Послеоперационные спайки – важное осложнение абдоминальной хирургии. Большинство стратегий по их предупреждению в оперативной гинекологии сфокусировано на оптимизации использования хирургической техники противоспаечных барьеров, которые делятся на 2 категории – фармакологические агенты и барьеры. Хирургическая техника, которая минимизирует перитонеальную травму, может уменьшить, но не предотвратить формирование послеоперационных спаек. Различные местные и системные лекарства могут уменьшить локальный воспалительный ответ, подавить коагуляционный каскад и способствовать фибринолизу. Барьеры общепринято рассматриваются как наиболее успешные помощники, способные редуцировать развитие спаек. Они разъединяют травмированные поверхности в период заживления. Существует ограниченное количество рандомизированных клинических испытаний, подтверждающих эффект большинства этих агентов в предотвращении интраперитонеальных адгезий после гинекологических операций. Тем не менее нельзя сделать окончательные выводы, и будущие исследования в этой области оправданы.
Post-operative adhesions are a significant complication of all abdominal surgical procedures. The major strategies for adhesion prevention in gynaecological surgery are focused on the optimization of surgical technique and use of anti-adhesive agents, which fall into two main categories: pharmacological agents and barriers. Surgical technique that minimizes peritoneal trauma can reduce, but cannot prevent post-operative adhesion formation. Various local and systemic drugs that can alter the local inflammatory response, inhibit the coagulation cascade and promote fibrinolysis have been evaluated. Barriers are currently considered the most useful adjuncts, which may reduce adhesion formation. They act by separating the traumatized peritoneal surfaces during the healing period. There is limited evidence from randomized clinical trials that support the beneficial effect of most of these barrier agents in the prevention of intra-peritoneal adhesions after gynaecological surgery. However, the evidence is not adequate for definite conclusions to be drawn and further research in this field is warranted.
1. Korell M. Aktuelle Adhasionsprophylaxe in der operativen Gynakologie. Gynakol 2002; 35: 1218–23.
2. Parker MC, Ellis H, Moran BJ et al. Postoperative adhesions: Ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum 2001; 44: 822–30.
3. Баранов Г.А., Карбовский М.Ю. Хирургия. 2006; 37: 56–9.
4. Gonzalez-Quintero V, Cruz-Pachano F. Preventing adhesions in obstetric and gynecologic surgical procedures. Rev Obstet Gynecol 2009; 2: 38–45.
5. Van der Wal JB, Jeekel J. The use of Statins in postoperative adhesion prevention. Ann Surg 2007; 245 (2): 185–6.
6. Wisemann DM. Disorders of adhesions or adhesion-related disorder: monolithic entities or part of something bigger – CAPPS? Semin Reprod Med 2008; 26: 356–68.
7. Menzies D, Hildago Pascual M et al. Use of icodextrin 4% solution in the prevention of adhesion formation following general surgery: from the multicentre ARIEL registry. Ann Roy Coll Surg Engl 2006; 88: 375–82.
8. Gutt C, Oniu T, Schemmer P et al. Fewer adhesions induced by laparoscopic surgery. Surg Endosc 2004; 18 (6): 898–906.
9. Rizzo A, Spedicato M, Mutinati M et al. Peritoneal adhesions in human and veterinary medicine: from pathogenesis to therapy. A review. Immunopharmacology and Immunotoxicology 2010; 32 (3): 481–94.
10. Alpay Z, Saed GM, Diamond MP. Postoperative adhesions: from formation to prevention. Semin Reprod Med 2008; 26: 313–21.
11. Irkorucu O, Ferahkose Z, Memis L et al. Reduction of post-surgical adhesions in a rat model: a comparative study. Clinics (Sao Paulo) 2009; 64: 143–8.
12. Oboh A, Trehan AK. Pelvic adhesion formation at second look surgery after laparoscopic partial and total peritoneal excision for women with endometriosis. Gynecol Surg 2007, 4: 261–5.
13. Lower AM, Hawthorn RJ, Ellis H et al. The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: an assessment from the Surgical and Clinical Adhesions Research Study. BJOG 2000; 107: 855–62.
14. Fletcher NM, Jiang ZL, Diamond M et al. Hypoxia-generated superoxide induces the development of the adhesion phenotype. Free Radic Biol Med 2008; 45 (4): 530–6.
