Review articlePolymer materials for prevention of postoperative adhesion
Graphical abstract
Introduction
Postoperative adhesion (POA) is a comprehensive inflection of various abnormal tissue hyperplasias, characterized by proliferated fibrous tissues sticking to the nearby normal organs. The adhesion bands can take diversified phenotypes ranging from a thin layer of fibrous films between the adjacent tissues to a mixture of fibrous tissues, blood vessels, and nerves [1]. Depending on distinct positions and levels of the adhesion, POA may be accompanied with acute complications or be “silent” for several years. These complications, such as chronic pain, dysfunction of adjacent organs, and intestinal obstruction, can reduce the life quality of patients or even become life-threatening [2], [3], [4].
Despite extensive efforts to prevent POA, its pathophysiology is not entirely understood. The factors involved in the formation of adhesion are complex, such as mechanical injury, ischemia, infection, local inflammation, endometriosis, and physical and chemical nature of the anti-adhesion materials [3], [5]. At present, the local inflammatory reaction is reckoned as the main cause of POA [6]. To be more specific, after receiving a surgery, our body would mistakenly assume that we are in a serious trauma, which will trigger the release of histamine, vasoactive peptides, and various cytokines from stromal mast cells. Moreover, vasodilators will be excreted from macrophages, increasing the permeability of blood vessels and leading to effusion of a large number of fibrous tissues, which will ultimately interrupt the balance between thrombin activity and plasmin activity. Consequently, plenty of fibrous bridges will be formed at inflamed sites and result in POA [7].
A large variety of methods have been conducted aiming at the alleviation of surgery associated complications. These strategies can be roughly divided into four categories: general principles, surgical techniques, physical barriers, and chemical agents [8]. For the past 30 years, biocompatible and biodegradable polymers have attracted wide attention in treating POA as promising physical barriers among tissues. For easy operation during surgery and overall coverage of wounded area, qualified anti-adhesion biomaterials are supposed to meet several basic requirements, such as excellent biocompatibility and biodegradability, appropriate retention time, good water solubility, and outstanding mechanical properties. Overall, natural and synthetic materials can significantly prevent the formation of POA with minimal side effects to wound healing.
In this review, the natural and synthetic polymer materials applied to postoperative anti-adhesion were introduced, as shown in Scheme 1. As to natural polymer materials, there are hyaluronic acid (HA), cellulose (CEL), dextran (DEX), chitosan (CS), icodextrin (ICO), and so forth. Synthetic polymer materials include polylactide (PLA), poly(ethylene glycol) (PEG), polyglycolide (PGA), poly(ε-caprolactone) (PCL), and poly(vinyl alcohol) (PVA), etc. The applications of these polymer-based materials in POA prevention are summarized in Table 1. Moreover, the specific features of polymer physical barriers are presented, and the possible prospects in POA prevention will be predicted.
Section snippets
Hyaluronic acid (HA)
The anti-adhesion effect of HA has been confirmed in many studies, including acting as a physical barrier, promoting the dissolution of fibrin and proliferation of mesothelial cells, inhibiting the inflammatory response, and promoting wound healing. Besides, it was shown that the inhibitory effect of HA toward granulocytes is positively correlated with its concentration and molecular weight. Therefore, HA with high concentration and large molecular weight exhibited better efficacy in
Discussion
POA has become a challenging clinical problem on account of the health issues it brings about as well as the heavy financial burdens exerted on patients. Therefore, researchers make it a priority to seek efficient methods to prevent or alleviate POA. In recent years, physical barriers composed of biocompatible and biodegradable polymers have attracted wide attention in treating POA. These barriers can prevent the contact among damaged tissues for the first few days after surgery, so as to
Conclusion
In this review, we focused on natural and synthetic polymer materials in prevention of POA, which showed notable capability in adhesion prevention profile. The specific features of each kind of anti-adhesion polymer materials were also presented and analyzed. Our review provides researchers with important insights to choose specific polymers for anti-adhesion studies or product manufacturing.
In general, natural polymer materials enjoy high bioadhesive ability and good hemostasis feature.
Acknowledgments
This work was financially supported by the National Natural Science Foundation of China (Grant Nos. 51673190, 51673187, 51603204, and 51520105004) and the Science and Technology Development Program of Jilin Province (Grant No. 20160204015SF).
References (171)
- et al.
Adhesion formation after tubal surgery: Results of the eighth-day laparoscopy in 188 patients
Fertil. Steril.
(1985) - et al.
Down-regulating ERK1/2 and SMAD2/3 phosphorylation by physical barrier of celecoxib-loaded electrospun fibrous membranes prevents tendon adhesions
Biomaterials
(2014) - et al.
Adhesion-related hospital readmissions after abdominal and pelvic surgery: A retrospective cohort study
Lancet
(1999) - et al.
Prevention of postoperative peritoneal adhesions: A review of the literature
Am. J. Surg.
(2011) Reduction of de novo postsurgical adhesions by intraoperative precoating with Sepracoat (HAL-C) solution: A prospective, randomized, blinded, placebo-controlled multicenter study. The Sepracoat Adhesion Study Group
Fertil. Steril.
(1998)- et al.
Reduction of postsurgical adhesions with Intergel® adhesion prevention solution: A multicenter study of safety and efficacy after conservative gynecologic surgery
Fertil. Steril.
(2001) - et al.
Reduction of adhesion formation by postoperative administration of ionically cross-linked hyaluronic acid
Fertil. Steril.
(1997) - et al.
In situ cross-linkable hyaluronic acid hydrogels prevent post-operative abdominal adhesions in a rabbit model
Biomaterials
(2006) - et al.
