Research on Mechanisms of Chinese Medicines in Prevention and Treatment of Postoperative Adhesion / 中国结合医学杂志

Postoperative adhesion (PA) is currently one of the most unpleasant complications following surgical procedures. Researchers have developed several new strategies to alleviate the formation of PA to a great extent, but so far, no single measure or treatment can meet the expectations and requirements of clinical patients needing complete PA prevention. Chinese medicine (CM) has been widely used for thousands of years based on its remarkable efficacy and indispensable advantages CM treatments are gradually being accepted by modern medicine. Therefore, this review summarizes the formating process of PA and the efficacy and action mechanism of CM treatments, including their pharmacological effects, therapeutic mechanisms and advantages in PA prevention. We aim to improve the understanding of clinicians and researchers on CM prevention in the development of PA and promote the in-depth development and industrialization process of related drugs.

Research progress on action mechanism and clinical application of hyaluronic acid / 药学实践杂志

Hyaluronic acid is widely present in the human body. It is an important component of extracellular matrix. It has unique hydrodynamic properties, good viscoelasticity and strain properties. At present, hyaluronic acid has been widely used in biomaterials, targeted-drug preparations, cosmetics and prevention of adhesion after abdominal surgery. With the expansion of the application scope of hyaluronic acid and the continuous emergence of new medical materials, the research on hyaluronic acid has been increasing in recent years. This paper reviews the clinical application of hyaluronic acid and its mechanism, in order to provide reference for the further development and safe application of hyaluronic acid products.

Research progress on anti-adhesive products in post peritoneal surgery / 药学实践杂志

This review described the post abdominal surgery anti-adhesive products and technology used domestically and internationally .The methods of administration ,evaluation of pharmacodynamics and safety ,and mechanism of adhesion were also summarized in this article .This review provides a theoretical basis and research ideas for the development of postoperative anti-adhesive products .

Postoperative Adhesion after Thyroid Surgery / 대한내분비외과학회지

PURPOSE: Postoperative adhesion after thyroidectomy results in neck discomfort and swallowing difficulty. However, risk factors for adhesive symptom after thyroidectomy have not been well studied. This study evaluated symptoms related to postoperative adhesion after thyroidectomy. METHODS: The Glasgow-Edinburgh Throat Scale (GETS) questionnaire was used to evaluate postoperative adhesion. Patients who completed the GETS questionnaire either pre- or post-operatively were enrolled. Patient clinical and pathological details including age, gender, body weight, body mass index (BMI), tumor size, thyroid volume, extent of thyroidectomy, postoperative months, and neck thickness on ultrasonography and computed tomography (CT) were abstracted. RESULTS: Twenty-eight preoperative (22 females, six males) and 101 postoperative (83 females, 18 males) patients were enrolled. The mean age of the pre-operative enrollees was 52.1±11.7, and of post-operative enrollees 51.8±12.4 years. Patients who were within one month post-surgery had higher GETS scores than preoperative patients (27.4±20.1 vs. 6.5±11.1, P<0.001). Two months after surgery, GETS scores of postoperative patients did not differ significantly from the scores of the preoperative patients. There were no significant associations between clinical and pathologic features (age, tumor size, BMI, neck thickness on ultrasonography and CT) and GETS scores. CONCLUSION: Postoperative adhesive symptoms were most severe at one month after surgery, while questionnaire scores two months after surgery were comparable with preoperative patients. Further studies will be required for better understanding of the natural course of postoperative adhesion after thyroidectomy.

