Erlanger OP-Workshop Adhäsionen: Was können wir tun, was müssen wir tun?

 

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Adhäsionen treten bei ca. 75 % aller Operationen im Bauchraum auf, unabhängig davon, ob ein laparoskopisches Vorgehen oder eine Operation per laparotomiam durchgeführt wird. Probleme durch Adhäsionen werden zum einen häufig unterschätzt, bzw. überhaupt nicht wahrgenommen, zum anderen stellen sie die Ärzte vor das Problem einer suffizienten und evidenzbasierten Prophylaxe. Die gesundheitsökonomischen Belastungen durch Adhäsionen mit assoziierten Operationen und Folgeoperationen sowie Einbuße von Lebensqualität und Arbeitsausfall sind enorm [1]. In den USA fallen allein durch die Behandlung von Adhäsionen (postoperativ bzw. postinfektiös) Kosten in Höhe von ca. 1,3 Mrd. Dollar an [2].

Für die Patientinnen stehen die Problematik der chronischen Unterbauchschmerzen und die damit verbundenen häufigen Folgeoperationen sowie stationären Krankenhausaufenthalte im Vordergrund. Obwohl der durch Adhäsionen bedingte Ileus eine Rarität darstellt, kann dieser ebenfalls nach regelgerecht durchgeführten gynäkologischen Operationen vorkommen und stellt dann eine lebensbedrohliche Komplikation dar. Gynäkologische Operationen – und hier insbesondere häufig durchgeführte Operationen, wie Zystenausschälungen, Myomenukleationen und Operationen aufgrund einer Endometriose – führen zu Adhäsionen im kleinen Becken, die sekundär wiederum eine Infertilitätsproblematik bedingen können.

Trotz vielseitiger Probleme durch Adhäsionen werden diese von vielen operativ tätigen Ärzten nicht entsprechend wahrgenommen. In den letzten Jahrzehnten sind mehrere Substanzen getestet worden, die teils lokal, teils systemisch appliziert werden und unterschiedliche Wirksamkeiten zeigten. Die Relevanz dieser Prävention in Bezug auf Schmerzen, Infertilität und Reoperationen wird jedoch aufgrund der kleinen Fallzahl in Studien kontrovers diskutiert. Die zusätzliche finanzielle Vergütung dieser Substanzen ist im aktuellen DRG-System (DRG: diagnosebezogene Fallgruppen) nicht abgebildet.

Im Rahmen des 2. Erlanger OP-Workshops zum Thema „Adhäsionen“ wurde ausführlich über die Möglichkeit und die Sinnhaftigkeit einer operativen bzw. medikamentösen Adhäsionsprophylaxe diskutiert und anhand ausgewählter Operationen Vor- und Nachteile von lokal applizierbaren Adhäsionsprophylaktika aufgezeigt. Hierbei wurde ein breites Spektrum gynäkologischer Operationen von der einfachen Zystenexstirpation, über operativ hysteroskopische Eingriffe, bis hin zu tief infiltrierender Endometriose mit Darmresektion präsentiert.

Dieser Artikel soll, auch anhand des Fallbeispiels, eine Zusammenfassung über die verschiedenen Möglichkeiten, Indikationen und Prophylaktika geben, die im Rahmen des Workshops diskutiert wurden.

