Adhesion Barrier Linked to Immediate Postoperative Complications

Sanjeet Bagcchi, MBBS

December 14, 2015

New research suggests that the use of adhesion-reducing substances, known as adhesion barrier, is associated with slightly increased incidence of fever and ileus after myomectomy and hysterectomy, and with small bowel obstruction after hysterectomy.

Togas Tulandi, MD, MHCM, from McGill University Health Center, Montreal, Quebec, Canada, and colleagues report the results of their research in an article published online December 7 in Obstetrics & Gynecology. They note that in most cases of abdominal surgeries (including open pelvic surgery and myomectomy), postoperative adhesion occurs and may lead to abdominal pain, intestinal obstruction, infertility, and other complications.

Previous studies had shown that adhesion barriers, such as sodium hyaluronate–carboxymethylcellulose and oxidized regenerated cellulose, reduce adhesions, although most of those studies looked at a relatively low number of participants. "The purpose of our study was to evaluate the use of adhesion barrier in myomectomy or hysterectomy and the complications in the immediate postoperative period," Dr Tulandi and colleagues write.

The researchers performed a retrospective cohort study evaluating the data of 473,788 women (who had had uterine myoma and underwent hysterectomy or myomectomy) from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database of 2003–2011. "The outcomes included the use rate and perioperative complications associated with the use of adhesion barriers," the researchers write. The primary outcomes were ileus and small intestinal obstruction; secondary outcomes included fever, pain, abscess, intraabdominal hematoma or seroma, and sepsis.

Of 473,788 women, 62,563 underwent myomectomy and 411,225 had had hysterectomy. Surgeons used adhesion barrier in 3392 (5.4%) patients with myomectomy and in 5590 (1.4%) patients with hysterectomy.

In patients who did not use adhesion barrier, the researchers found a lower rate of ileus after myomectomy compared with in those who used adhesion barrier (1290/59,171 [2.2%] vs 109/3392 [3.2%]; adjusted odds ratio [OR], 1.50; 95% confidence interval [CI], 1.22 - 1.83). The researchers noted similar findings for hysterectomy cases (10,329/405,635 [2.5%] vs 288/5590 [5.1%]; adjusted OR, 1.97; 95% CI, 1.75 - 2.23).

Dr Tulandi and colleagues also found a higher incidence of fever in the adhesion barrier group compared with in the nonbarrier group after myomectomy (4.4% vs 2.9%; adjusted OR, 1.44; 95% CI, 1.21 - 1.71) and hysterectomy (2.5% vs 1.6%; OR, 1.65; 95% CI, 1.40 - 1.96). However, small bowel obstruction was "less frequent" in the nonbarrier group compared with the barrier group in cases of hysterectomy (804/405,635 [0.2%] vs 23/5590 [0.4%]; OR, 1.90; 95% CI, 1.25 - 2.89), but not in cases of myomectomy.

As the researchers point out, the study had some limitations: it was retrospective in nature, there was no detailed information about the surgery or the type of adhesion barrier, the criteria for diagnosing ileus or small intestinal obstruction were also not clear, and there were possibilities of inaccuracy resulting from the use of an administrative database.

However, the strength of the study was the large number of patients involved. The authors also note that whereas the use of adhesion barrier was associated with complications, the overall incidence of complication remained low. However, the use of adhesion barrier might lead to a longer hospital stay.

"Accordingly," Dr Tulandi and colleagues conclude, "one should weigh the benefits, the risks, and the financial implications of applying adhesion barriers. The use of an adhesion-reducing substance is more beneficial in an infertile woman undergoing a myomectomy than in a menopausal woman undergoing a hysterectomy."

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. Published online December 7, 2015. Abstract