Adhesion formation after applying adhesion barrier in laparoscopic gynecologic surgery: Experience of 7 patients / 대한산부인과내시경학회지

OBJECTIVE: Adhesion barrier has been commonly used in gynecologic surgery. The objective of this study is to evaluate the outcome of applying adhesion barrier in preventing adhesion formation after laparoscopic surgery. METHODS: Between March 2000 and March 2010, we retrospectively reviewed the medical records of patients who performed laparoscopic surgery twice at Samsung Medical Center. The patients to whom adhesion barrier was applied at the end of the first laparoscopic surgery and had imaging files of pelvic cavity at second laparoscopic surgery were included. The patients with recurrent endometriosis and pelvic inflammatory disease which can make postoperative adhesion by itself due to the nature of the disease were excluded. RESULTS: Ten patients were eligible to be analyzed. Only 3 among 10 showed adhesion free and we could find de novo adhesion formation in 7 patients at second laparoscopic surgery. Eight patients used Intercede(R) (oxidized regenerated cellulose mesh; Johnson & Johnson, New Brunswick, NJ, USA) and two patients used Guardix(R) (sodium hyaluronic acid solution and carboxymethylcellulose: Hanmi, Seoul, Korea). In six patients, adhesion formation was found at the operation site and one patient showed postoperative adhesion distant from operation site between omentum and anterior peritoneum of pelvic wall. CONCLUSION: We observed adhesion formation despite of prior use of adhesion barrier after laparoscopic gynecological surgery. These results suggest that the use of adhesion barrier alone after gynecologic laparoscopic surgery may not guarantee adhesion prevention.

Efficacy of an Injectable Thermosensitive Gel on Postoperative Adhesion in Rat Model

PURPOSE: For easy application to targeted area or in laparoscopic surgery, proper injectable antiadhesive agents are needed. The efficacy of two injectable antiadhesive agents- the thermosensitive poly (organophosphazene) hydrogel (Gel group) and a mixed solution of hyaluronate and carboxymethyl cellulose (Guardix-sol(R), Hanmi Medicare, Korea; Gd group) were compared with that of a positive control (one established membranous agent [Interceed(R), Johnson & Johnson, USA; IC group]) and negative control (phosphate buffered saline, control group). METHODS: Eight ischemic buttons were created on both sides of the peritoneum in twenty-four male Sprague Dawley rats. Each of the solutions, or membrane agent was applied before closing of the wound according to groups (six rats per group). Two rats in the IC group were excluded because of death or intraoperative bleeding. Animals were sacrificed at two or four weeks after surgery. The number of adhesion-forming ischemic buttons and the weight gain were analyzed. RESULTS: The overall number of adhered ischemic buttons were 23 in the control group (n=48), 22 in the Gd group (n=48), 14 in the Gel group (n=48) and 0 in the IC group (n=32). Overall number of adhered ischemic buttons of the Gd group was not significantly different from that of the control group (P=1.000). However that of the Gel group was smaller than that of the control group, although not statistically significant (P=0.093). CONCLUSION: The Gel group demonstrated some possibility of having an antiadhesive effect, and the Gd group failed to show antiadhesive effect, in contrast to IC group. A large-scale preclinical study is required to verify these findings.

The Efficacy and Safety of Guardix-SG® in Patients Who Are Undergoing Thyroid Surgery: A Randomized, Prospective, Double-blinded Study / 대한내분비외과학회지

PURPOSE: Postoperative adhesion of the surgical field seems to be troublesome not only to the patients, but also to the surgeons. Guardix-SG® is a poloxamer/alginate mixture that reduced the incidence of postoperative adhesions when it is added to the abdominal surgery in animal models and also in clinical trials. This study was a randomized, prospective, double-blinded study to evaluate the antiadhesive efficacy and safety of Guardix-SG® after total thyroidectomy. METHODS: A total of 89 patients who underwent total thyroidectomy between July 2008 and February 2009 in Severance Hospital and Gang-Nam Severance Hospital were randomized to either the Guardix-SG® treatment group (n=45) or the non-treatmentcontrol group (n=44). The patients were asked about their clinical symptoms (hypesthesia or paresthesia on the operative site (SN) and swallowing discomfort (SW)) by using a questionnaire, and the swallowing function was evaluated using Marshmallow Esophagography by one physician. The clinical symptoms and Marshmallow Esophagography were scored according to the results of assessment. The most severe state was scored as 0 and normal was scored as 3. RESULTS: The scores of the clinical symptoms (SN and SW) were 2.67 and 2.49 in the treatment group, and 2.09 and 1.80 in the control group, respectively, at the postoperative 6th week (P=0.001, <0.001). The scores of the Marshmallow Esophagography were 2.93 in the treatment group and 2.73 in the control group (P=0.033). Abnormal findings were seen in 2 patients (4.4%) in the treatment group and in 10 patients (22.7%) in the control group (P=0.014). CONCLUSION: Guardix-SG® seems to be effective in preventing adhesion after thyroidectomy. Further studies involving a larger number of subjects will be needed to make an application guideline.