• Literatur

• 1 Nappi C et al. Prevention of adhesions in gynaecological endoscopy. Hum Reprod Update 2007; 13: 379-394
  CrossrefPubMedGoogle Scholar
• 2 Ray NF, Denton WG, Thamer M et al. Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994. J Am Coll Surg 1998; 186: 1-9
  CrossrefPubMedGoogle Scholar
• 3 Lundorff P, Hahlin M, Kallfelt B et al. Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. Fertil Steril 1991; 55: 911-915
  PubMedGoogle Scholar
• 4 Schäfer M, Krähenbühl L, Büchler MW. Comparison of adhesion formation in open and laparoscopic surgery. Dig Surg 1998; 15: 148-152
  CrossrefPubMedGoogle Scholar
• 5 Sutton C. Adhesions and their prevention. Obstet Gynaecol 2005; 7: 168-176
  PubMedGoogle Scholar
• 6 Practice Committee of the American Society for Reproductive Medicine. Control and prevention of peritoneal adhesions in gynecologic surgery. Fertil Steril 2006; 86: 1-5
  CrossrefPubMedGoogle Scholar
• 7 Korrell M. Methoden der Adhäsionsprophylaxe – Pro und Kontra. J Gynäkol Endokrinol 2010; 20: 6-13
  PubMedGoogle Scholar
• 8 Menzies D, Ellis H. Intestinal obstruction from adhesions—how big is the problem?. Ann R Coll Surg Eng 1990; 72: 60-63
  PubMedGoogle Scholar
• 9 American Fertility Society. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, müllerian anomalies and intrauterine adhesions. Fertil Steril 1988; 49: 944-955
  CrossrefPubMedGoogle Scholar
• 10 Schnüriger B, Barmparas G, Branco BC et al. Prevention of postoperative peritoneal adhesions: a review of the literature. Am J Surg 2011; 201: 111-121
  CrossrefPubMedGoogle Scholar
• 11 Azziz R. Microsurgery alone or with INTERCEED Absorbable Adhesion Barrier for pelvic sidewall adhesion re-formation. The INTERCEED (TC7) Adhesion Barrier Study Group II. Surg Gynecol Obstet 1993; 177: 135-139
  PubMedGoogle Scholar
• 12 Nordic Adhesion Prevention Study Group. The efficacy of Interceed (TC7)* for prevention of reformation of postoperative adhesions on ovaries, fallopian tubes, and fimbriae in microsurgical operations for fertility: a multicenter study. Fertil Steril 1995; 63: 709-714
  PubMedGoogle Scholar
• 13 Reijnen MM, Bleichrodt RP, van Goor H. Pathophysiology of intra-abdominal adhesion and abscess formation, and the effect of hyaluronan. Br J Surg 2003; 90: 533-541
  CrossrefPubMedGoogle Scholar
• 14 Beck DE et al. A prospective, randomized, multicenter, controlled study of the safety of Seprafilm adhesion barrier in abdominopelvic surgery of the intestine. Dis Colon Rectum 2003; 46: 1310-1319
  CrossrefPubMedGoogle Scholar
• 15 Kumar S, Wong PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after non-gynaecological abdominal surgery. Cochrane Database Syst Rev 2009; (1) CD005080
  PubMedGoogle Scholar
• 16 Diamond MP. Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F): a blinded, prospective, randomized, multicenter clinical study. Seprafilm Adhesion Study Group. Fertil Steril 1996; 66: 904-910
  PubMedGoogle Scholar
• 17 Lundorff P, Donnez J, Korell M et al. Clinical evaluation of a viscoelastic gel for reduction of adhesions following gynaecological surgery by laparoscopy in Europe. Hum Reprod 2005; 20: 514-520
  PubMedGoogle Scholar
• 18 Young P, Johns A, Templeman C et al. Reduction of postoperative adhesions after laparoscopic gynecological surgery with Oxiplex/AP Gel: a pilot study. Fertil Steril 2005; 84: 1450-1456
  CrossrefPubMedGoogle Scholar
• 19 Sawada T, Nishizawa H, Nishio E et al. Postoperative adhesion prevention with an oxidized regenerated cellulose adhesion barrier in infertile women. J Reprod Med 2000; 45: 387-389
  PubMedGoogle Scholar