15. DiZerega GS. Biochemical events in peritoneal tissue repair. Eur J Surg Suppl 1997; 577: 10–6.
16. Diamond MP, El-Mowafi DM. Pelvic adhesions. Surg Technol Int 1998; 7: 273–83.
17. DiZerega GS. Peritoneum, peritoneal healing and adhesion formation. In: DiZerega GS (ed.) Peritoneal Surgery. New York: Springer, Berlin Heidelbergh, 2006; p. 3–38.
18. Boland GM, Weigel RJ. Formation and prevention of postoperative abdominal adhesions. J Surg Res 2006; 132: 3–12.
19. Koninckx PR, Molinas R, Binda MM. Профилактика послеоперационных спаек. Проблемы репродукции 2009; 3: 26–33.
20. Ordemann J, Jakob J, Braumann C et al. Morphology of the rat peritoneum after carbon dioxide and helium pneumoperitoneum: a scanning electron microscopic study. Surg Endosc 2004; 18: 1389–93.
21. Suematsu T, Hirabayashi Y, Shiraishi N et al. Morphology of the murine peritoneum after pneumoperitoneum vs laparotomy. Surg Endosc 2001; 15: 954–8.
22. Molinas CR, Binda MM, Koninckx PR. Angiogenic factors in peritoneal adhesion formation. Gynecol Surg 2006, 3: 157–67.
23. Бурлев В.А., Дубинская Е.Д., Гаспаров А.С. Перитонеальные спайки: от патогенеза до профилактики. Проблемы репродукции 2009; 3: 36–44.
24. Гринберг М.И., Лоэрсон Н.Х. Послеоперационные спайки: этиология и патогенез. Под ред. Д.В.Рейньяка, Н.Х. Лоэрсена. Пер.с англ. М., 1986; с. 185–96.
25. Hertzler AE. Peritoneum 1919; 1: 264–5.
26. Mutsaers SE, Prêle CM, Lansley SM, Herrick SE. The origin of regenerating mesothelium: a historical perspective. Int J Artif Organs 2007; 30 (6): 484–94.
27. Kamel RM. Prevention of postoperative peritoneal adhesions. Eur J Obstet Gynecol Reprod Biol 2010; 150: 111–8.
28. Pados G, Venetis CA, Almaloglou K, Tarlatzis BC. Prevention of intra-peritoneal adhesions in gynaecological surgery: theory and evidence. Reprod BioMed Online 2010; 21: 290–303.
29. Tulandi T, Chen MF, Al-Took S, Watkin K. A study of nerve fibers and histopathology of postsurgical, postinfectious, and endometriosis-related adhesions. Obstet Gynecol 1998; 92: 766–8.
30. Chegini N, Rossi MJ, Holmdahl L. Cellular distribution of 5-lipoxygenase and leukotriene receptors in postsurgical peritoneal wound repair. Wound Repair Regen 1997; 5: 235–42.
31. Mueller POE. Advances in prevention and treatment of intra-abdominal adhesions in horses. Clin Tech Equine Pract 2002; 1: 163–73.
32. DeWilde R, Trew GB. Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert concensus potion. Gynecol Surg 2007; 4: 161–8.
33. Shavell V, Saed G, Diamond M. Review: cellular metabolism: contribution to postoperative adhesion development. Reprod Sci 2009; 16: 627–34.
34. Murphy G, Atkinson S, Ward R et al. The role of plasminogen activators in the regulation of connective tissue metalloproteinases. Ann NY Acad Sci 1992; 667: 1–12.
35. Alpay Z, Saed GM, Diamond MP. Female infertility and free radicals: potential role in adhesions and endometriosis. J Soc Gynecol Investig 2006; 13: 390–8.
36. Saed GM, Jiang Z, Diamond MP, Abu-Soud HM. The role of myeloperoxidase in the pathogenesis of postoperative adhesions. Wound Rep Reg 2009; 17: 531–9.
37. Harold E. The Etiology of Post-operative Adhesions. Proc R Soc Med 1962; 55 (7): 599–600.
38. Saed GM, Diamond MP. Molecular characterization of postoperative adhesions: the adhesion phenotype. J Am Assoc Gynecol Laparosc 2004; 11: 307–14.
39. Basoglu M, Kiziltunc A, Akcay F et al. Tumor necrosis factor-a and interleukin-6 in peritoneal adhesion formation. Tr J Med Sci 1998; 28: 253–8.
40. Tietze L, Elbrecht A, Schauerte C et al. Modulation of pro- and antifibrinolytic properties of human peritoneal mesothelial cells by transforming growth factor beta1 (TGF-beta1), tumor necrosis factor alpha (TNF-alpha) and interleukin 1beta (IL-1beta). Thromb Haemost 1998, 79: 362–70.