Crosslinked hyaluronan hydrogels containing mitomycin C reduce postoperative abdominal adhesions
Fertil. Steril.
(2005) - et al.
Hyaluronic acid fluid agents for the prevention of adhesions after fertility-preserving gynecological surgery: A meta-analysis of randomized controlled trials
Fertil. Steril.
(2007)
The effect of Interceed® for reducing adhesion as a middle ear packing agent: An experimental study
Int. J. Pediatr. Otorhinolaryngol.
A randomized clinical trial of oxidized regenerated cellulose adhesion barrier (Interceed®, TC7) alone or in combination with heparin
Fertil. Steril.
Effect of Oxiplex® films (PEO/CMC) on adhesion formation and reformation in rabbit models and on peritoneal infection in a rat model
Fertil. Steril.
Intercoat gel (Oxiplex®): Efficacy, safety, and tissue response in a laparoscopic mouse model
J. Minim. Invas. Gynecol.
G. diZerega, Reduction of postoperative adhesions after laparoscopic gynecological surgery with Oxiplex/AP® Gel: A pilot study
Fertil. Steril.
Clinical evaluation of endometriosis and differential response to surgical therapy with and without application of Oxiplex/AP® adhesion barrier gel
Fertil. Steril.
G.S. diZerega, R.A. Berg, Reduction of epidural fibrosis in lumbar surgery with Oxiplex® adhesion barriers of carboxymethylcellulose and polyethylene oxide
Spine J.
Adhesion prevention in endometriosis: A neglected critical challenge
J. Minim. Invas. Gynecol.
Prevention of restrictive adhesions in primary tendon repair by HA-membrane: Experimental research in chickens
Br. J. Plast. Surg.
Prevention of adhesion formation after radical oophorectomy using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier
Gynecol. Oncol.
Effectiveness of antiadhesion barriers in preventing adhesion after myomectomy in patients with uterine leiomyoma
Eur. J. Obstet. Gynecol. Reprod. Biol.
A sprayable hyaluronate/carboxymethylcellulose adhesion barrier exhibits regional adhesion reduction efficacy and does not impair intestinal healing
J. Gastrointest. Surg.
Efficacy of Seprafilm for preventing adhesive bowel obstruction and cost-benefit analysis in pediatric patients undergoing laparotomy
J. Pediatr. Surg.
Adjuvant therapy for the reduction of postoperative intra-abdominal adhesion formation
Asian J. Surg.
Dextran-based in situ cross-linked injectable hydrogels to prevent peritoneal adhesions
Biomaterials
The antithrombotic effect of dextran-40 in man is due to enhanced fibrinolysis in vivo
J. Vasc. Surg.
Influence of poly(ethylene glycol) 4000 and dextran 70 on adhesion formation in rats
J. Surg. Res.
Transient liver function disturbances after the intraperitoneal use of 32% dextran 70 as adhesion prophylaxis in infertility surgery
Fertil. Steril.
Use of a modified chitosan-dextran gel to prevent peritoneal adhesions in a rat model
J. Surg. Res.
Use of a modified chitosan-dextran gel to prevent peritoneal adhesions in a porcine hemicolectomy model
J. Surg. Res.
In vivo evaluation of in situ polysaccharide based hydrogel for prevention of postoperative adhesion
Carbohyd. Polym.
Prevention of experimental postoperative peritoneal adhesions by N O-carboxymethyl chitosan
Surgery
Use of methylene blue and N, O-carboxymethylchitosan to prevent postoperative adhesions in a rat uterine horn model
Fertil. Steril.
Reduction of postoperative adhesions by N, O-carboxymethylchitosan: A pilot study
Fertil. Steril.
Evaluation of chitosan-gelatin films for use as postoperative adhesion barrier in rat cecum model
Int. J. Surg.
Prevention of peritendinous adhesions with electrospun chitosan-grafted polycaprolactone nanofibrous membranes
Acta Biomater.
Biodegradable and injectable in situ cross-linking chitosan-hyaluronic acid based hydrogels for postoperative adhesion prevention
Biomaterials
Synergism between keratinocyte growth factor and carboxymethyl chitosan reduces pericardial adhesions
Ann. Thorac. Surg.
Reduction in postoperative adhesion formation and re-formation after an abdominal operation with the use of N O-carboxymethyl chitosan
Surgery
G.S. diZerega, Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: A double-blind, randomized, controlled study
Fertil. Steril.
Adhesion-preventing properties of 4% icodextrin and canola oil: A comparative experimental study
Clinics
P.O.P.A. study: Prevention of postoperative abdominal adhesions by icodextrin 4% solution after laparotomy for adhesive small bowel obstruction. A prospective randomized controlled trial
J. Gastrointest. Surg.
Polyvinyl alcohol gel prevents abdominal adhesion formation in a rabbit model
Fertil. Steril.
Pathophysiology and prevention of postoperative peritoneal adhesions
World J. Gastroenterol.
Pathogenesis of postoperative adhesion formation
Br. J. Surg.
Drug-incorporated electrospun fibers efficiently prevent postoperative adhesion
Curr. Pharm. Des.
Biology of the peritoneum in normal homeostasis and after surgical trauma
Colorectal Dis.
The effects of a combination of hyaluronic and amniotic membrane on the formation of peritendinous adhesions after flexor tendon surgery in chickens
J. Bone Joint Surg. Br.
Efficacy and safety of hyaluronate membrane in the rabbit cecum-abdominal wall adhesion model
J. Korean Surg. Soc.
Application of hyaluronic acid/sodium alginate-based microparticles to prevent tissue adhesion in a rabbit model
Surg. Today
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