Adherencias Perotoneales

The American Journal of Surgery (2011) 201, 111–121

Review

Prevention of postoperative peritoneal adhesions: a review of the literature
Beat Schnüriger, M.D., Galinos Barmparas, M.D., Bernardino C. Branco, M.D., Thomas Lustenberger, M.D., Kenji Inaba, M.D., F.R.C.S.C., F.A.C.S., Demetrios Demetriades, M.D., Ph.D., F.A.C.S.*
Los Angeles County Medical Center, University of SouthernCalifornia, Department of Surgery, Division of Acute Care Surgery, Trauma, Emergency Surgery and Surgical Critical Care, LAC USC Medical Center, Room 1105, 1200 North State St, Los Angeles, CA, USA KEYWORDS:
Prevention; Postoperative peritoneal adhesions; Review; Bioabsorbable barriers; Risk factors Abstract BACKGROUND: Postoperative adhesions are a significant health problem with major implications onquality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies. METHODS: The National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions. RESULTS: Ilealpouch–anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopictechniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence). CONCLUSIONS: Postoperative adhesions are a significant health problem with major implications on quality of life andhealth care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions. © 2011 Elsevier Inc. All rights reserved.

Patients undergoing laparotomy for various reasons have a 90% risk of developing intraperitoneal adhesions,1,2 and the incidence ofre-admissions directly related to adhesions
* Corresponding author: Tel.: 1-323-409-7761; fax: 1-323-4419909. E-mail address: demetria@usc.edu Manuscript received October 22, 2009; revised manuscript February 16, 2010

varies from 5% to 20%.3– 6 It is estimated that in the United States there are 117 hospitalizations for adhesion-related problems per 100,000 people and the total cost for hospital andsurgeon expenditures is about $1.3 billion.7 In some European countries the direct medical costs for adhesionrelated problems were more than the surgical expenditure for gastric cancer and almost as much as for rectal cancer.8,9 In view of the magnitude of the health problems and financial burden related to adhesions, prevention or reduc-

0002-9610/$ - see front matter © 2011 Elsevier Inc. Allrights reserved. doi:10.1016/j.amjsurg.2010.02.008

112 tion of postoperative adhesions is an important priority. Numerous articles on the prevention of postoperative adhesions have been published but several controversies such as the effectiveness of available agents and their indication in general surgical patients still exist. Most of the available literature is based on gynecologic patients.For general surgical patients no recommendations or guidelines exist. The purpose of this literature review was to assess the efficacy of various described adhesion prevention strategies after emergency and elective general surgery and to identify those patients who are most likely to benefit from these various prevention strategies.

The American Journal of Surgery, Vol 201, No 1, January 2011...