41. Sutton C. Adhesions and their prevention. Obstet Gynaecol 2005; 7: 168–76.
42. DiZerega G, Tulandi T. Prevention of intra-abdominal adhesions in gynaecological surgery. Reprod Biomed Online 2008; 17: 303–6.
42. Ten Raa S, van den Tol MP, Sluiter W et al. The role of neutrophils and oxygen free radicals in post-operative adhesions. J Surg Res 2006; 136: 45–52.
43. De la Portilla F, Ynfante I, Bejarano D et al. Prevention of peritoneal adhesions by intraperitoneal administration of vitamin E: an experimental study in rats. Dis Colon Rectum 2005; 47: 2157–61.
44. Jiang ZL, Zhu X, Diamond MP et al. Nitric oxide synthase isoforms expression in fibroblasts isolated from human normal peritoneum and adhesion tissues. Fertility and Sterilitya 2008; 90 (3): 769–74.
45. Saed GM, Zhao M, Diamond MP, Abu-Soud HM. Regulation of inducible nitric oxide synthase in post-operative adhesions. Hum Reprod 2006; 21: 1605–11.
46. Saed GM, Diamond MP. Apoptosis and proliferation of human peritoneal fibroblasts in response to hypoxia. Fertil Steril 2002; 78: 137–43.
47. Aarons C, Cohen P, Gower A et al. Statins (HMG-CoA reductase inhibitors) decrease postoperative adhesions by increasing peritoneal fibrinolytic activity. Ann Surg 2007; 245: 176–84.
48. Thomas JW, Greene JWJ, Rhoads JE. An experimental study of factors affecting the development and persistence of intraperitoneal adhesions. Surg Forum 1950; 125–8.
49. Gleadle JM, Ratcliffe PJ. Hypoxia and the regulation of gene expression. Mol Med Today 1998; 4: 122–9.
50. Luttun A, Tjwa M, Moons L et al. Revascularization of ischemic tissues by PlGF treatment, and inhibition of tumor angiogenesis, arthritis and atherosclerosis by anti-Flt1. Nat Med 2002; 8: 831–40.
51. Rout UK, Oommen K, Diamond MP. Altered expressions of VEGF mRNA splice variants during progression of uterine-peritoneal adhesions in the rat. Am J Reprod Immunol 2000; 43 (5): 299–304.
52. Diamond MP. An Overview of Postoperative Healing and Adhesion Development. Infert Reprod Med Clin N Am 2003; 14: 387–90.
53. Wallwiener M, Brucker S, Hierlemann H et al. Innovative barriers for peritonealadhesion prevention: liquid or solid? A rat uterine horn model. Fertil Steril 2006; 86: 1266–76.
54. Mage G, Pouly JL, Bouquet de Joliniere J et al. Apreoperative classification to predict the intrauterine and ectopic pregnancy rates after distal tubal microsurgery. Fertil Steril 1986; 46 (5): 807–10.
________________________________________________
1. Korell M. Aktuelle Adhasionsprophylaxe in der operativen Gynakologie. Gynakol 2002; 35: 1218–23.
2. Parker MC, Ellis H, Moran BJ et al. Postoperative adhesions: Ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum 2001; 44: 822–30.
3. Баранов Г.А., Карбовский М.Ю. Хирургия. 2006; 37: 56–9.
4. Gonzalez-Quintero V, Cruz-Pachano F. Preventing adhesions in obstetric and gynecologic surgical procedures. Rev Obstet Gynecol 2009; 2: 38–45.
5. Van der Wal JB, Jeekel J. The use of Statins in postoperative adhesion prevention. Ann Surg 2007; 245 (2): 185–6.
6. Wisemann DM. Disorders of adhesions or adhesion-related disorder: monolithic entities or part of something bigger – CAPPS? Semin Reprod Med 2008; 26: 356–68.
7. Menzies D, Hildago Pascual M et al. Use of icodextrin 4% solution in the prevention of adhesion formation following general surgery: from the multicentre ARIEL registry. Ann Roy Coll Surg Engl 2006; 88: 375–82.
8. Gutt C, Oniu T, Schemmer P et al. Fewer adhesions induced by laparoscopic surgery. Surg Endosc 2004; 18 (6): 898–906.
9. Rizzo A, Spedicato M, Mutinati M et al. Peritoneal adhesions in human and veterinary medicine: from pathogenesis to therapy. A review. Immunopharmacology and Immunotoxicology 2010; 32 (3): 481–94.