The Effect of the Amniotic Membrane and Methocel (R) on the Postoperative Adhesion after Strabismus Surgery

PURPOSE: To evaluate the effect of amniotic membrane and additional use of 2% methylcellulose(Methocel(R)) in reducing the postoperative adhesions following strabismus surgery. METHODS: Twenty white rabbits (40 eyes) were divided into 4 groups: control group C (12 eyes), trial group A (12 eyes), trial group B (12 eyes), and normal group N (4 eyes). In group C, the superior rectus was detached and scleral scratching was done to provoke a fibrotic reaction, and then, the superior rectus was reattached to the original insertion site. In group A, the above procedure was done and in addition, the superior rectus was covered with two-folded amniotic membrane. In group B, the same procedure was done as in group A and in addition, Methocel(R) was coated between the muscle and adjacent tissues. Eight weeks later, we divided each group into two subgroups. In one group, we examined the degree of adhesion by the blunt dissection between the muscle and adjacent tissues, and in the other group, the histologic findings with a light microscope between the muscle and adjacent tissues. RESULTS: The adhesion degree on the blunt dissection and histologic examination was significantly reduced in groups A and B. But no statistically significant difference between groups A and B was shown in the postoperative adhesion. CONCLUSIONS: From these findings, it is expected that the use of amniotic membrane may reduce the postoperative adhesion after strabismus surgery and theadditional use of Methocel(R) may not be useful.

Use of Polytetrafluorethylene for Delayed Adjustable Strabismus Surgery in Humans II

The author attempted to discover a method for performing delayed suture adjustment to investigate whether it actually provides more relable and stable results. In order to prevent the fromation of postoperative adhesions and delay the time of adjustment, the author used 0.1mm-thick polyteetraful-oroethylene(PTFE) as a physical barrier. PTFE was placed between the free muscle end and the sclera in 60 strabismic patients during adjustable strabismus surgery. Adjustment was not necessary in eight patients until PTFE removal. In thirteen patients, adjustment was not necessayr after first adjustment until two weeks postoperatively. PTFE was effective in delaying the adjustment after two weeks postoperatively in the remaining 39 patients. To my knowledge, this study represents the longest delayed adjustment in humans. In conclusion, PTFE can be clinically beneficial for delaying the timing of adjustment in strabismus surgery.

The Adequate Concentration of Subconjunctivally Injected Mitomycin c for the Prevention of Postoperative Adhesion in Strabisrnus

It. has been reported that, subconjunctival mitornycin c is strongiy effective in the reduction of postoperative fibrosis and adhesion. However we have to be cautious in using it clinically because of severe complications, scleral necrosis, endophthalmitis, etc. To find out the adequate concentration of mitomycin C, the authors performed 3mm recession of the superior rectus muscle (SR) in the left sys of 24 rabbits which were divided into 4 groups. Each group was composed of 6 rabbits. The 0.1%of 0.9% normal saline, 0.005% 0.01%, and 0.02% mitomycin c were injected subcounctivally through the site of SR recession in each group, respectively. The severity of the adhesion between SR and its surrounding tissues and the reduction of fibroblast. proliferation were evaluated histopathologically with the light microscope one month after surgery. The 0.01% and 0.02%mitomycin C-injected groups demonstrated considerable inhibition of postoperative adhesion and fibroblastic proliferation (p0. 15), This study reveals that the concentration of mitomycin c between 0.01% and 0.02% may prevent postoperative adhesions effectively after strabisrnus surgery. Further studies are needed to demonstrate the lowest concentration of mitoniycin c to prevent postoperative adhesion effectively without any com.plicat.ions in clinical use.

