Barrier agents for preventing adhesions after surgery for subfertility
Abstract
Background
Pelvic adhesions can be the result of inflammation, endometriosis or surgical trauma. Prevention of postoperative adhesions (either new or reoccurance) has been postulated by using barriers to prevent two surfaces being in contact. When pelvic surgery is being undertaken strategies to reduce pelvic adhesions occurring may be undertaken and these include barrier agents which are placed between the pelvic structures. Two synthetic barriers with differential characteristics are commercially available: oxidised regenerated cellulose (Interceed) and polytetrafluoroethylene (PTFC) (GoreTex).
Objectives
The objective of this review was to assess the effect of mechanical barriers (materials interposed between pelvic structures to prevent adherence of serosal surfaces) used during pelvic surgery in women of reproductive age on pregnancy rates, pelvic pain, or postoperative adhesion reformation.
Search methods
We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 22 May 2003). The Cochrane Menstrual Disorders and Subfertility Group register is based on regular searches of MEDLINE, EMBASE, CINAHL, PsycINFO and CENTRAL, the handsearching of 20 relevant journals and conference proceedings, and searches of several key grey literature sources. In addition, companies were contacted for unpublished trials.
Selection criteria
Randomised controlled trials or controlled clinical trials of barriers versus no treatment or other barriers in women undergoing fertility preserving pelvic surgery.
Data collection and analysis
Reviewers assessed eligibility and trial quality.
Main results
Fifteen randomised controlled trials were included. Five trials randomised patients while the remainder randomised pelvic organs. Laparoscopy was the primary surgical technique in six trials while the remaining trials were laparotomy. Indications for surgery included myomectomy (five trials), ovarian surgery (four trials), pelvic adhesions (six trials), endometriosis (two trials) and mixed (one trial). Thirteen trials assessed Interceed versus no treatment, two assessed Interceed versus Gore‐Tex, one trial assessed Gore‐Tex versus no treatment, and one trial assessed Seprafilm versus no treatment. No study reported pregnancy or reduction in pain as an outcome. The use of Interceed in women was associated with reduced incidence of pelvic adhesion formation, both new formation and re‐formation following laparoscopic surgery and after laparotomy. Gore‐Tex was more effective than no barrier or Interceed in preventing adhesion formation. There was limited evidence that Seprafilm was effective in preventing adhesion formation in women following myomectomy.
Authors' conclusions
The absorbable adhesion barrier Interceed reduces the incidence of adhesion formation, both new formation and re‐formation, at laparoscopy and laparotomy, but there are insufficient data to support its use to improve pregnancy rates. Gore‐Tex may be superior to Interceed in preventing adhesion formation but its usefulness is limited by the need for suturing and later removal. There was no evidence of effectiveness of Seprafilm in preventing adhesion formation.
PICOs
Plain language summary
Barrier agents may be effective in reducing the formation of pelvic adhesions but there is no evidence on their effect on pregnancy rates
Sometimes following surgery, adhesions occur (where two normally separate surfaces join). Pelvic adhesions can be caused by swelling, endometriosis or surgical trauma. Various materials have been used as 'mechanical' barriers to prevent these adhesions forming. The review of trials assessed the effect of these barriers on pregnancy rates, pelvic pain and adhesion formation after pelvic surgery. The review found the absorbable barrier Interceed reduces adhesions but found no evidence on its effect on pregnancy rates. Gore‐Tex is better than Interceed but is not absorbable. There was no evidence of the effectiveness of Seprafilm. More research is needed.