10. Alpay Z, Saed GM, Diamond MP. Postoperative adhesions: from formation to prevention. Semin Reprod Med 2008; 26: 313–21.
11. Irkorucu O, Ferahkose Z, Memis L et al. Reduction of post-surgical adhesions in a rat model: a comparative study. Clinics (Sao Paulo) 2009; 64: 143–8.
12. Oboh A, Trehan AK. Pelvic adhesion formation at second look surgery after laparoscopic partial and total peritoneal excision for women with endometriosis. Gynecol Surg 2007, 4: 261–5.
13. Lower AM, Hawthorn RJ, Ellis H et al. The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: an assessment from the Surgical and Clinical Adhesions Research Study. BJOG 2000; 107: 855–62.
14. Fletcher NM, Jiang ZL, Diamond M et al. Hypoxia-generated superoxide induces the development of the adhesion phenotype. Free Radic Biol Med 2008; 45 (4): 530–6.
15. DiZerega GS. Biochemical events in peritoneal tissue repair. Eur J Surg Suppl 1997; 577: 10–6.
16. Diamond MP, El-Mowafi DM. Pelvic adhesions. Surg Technol Int 1998; 7: 273–83.
17. DiZerega GS. Peritoneum, peritoneal healing and adhesion formation. In: DiZerega GS (ed.) Peritoneal Surgery. New York: Springer, Berlin Heidelbergh, 2006; p. 3–38.
18. Boland GM, Weigel RJ. Formation and prevention of postoperative abdominal adhesions. J Surg Res 2006; 132: 3–12.
19. Koninckx PR, Molinas R, Binda MM. Профилактика послеоперационных спаек. Проблемы репродукции 2009; 3: 26–33.
20. Ordemann J, Jakob J, Braumann C et al. Morphology of the rat peritoneum after carbon dioxide and helium pneumoperitoneum: a scanning electron microscopic study. Surg Endosc 2004; 18: 1389–93.
21. Suematsu T, Hirabayashi Y, Shiraishi N et al. Morphology of the murine peritoneum after pneumoperitoneum vs laparotomy. Surg Endosc 2001; 15: 954–8.
22. Molinas CR, Binda MM, Koninckx PR. Angiogenic factors in peritoneal adhesion formation. Gynecol Surg 2006, 3: 157–67.
23. Бурлев В.А., Дубинская Е.Д., Гаспаров А.С. Перитонеальные спайки: от патогенеза до профилактики. Проблемы репродукции 2009; 3: 36–44.
24. Гринберг М.И., Лоэрсон Н.Х. Послеоперационные спайки: этиология и патогенез. Под ред. Д.В.Рейньяка, Н.Х. Лоэрсена. Пер.с англ. М., 1986; с. 185–96.
25. Hertzler AE. Peritoneum 1919; 1: 264–5.
26. Mutsaers SE, Prêle CM, Lansley SM, Herrick SE. The origin of regenerating mesothelium: a historical perspective. Int J Artif Organs 2007; 30 (6): 484–94.
27. Kamel RM. Prevention of postoperative peritoneal adhesions. Eur J Obstet Gynecol Reprod Biol 2010; 150: 111–8.
28. Pados G, Venetis CA, Almaloglou K, Tarlatzis BC. Prevention of intra-peritoneal adhesions in gynaecological surgery: theory and evidence. Reprod BioMed Online 2010; 21: 290–303.
29. Tulandi T, Chen MF, Al-Took S, Watkin K. A study of nerve fibers and histopathology of postsurgical, postinfectious, and endometriosis-related adhesions. Obstet Gynecol 1998; 92: 766–8.
30. Chegini N, Rossi MJ, Holmdahl L. Cellular distribution of 5-lipoxygenase and leukotriene receptors in postsurgical peritoneal wound repair. Wound Repair Regen 1997; 5: 235–42.
31. Mueller POE. Advances in prevention and treatment of intra-abdominal adhesions in horses. Clin Tech Equine Pract 2002; 1: 163–73.
32. DeWilde R, Trew GB. Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert concensus potion. Gynecol Surg 2007; 4: 161–8.
33. Shavell V, Saed G, Diamond M. Review: cellular metabolism: contribution to postoperative adhesion development. Reprod Sci 2009; 16: 627–34.