• 20 Pellicano M, Bramante S, Cirillo D et al. Effectiveness of autocrosslinked hyaluronic acid gel after laparoscopic myomectomy in infertile patients: a prospective, randomized, controlled study. Fertil Steril 2003; 80: 441-444
  CrossrefPubMedGoogle Scholar
• 21 Fuchs S, Hackethal A, Ikenberg R et al. Prävention von posteropativen Adhäsionen – Effektivität und ökonomische Aspekte von hyluronsäurehaltigem Gel. Frauenarzt 2011; 52: 356-368
  PubMedGoogle Scholar
• 22 Acunzo G, Guida M, Pellicano M et al. Effectiveness of auto-cross-linked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic adhesiolysis: a prospective, randomized, controlled study. Hum Reprod 2003; 18: 1918-1921
  CrossrefPubMedGoogle Scholar
• 23 Brown CB et al. Adept (icodextrin 4 % solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study. Fertil Steril 2007; 88: 1413-1426
  CrossrefPubMedGoogle Scholar
• 24 Trew G, Pistofidis G, Pados G et al. Gynaecological endoscopic evaluation of 4 % icodextrin solution: a European, multicentre, double-blind, randomized study of the efficacy and safety in the reduction of de novo adhesions after laparoscopic gynaecological surgery. Hum Reprod 2011; 26: 2015-2027
  CrossrefPubMedGoogle Scholar
• 25 Risberg B. Adhesions: preventive strategies. Eur J Surg 1997; 577 (Suppl.) 32-39
  PubMedGoogle Scholar
• 26 Trew G. Postoperative adhesions and their prevention. Rev Gynaecol Perinat Pract 2006; 6: 47-56
  PubMedGoogle Scholar
• 27 Jansen RP. Failure of intraperitoneal adjuncts to improve the outcome of pelvic operations in young women. Am J Obstet Gynecol 1985; 153: 363-371
  PubMedGoogle Scholar
• 28 Querleu D, Vankeerberghen-Deffense F, Boutteville C. The effect of noxytioline and systemic corticosteroids in infertility surgery. A prospective randomized study. (Traitement adjuvant des plasties tubaires. Etude prospective randomisee des corticoides par voie generale et de la noxytioline). J Gynecol Obstet Biol Reprod 1989; 18: 935-940
  PubMedGoogle Scholar
• 29 Rock JA, Siegler AM, Meisel MB et al. The efficacy of postoperative hydrotubation: a randomized prospective multicenter clinical trial. Fertil Steril 1984; 42: 373-376
  PubMedGoogle Scholar
• 30 Jansen RP. Controlled clinical approaches to investigating the prevention of peritoneal adhesions. Prog Clin Biol Res 1990; 358: 177-192
  PubMedGoogle Scholar
• 31 Granat M, Schenker JG, Mor-Yosef S et al. Effects of dexamethasone on proliferation of autologous fibroblasts and on the immune profile in women undergoing pelvic surgery for infertility. Fertil Steril 1983; 39: 180-186
  PubMedGoogle Scholar
• 32 Harris WJ, Daniell JF. Use of corticosteroids as an adjuvant in terminal salpingostomy. Fertil Steril 1983; 40: 785-789
  PubMedGoogle Scholar
• 33 Steinleitner A, Lambert H, Kazensky C et al. Reduction of primary postoperative adhesion formation under calcium channel blockade in the rabbit. J Surg Res 1990; 48: 42-45
  CrossrefPubMedGoogle Scholar
• 34 Liakakos T, Thomakos N, Fine PM et al. Peritoneal adhesions: etiology, pathophysiology and clinical significance. Recent advances in prevention and management. Dig Surg 2001; 18: 260-273
  CrossrefPubMedGoogle Scholar
• 35 Luciano AA, Hauser KS, Benda J. Evaluation of commonly used adjuvants in the prevention of postoperative adhesions. Am J Obstet Gynecol 1983; 146: 88-92
  PubMedGoogle Scholar
• 36 Kaya U, Oktem M, Zeyneloglu HB et al. Impact of aromatase inhibitors on adhesion formation in a rat model. Fertil Steril 2007; 87: 934-939
  CrossrefPubMedGoogle Scholar
• 37 Montanino-Oliva M, Metzger DA, Luciano AA. Use of medroxyprogesterone acetate in the prevention of postoperative adhesions. Fertil Steril 1996; 65: 650-654