Use of Polytetrafluoroethylene for Delayed Adjustable Strabismus Surgery in Humans

Delayed reattachment of the muscle to the sclera may be desirable to correct the deviation of eye developed after the surgery. Based upon the results of the author` s previous experimental study on rabbits, polytetrafluoroethylene was placed around the cut end of the muscle as a physical barrier between the free muscle end and the sclera in seven strabismus patients in order to prevent the postoperative adhesions. Polytetrafluoroethylene (PTFE) was effective in delaying the adjustment more than 2 weeks after surgery in 4 out of 7 patients. In 3 remaining patients, adjustment was not necessary in 2 patients up to 22 days postoperatively because of the desirable postoperative state and suture was lost in a 65-year-old patient. In every case, PTFE was removed after final adjustment. In conclusion, PTFE may be clinically useful for delaying the timing of adjustment.

The Effect of Polytetrafluoroethylene on Delayed Adjustable Strabismus Surgery

Delayed reattachment of the muscle to the sclera may be desirable to correct the deviation of eye developed after the surgery. Polytetrafluoroethylene(PTFE) was placed around the cut end of the muscle as a physical barrier between the free muscle end and the sclera in 16 rabbits in order to prevent the postoperative adhesions. PTFE was effective in delaying the adjustment for up to 4 weeks after surgery in 4 out of 10 eyes. After removal of PTFE, adjustment was possible up to 12 weeks in 24 out of 25 eyes because there was no adhesion between the muscle and PTFE. In conclusion, PTFE may be clinically helpful for delaying the timing of adjustment.

Effects of 5-Fluorouracil on Delayed Adjustment in Experimental Strabismus Surgery

Adjustable sutures increased the rate of success with a single procedure, but sometimes fails because of changes in the angle of deviation which develops a few days after surgery. Therefore, the delayed adjustment was attempted;however, the postoperative adhesion following strabismus surgery make delayed adjustment impossible. We studied 45 eyes of 25 rabbits; adjustable strabismus surgery underwent a hang-back technique in the superior rectus muscle. In experimental group, a sponge was soaked in 5-Fluorouracil, and the sponge was placed between the conjunctiva and the sclera for 5 minutes during the operation. We studied the possible time of delayed adjustment and estimated the minimal forces required for the adjustment. The experimental group A (5-Fluorouracil, 50mg/ml) allowed for a 6 day delayed adjustment after surgery, control group allowed for a 2 day delayed adjustment after surgery. These results suggest that 5-Fluorouracil may valuable resource to delayed adjustment strabismus surgery by reduce postoperative adhesion.

Reduction of postoperative adhesions in strabismus surgery

An animal experiment was done to evaluate the efficacy of tissue coating with sodium hyaluronic acid and subconjunctival injection of triamcinolone acetate in reducing the severity of postoperative adhesions following strabismus surgery. Experimental animals underwent a mild traumatic surgical procedure in one superior rectus muscle and a severe traumatic surgical procedure in the other superior rectus muscle. Each group was divided into control group, sodium hyaluronate coating group and triamcinolone acetonide injection group. Grading the severity of adhesions through surgical exploration of operative sites and histological comparison after 4 weeks revealed a significant reduction of postoperative adhesions in sodium hyaluronate group compared with control group under conditions of severe surgical trauma. But triamcinolone groups have no significant differences compared with control groups by statistical analysis. Tissue protection afforded by sodium hyaluronate may lead to an effective method which minimizes the surgical trauma to the tissues and reduces the postsurgical adhesions following strabismus surgery.