Barrier agents for adhesion prevention after gynaecological surgery
Abstract
Background
Pelvic adhesion can form as a result of inflammation, endometriosis or surgical trauma. During pelvic surgery, strategies to reduce pelvic adhesion formation may include placing synthetic barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene or Fibrin sheets between the pelvic structures.
Objectives
To assess the effect of physical barriers used during pelvic surgery in women of reproductive age on pregnancy rates, pelvic pain, or postoperative adhesion reformation.
Search methods
We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched September 2007) which is based on regular searches of MEDLINE, EMBASE, CINAHL, PsycINFO and CENTRAL, plus handsearching of 20 relevant journals and conference proceedings, and searches of several key grey literature sources. In addition, companies were contacted for unpublished trials.
Selection criteria
Any randomised controlled trials (RCTs) comparing the use of physical barriers versus no treatment or other physical barriers in the prevention of adhesions in women undergoing gynaecological surgery.
Data collection and analysis
Review authors assessed trial eligibility and quality.
Main results
Sixteen RCTs were included. Five trials randomised patients while the remainder randomised pelvic organs. Laparoscopy (six trials) and laparotomy (10 trials) were the primary surgical techniques. Indications for surgery included myomectomy (five trials), ovarian surgery (five trials), pelvic adhesions (four trials), endometriosis (one trial), and mixed (one trial). Eleven trials assessed Interceed versus no treatment, two assessed Interceed versus Gore‐Tex, one trial assessed Gore‐Tex versus no treatment, and one trial assessed Seprafilm versus no treatment. A single trial assessed Fibrin sheet versus no treatment. No studies reported pregnancy or reduction in pain as outcomes. The use of Interceed was associated with reduced incidence of pelvic adhesion formation, both new formation and reformation following laparoscopic surgery or laparotomy. However, this result should be interpreted with caution. Gore‐Tex was more effective than no barrier or Interceed in preventing adhesion formation. There was only limited evidence that Seprafilm was effective in preventing adhesion formation following myomectomy and no evidence to support Fibrin sheet.
Authors' conclusions
The absorbable adhesion barrier Interceed reduces the incidence of adhesion formation following laparoscopy and laparotomy, but there are insufficient data to support its use to improve pregnancy rates. Gore‐Tex may be superior to Interceed in preventing adhesion formation but its usefulness is limited by the need for suturing and later removal. There was no evidence of effectiveness of Seprafilm and Fibrin sheet in preventing adhesion formation.
PICOs
Plain language summary
Barrier agents may be effective in reducing the formation of pelvic adhesions but there is no evidence on their direct effects including pregnancy rates
Sometimes following surgery, adhesions can develop (where two normally separate surfaces join). Pelvic adhesions are most likely to form in association with swelling, endometriosis or surgical trauma. Various materials have been used as 'mechanical' barriers to prevent these adhesions forming. The review of trials assessed the effect of these barriers on pregnancy rates, pelvic pain and adhesion formation after pelvic surgery. The review found the absorbable barrier Interceed reduces adhesion formation. Gore‐Tex is more effective than Interceed but is not absorbable and therefore requires further operation to be removed. There was no evidence of the effectiveness of Seprafilm or Fibrin sheet. More research is needed.
