effective adhesion reduction strategy. Measures include gentle tissue handling, optimal hemostasis, avoiding tissue desiccation, and preventing thermal injury, foreign body reaction, and infection.^5,6,19

The key requirement of any adhesion barrier is that it should effectively separate traumatized peritoneal surfaces during the critical period of adhesion development in the 3–5 days after surgery, during which, peritoneal healing occurs.¹⁹

Barrier products range from natural to synthetic and can broadly be classified into solid barriers (membranes), gels, or solutions.⁵

Adhesion barriers have been tested extensively in clinical trials. Several studies have shown that SEPRAFILM Adhesion Barrier, a sodium hyaluronate and carboxymethylcellulose bioresorbable membrane, can reduce the incidence and severity of post-surgical adhesions.^8,11

For instance, a pivotal study compared adhesion formation following colectomy and ileal pouch-anal anastomosis with diverting-loop ileostomy with or without the use of SEPRAFILM.¹¹ Forty-three of 85 patients (51%) in the intervention group were free of adhesions 8–12 weeks after the procedure versus 6% (5/90) of those who underwent surgery without adhesion barrier (p<0.00000000001). Dense adhesions were reported in only 13 patients (15%) who received SEPRAFILM compared with 52 patients (58%) in the control group (p<0.0001).¹¹

The safety of SEPRAFILM was evaluated in a prospective, randomized, double-blind multicenter study in patients undergoing abdominopelvic surgery for benign diseases of the colon and rectum or small intestinal obstruction.⁹ There were 981 operative procedures performed on the 882 patients who received SEPRAFILM, and 1,003 procedures performed in 909 patients in the control group.⁹ Patients in the SEPRAFILM group (n=882) received an average of 4.4 sheets (range: less than 3 and up to 10 sheets).⁹  The incidence of complications between study groups was comparable with 249 (28%) and 223 (25%) of patients experiencing adverse events in the SEPRAFILM group and control cohort, respectively. No patients had a foreign body reaction.⁹ Likewise, additional clinical trials of SEPRAFILM in patients undergoing abdominal or pelvic surgery have detected no significant differences between barrier and control groups.⁸