  PubMedGoogle Scholar
• 38 Diamond MP, Linsky CB, Cunningham T et al. Adhesion reformation: reduction by the use of Interceed (TC7) plus heparin. J Gynecol Surg 1991; 7: 1-6
  CrossrefPubMedGoogle Scholar
• 39 Jansen RP. Failure of peritoneal irrigation with heparin during pelvic operations upon young women to reduce adhesions. Surg Gynecol Obstet 1988; 166: 154-160
  PubMedGoogle Scholar
• 40 Doody KJ, Dunn RC, Buttram jr. VC. Recombinant tissue plasminogen activator reduces adhesion formation in a rabbit uterine horn model. Fertil Steril 1989; 51: 509-512
  PubMedGoogle Scholar
• 41 Reid RL, Hahn PM, Spence JE et al. A randomized clinical trial of oxidized regenerated cellulose adhesion barrier (Interceed, TC7) alone or in combination with heparin. Fertil Steril 1997; 67: 23-29
  CrossrefPubMedGoogle Scholar
• 42 Bothin C. Counteracting postsurgical adhesions – the effect of combining oxidized regenerated cellulose and tissue plasminogen activator. Int J Fertil Menopausal Stud 1995; 40: 102-105
  PubMedGoogle Scholar
• 43 Gehlbach DL, OʼHair KC, Parks AL et al. Combined effects of tissue plasminogen activator and carboxymethylcellulose on adhesion reformation in rabbits. Int J Fertil Menopausal Stud 1994; 39: 172-176
  PubMedGoogle Scholar
• 44 Robertson D, Lefebvre G, Leyland N et al. Society of Obstetricians and Gynaecologists of Canada. Adhesion prevention in gynaecological surgery. J Obstet Gynaecol Can 2010; 32: 598-608
  PubMedGoogle Scholar
• 45 Steinleitner A, Lambert H, Montoro L et al. The use of calcium channel blockade for the prevention of postoperative adhesion formation. Fertil Steril 1988; 50: 818-821
  PubMedGoogle Scholar
• 46 Imai A et al. Non-barrier agents for postoperative adhesion prevention: clinical and preclinical aspects. Arch Gynecol Obstet 2010; 282: 269-275
  CrossrefPubMedGoogle Scholar
• 47 Pados G et al. Prevention of intra-peritoneal adhesions in gynaecological surgery: theory and evidence. RBM online 2010; 21: 290-303
  PubMedGoogle Scholar
• 48 Mishell DR, Davajan V. Evaluation of the infertile Couple. In: Mishell DR, Davajan V, Lobo RA, eds. Infertility, Contraception, and reproductive Endocrinology. 3rd. ed. Boston: Blackwell Scientific Publications; 1991: 557-570
  Google Scholar
• 49 Franklin RR. Ovarian Adhesion Study Group. Reduction of ovarian adhesions by the use of Interceed. Obstet Gynecol 1995; 86: 335-340
  CrossrefPubMedGoogle Scholar
• 50 Gehlbach DL, Sousa RC et al. Abdominal myomectomy in the treatment of infertility. Int J Gynaecol Obstet 1993; 40: 45-50
  CrossrefPubMedGoogle Scholar
• 51 Tulandi T, Murray C et al. Adhesion formation and reproductive outcome after myomectomy and second-look laparoscopy. Obstet Gynecol 1993; 82: 213-215
  PubMedGoogle Scholar
• 52 Sekiba K. The Obstetrics and Gynecology Adhesion Prevention Committee. Use of Interceed (TC7) absorbable adhesion barrier to reduce postoperative adhesion reformation in infertility and endometriosis surgery. Obstet Gynecol 1992; 79: 518-522
  PubMedGoogle Scholar
• 53 Diamond MP, Linsky CB et al. Synergistic effects of INTERCEED (TC7) and heparin in reducing adhesion formation in the rabbit uterine horn model. Fertil Steril 1991; 55: 389-394
  PubMedGoogle Scholar
• 54 Keckstein J, Ulrich U et al. Reduction of postoperative adhesion formation after laparoscopic ovarian cystectomy. Hum Reprod 1996; 11: 579-582
  CrossrefPubMedGoogle Scholar
• 55 Mais V, Ajossa S et al. Prevention of de-novo adhesion formation after laparoscopic myomectomy: a randomized trial to evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier. Hum Reprod 1995; 10: 3133-3135
