Anti-adhesion Membrane

adhesionsThe anti-adhesion membrane marketed as Seprafilm is hyaluronic acid based and made by Genzyme Corporation. It is bioresorbable and is resorbed after about a week or so.

I was exposed to this film as the multicenter trial that was recently published in J Am Coll Surg was underway when I was doing fellowship in the US. As correctly mentioned by Moshe, the film was placed under the midline incision after restorative proctocolectomy. At time of closure of the protective ileostomy, a laparoscopic assessment of the midline wound was assessed by an observer who was not privy to whether or not the film was used. The trial was prospective, randomised and blinded. The results that were obtained were as published with adhesions to the midline wound as the main criteria. Long term data with regards to bowel obstruction is not known.

This study did not address interloop adhesions, which understandably are very important. Previous studies have established that post surgical adhesions can even cause bowel obstruction many years after the initial surgery.

As was mentioned, it would cost quite a bit to wrap each loop of bowel with the film, and for those who have tried to use it, will know that it gets rather sticky after it contacts with bowel. I know that it is being used on a compassionate protocol basis for patients who are being operated on for complications of adhesions and the trial is underway.

I suppose that the ideal anti-adhesion product would be one that the surgeon would be able to slosh around the abdomen to overcome the application difficulty. I know that Genzyme is working on a gel (trials are being started) that would be easier to apply and possibly address interloop adhesions, we await data.

With regards to anastomotic leaks, preclinical studies did not show any difference and neither did the clinical study, although, as Moshe pointed out, it would be difficult to convince anyone to wrap the film around any anastomoses in the clinical setting.

There have been no trials to address the issue of its use in malignancy but theoretically, there do not seem to be any contraindications (I think).

Surgeons suggested using this to “close” the pelvic floor to prevent small bowel loops being trapped in the pelvis. I’m afraid you will be disappointed as there is no innate strength in the film and it will completely resorb in about a week. I think that Goretex is marketing a sheet that is adhesion proof and might do the job, but this is non-resorbable.

Dr very correctly mentioned that “scrupulous surgical technique” minimises adhesions and this is very important. However, it is not the only factor involved and some patients develop more adhesions than others no matter what the technique. The trial with the Hartmann’s procedure may not yield consistent results as the indications for Hartmann’s are usually in emergency situations where there is usually infection, spillage eg perforated diverts, trauma with gross soilage etc. I am sure that both scrupulous surgical technique and whatever anti-adhesion product that is used will be put to a great test!

All panaceas in the past turned out to be of little universal value, and were only effective in the hands of the ones that published them, if you feel what I mean.

While, this impression always lingers in one’s mind especially if results are “too good or bad to be true”, it would be difficult to suggest that a randomised, multi-center trial involving some of the more prestigious institutions in the world, would have 10 collaborators having consistently inaccurate results.

We still wait for the perfect anti-adhesion product. One that is easy to apply, addresses adhesions to the wound, inter-loop adhesions, spares anastomoses, healing and “good” adhesions, yet inexpensive. This must be any surgeon’s prayer, especially when one is lysing adhesions in the wee hours of the morning!

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