Fluid and pharmacological agents for adhesion prevention after gynaecological surgery
Abstract
Background
Pelvic surgery is associated with high rates of both de novo adhesion formation and adhesion reformation. Since subsequent fertility is reduced with increasing severity of peri adnexal adhesions, pelvic adhesions will remain a clinical problem in infertility patients. Steroids, antihistamines and heparin were amongst the first substances to be advocated for adhesion prevention. More recently icodextrin 4%, hyaluronic acid agents and SprayGel have been used. This review aims to evaluate the role of fluid and pharmacological agents in the prevention of adhesions in fertility‐conserving gynaecological surgery.
Objectives
To investigate fluid and pharmacological agents for adhesion prevention when used as adjuvants during pelvic surgery.
Search methods
This review has drawn on the search strategy developed for the Menstrual Disorders and Subfertility Group. The following databases were searched: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE.
Selection criteria
Randomised controlled trials investigating the use of fluid and pharmacological agents to prevent adhesion formation after fertility‐conserving gynaecological surgery.
Data collection and analysis
Data extraction and analysis was performed independently by two authors (Metwally M and Watson A). Two‐by‐two tables were generated for dichotomous outcomes and expressed as odds ratios (OR) with 95% confidence intervals (CI). For continuous outcomes a standardised mean difference was used.
Main results
There is no evidence of benefit from the use of steroids, dextran or other pharmacological agents in any of the outcomes. The use of hyaluronic acid agents may decrease adhesion formation (OR 0.31, 95% CI 0.19 to 0.51) and prevent the deterioration of pre‐existing adhesions (OR 0.28 (95% CI 0.12 to 0.66). There is insufficient evidence for the use of icodextrin 4% or SprayGel as adhesion‐preventing agents. None of the studied agents has been shown to improve the pregnancy rate when used as an adjunct during pelvic surgery.
Authors' conclusions
The current evidence for the use of fluid and pharmacological agents for the prevention of adhesions is limited. There is no evidence on any benefit for improving pregnancy outcomes when pharmacological and fluid agents are used as an adjunct during pelvic surgery.
There is insufficient evidence for the use of the following agents: steroids, icodextrin 4%, SprayGel and dextran in improving adhesions following surgery.
There is some evidence that hyaluronic acid agents may decrease the proportion of adhesions and prevent the deterioration of pre existing adhesions. However, due to the limited number of studies available, this evidence should be interpreted with caution and further studies are needed.
PICOs
Plain language summary
The use of fluids and pharmacological agents (medicinal drugs) to prevent the formation of adhesions (scar tissue) that may interfere with becoming pregnant after surgery of the female pelvis.
Adhesion formation is a condition in which bodily tissues that are normally separate grow together. This can occur after surgical procedures such as operations on the female pelvis to remove a cyst, treat endometriosis, remove a tubal pregnancy, or remove a fibroid (a benign tumour of the womb). This scar tissue can have serious effects on the woman's future fertility as it can lead to blockage of her tubes. Careful tissue handling at the time of surgery and control of the blood loss are important ways of reducing scar tissue, however, over the years other methods have been developed to minimise the risk of scar tissue formation. Surgeons have tried using different types of drugs or leaving different types of fluids inside the pelvis at the end of surgery to prevent tissue surfaces from sticking to each other. Fluids include dextran, icodextrin (Adept), SprayGel, and fluids containing the chemical hyaluronic acid (Intergel, auto‐cross linked hyaluronic acid, Sepracoat). Drugs that have been tried include steroids (anti‐inflammatory drug), the anti‐coagulant heparin, promethazine, and noxytioline.
This review aimed to evaluate the role of these different agents in the prevention of adhesion formation. The results showed that there is currently insufficient evidence to recommend the use of steroids, icodextrin, SprayGel or dextran. The review did show that fluids that contained hyaluronic acid may help lower the chance of scar tissue forming; however, more studies are needed to confirm this. There are also some major safety issues concerning the use of one of these agents (Intergel), which has been withdrawn from the market due to reports of serious side effects such as allergic reactions and pain.
A major problem with studies in this review is that most of them did not look at the rate of pregnancy following the use of these substances. Since the occurrence of pregnancy is the gold standard for measuring how well these agents work to preserve fertility, it is important that future studies take this into consideration.