  PubMedGoogle Scholar
• 56 Mais V, Ajossa S et al. Reduction of adhesion reformation after laparoscopic endometriosis surgery: a randomized trial with an oxidized regenerated cellulose absorbable barrier. Obstet Gynecol 1995; 86 (4 Pt 1) 512-515
  PubMedGoogle Scholar
• 57 Tulandi T, Collins JA et al. Treatment-dependent and treatment-independent pregnancy among women with periadnexal adhesions. Am J Obstet Gynecol 1990; 162: 354-357
  CrossrefPubMedGoogle Scholar
• 58 Pellicano M, Guida M et al. Reproductive outcome after autocrosslinked hyaluronic acid gel application in infertile patients who underwent laparoscopic myomectomy. Fertil Steril 2005; 83: 498-500
  CrossrefPubMedGoogle Scholar
• 59 De Ziegler D, Borghese B et al. Endometriosis and infertility: pathophysiology and management. Lancet 2010; 376: 730-738
  CrossrefPubMedGoogle Scholar
• 60 Vercellini P, Fedele L et al. Reproductive performance, pain recurrence and disease relapse after conservative surgical treatment for endometriosis: the predictive value of the current classification system. Hum Reprod 2006; 21: 2679-2685
  CrossrefPubMedGoogle Scholar
• 61 Kennedy S, Bergqvist A et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005; 20: 2698-2704
  CrossrefPubMedGoogle Scholar
• 62 Carbonnel M, Ducarme G et al. Efficacy of transient abdominal ovariopexy in patients with severe endometriosis. Eur J Obstet Gynecol Reprod Biol 2011; 155: 183-187
  CrossrefPubMedGoogle Scholar
• 63 Lasmar RB, Barrozo PR et al. [Hysteroscopic evaluation in patients with infertility]. Rev Bras Ginecol Obstet 2010; 32: 393-397
  CrossrefPubMedGoogle Scholar
• 64 March CM. Management of Ashermanʼs syndrome. Reprod Biomed Online 2011; 23: 63-76
  PubMedGoogle Scholar
• 65 Acunzo G, Guida M et al. Effectiveness of auto-cross-linked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic adhesiolysis: a prospective, randomized, controlled study. Hum Reprod 2003; 18: 1918-1921
  CrossrefPubMedGoogle Scholar
• 66 Duffy JM, Johnson N, Ahmad G et al. Postoperative procedures for improving fertility following pelvic reproductive surgery. Cochrane Database Syst Rev 2009; (2) CD001897
  PubMedGoogle Scholar
• 67 Sepilian V, Ku L, Wong H et al. Prevalence of infraumbilical adhesions in women with previous laparoscopy. JSLS 2007; 11: 41-44
  PubMedGoogle Scholar
• 68 Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol 2011; 17: 4545-4553
  CrossrefPubMedGoogle Scholar
• 69 Ahmad G, Duffy JM, Farquhar C et al. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2008; (2) CD000475
  PubMedGoogle Scholar
• 70 Abuzeid MI, Ashraf M, Shamma FN. Temporary ovarian suspension at laparoscopy for prevention of adhesions. J Am Assoc Gynecol Laparosc 2002; 9: 98-102
  CrossrefPubMedGoogle Scholar
• 71 Ouahba J, Madelenat P, Poncelet C. Transient abdominal ovariopexy for adhesion prevention in patients who underwent surgery for severe pelvic endometriosis. Fertil Steril 2004; 82: 1407-1411
  CrossrefPubMedGoogle Scholar
• 72 Cutner AS, Lazanakis MS, Saridogan E. Laparoscopic ovarian suspension to facilitate surgery for advanced endometriosis. Fertil Steril 2004; 82: 702-704
  CrossrefPubMedGoogle Scholar
• 73 De Wilde RL, Trew G. Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert consensus position. Gynecol Surg 2007; 4: 161-168
  CrossrefPubMedGoogle Scholar
• 74 Hirschelmann A, Tchartchian G, Wallwiener M et al. A review of the problematic adhesion prophylaxis in gynaecological surgery. Arch Gynecol Obstet 2012; 285: 1089-1097
  CrossrefPubMedGoogle Scholar