34. Murphy G, Atkinson S, Ward R et al. The role of plasminogen activators in the regulation of connective tissue metalloproteinases. Ann NY Acad Sci 1992; 667: 1–12.
35. Alpay Z, Saed GM, Diamond MP. Female infertility and free radicals: potential role in adhesions and endometriosis. J Soc Gynecol Investig 2006; 13: 390–8.
36. Saed GM, Jiang Z, Diamond MP, Abu-Soud HM. The role of myeloperoxidase in the pathogenesis of postoperative adhesions. Wound Rep Reg 2009; 17: 531–9.
37. Harold E. The Etiology of Post-operative Adhesions. Proc R Soc Med 1962; 55 (7): 599–600.
38. Saed GM, Diamond MP. Molecular characterization of postoperative adhesions: the adhesion phenotype. J Am Assoc Gynecol Laparosc 2004; 11: 307–14.
39. Basoglu M, Kiziltunc A, Akcay F et al. Tumor necrosis factor-a and interleukin-6 in peritoneal adhesion formation. Tr J Med Sci 1998; 28: 253–8.
40. Tietze L, Elbrecht A, Schauerte C et al. Modulation of pro- and antifibrinolytic properties of human peritoneal mesothelial cells by transforming growth factor beta1 (TGF-beta1), tumor necrosis factor alpha (TNF-alpha) and interleukin 1beta (IL-1beta). Thromb Haemost 1998, 79: 362–70.
41. Sutton C. Adhesions and their prevention. Obstet Gynaecol 2005; 7: 168–76.
42. DiZerega G, Tulandi T. Prevention of intra-abdominal adhesions in gynaecological surgery. Reprod Biomed Online 2008; 17: 303–6.
42. Ten Raa S, van den Tol MP, Sluiter W et al. The role of neutrophils and oxygen free radicals in post-operative adhesions. J Surg Res 2006; 136: 45–52.
43. De la Portilla F, Ynfante I, Bejarano D et al. Prevention of peritoneal adhesions by intraperitoneal administration of vitamin E: an experimental study in rats. Dis Colon Rectum 2005; 47: 2157–61.
44. Jiang ZL, Zhu X, Diamond MP et al. Nitric oxide synthase isoforms expression in fibroblasts isolated from human normal peritoneum and adhesion tissues. Fertility and Sterilitya 2008; 90 (3): 769–74.
45. Saed GM, Zhao M, Diamond MP, Abu-Soud HM. Regulation of inducible nitric oxide synthase in post-operative adhesions. Hum Reprod 2006; 21: 1605–11.
46. Saed GM, Diamond MP. Apoptosis and proliferation of human peritoneal fibroblasts in response to hypoxia. Fertil Steril 2002; 78: 137–43.
47. Aarons C, Cohen P, Gower A et al. Statins (HMG-CoA reductase inhibitors) decrease postoperative adhesions by increasing peritoneal fibrinolytic activity. Ann Surg 2007; 245: 176–84.
48. Thomas JW, Greene JWJ, Rhoads JE. An experimental study of factors affecting the development and persistence of intraperitoneal adhesions. Surg Forum 1950; 125–8.
49. Gleadle JM, Ratcliffe PJ. Hypoxia and the regulation of gene expression. Mol Med Today 1998; 4: 122–9.
50. Luttun A, Tjwa M, Moons L et al. Revascularization of ischemic tissues by PlGF treatment, and inhibition of tumor angiogenesis, arthritis and atherosclerosis by anti-Flt1. Nat Med 2002; 8: 831–40.
51. Rout UK, Oommen K, Diamond MP. Altered expressions of VEGF mRNA splice variants during progression of uterine-peritoneal adhesions in the rat. Am J Reprod Immunol 2000; 43 (5): 299–304.
52. Diamond MP. An Overview of Postoperative Healing and Adhesion Development. Infert Reprod Med Clin N Am 2003; 14: 387–90.
53. Wallwiener M, Brucker S, Hierlemann H et al. Innovative barriers for peritonealadhesion prevention: liquid or solid? A rat uterine horn model. Fertil Steril 2006; 86: 1266–76.
54. Mage G, Pouly JL, Bouquet de Joliniere J et al. Apreoperative classification to predict the intrauterine and ectopic pregnancy rates after distal tubal microsurgery. Fertil Steril 1986; 46 (5): 807–10.
Авторы
С.О.Дубровина
ФГБУ Ростовский научно-исследовательский институт акушерства и педиатрии Минздравсоцразвития РФ;
ГОУ ВПО Ростовский государственный медицинский университет