粘连:预防策略。

B Risberg
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引用次数: 0

摘要

67%至93%的腹部手术后会出现粘连,这是一个主要的临床问题,它会导致肠梗阻、不孕和疼痛,并带来可观的经济成本。粘连问题的规模和严重性一直被低估。此外,由于缺乏经验基础,缺乏良好的预测性动物模型,以及粘连发生的生化复杂性,预防或减少粘连的努力在很大程度上是不成功的。预防或减少粘连的两个主要策略是调整手术技术和应用佐剂。所有外科医生应实施的技术改进包括尽量减少手术的侵入性,尽量减少手术创伤(如腹膜缝合引起的缺血),避免异物(如淀粉手套粉)进入体内。然而,考虑到腹膜修复的粘连性,仅靠手术技术的改进将有助于减少粘连的形成,但不能防止粘连的形成。辅助治疗是必要的。佐剂主要分为两大类:药物和屏障。非甾体抗炎药的临床疗效值得怀疑,可能是因为药物递送困难。皮质类固醇,单独或与抗组胺药,也有模棱两可的临床结果,可能是免疫抑制和延迟伤口愈合。实验上,纤维蛋白溶解剂如组织纤溶酶原激活剂(tPA),全身或腹腔注射(i.p),已经证明了相互矛盾的结果和出血并发症。然而,最近,tPA在羧甲基纤维素(CMC)凝胶中局部施用,已有效地减少和防止家兔的粘连。磷脂酰胆碱,口服或口服,在动物研究中也显示出希望。屏障是一种有用的佐剂,可在腹膜上皮再形成的关键前5至7天隔离创伤表面,包括大分子溶液和机械装置。右旋糖酐是一种大分子溶液,已被广泛研究,但尚未表现出一致的临床疗效,并且在很大程度上已被放弃作为抗黏附屏障。在一项针对妇科剖腹手术妇女的大型多中心研究中,一种新开发的透明质酸-磷酸盐缓冲生理盐水在术中应用,可有效安全地保护腹膜表面免受间接手术创伤,减少粘连。最近开发的三种机械屏障在预防粘连方面也取得了临床进展。一种由透明质酸和CMC组成的生物可吸收膜在减少粘连方面的有效性和安全性得到了监管部门的批准,可用于普通和妇科手术的临床应用。一种由膨胀聚四氟乙烯制成的屏障和另一种由氧化再生纤维素制成的屏障目前可用于妇科手术。随着研究的继续,新的和改进的方法有望成为可用的,以防止粘连的形成。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Adhesions: preventive strategies.

Adhesions, which occur after 67% to 93% of abdominal operations, represent a major clinical problem, resulting in intestinal obstruction, infertility, and pain and incurring considerable economic costs. The magnitude and seriousness of the problem of adhesions have been underappreciated. Moreover, efforts to prevent or reduce adhesions largely have been unsuccessful, hindered by their empirical basis, the lack of good predictive animal models, and the biochemical complexities of adhesiogenesis. The two major strategies for adhesion prevention or reduction are adjusting surgical technique and applying adjuvants. Modifications in technique that all surgeons should implement include minimizing the invasiveness of surgery, minimizing surgical trauma, such as ischemia from peritoneal suturing, and avoiding the introduction of foreign material, e.g., starch glove powder, into the body. Given the adhesiogenic nature of peritoneal repair, however, improvements in surgical technique alone will help decrease but not prevent adhesion formation. Adjuvant therapy is necessary. Adjuvants fall into two main categories, drugs and barriers. Nonsteroidal anti-inflammatory drugs have shown questionable clinical efficacy, possibly because of difficulties in drug delivery. Corticosteroids, alone or with antihistamines, also have had equivocal clinical results and may be immunosuppressive and delay wound healing. Experimentally, fibrinolytics such as tissue plasminogen activator (tPA), administered systemically or intraperitoneally (i.p.), have demonstrated conflicting results and hemorrhagic complications. However, recently, tPA, administered topically in a carboxymethylcellulose (CMC) gel, has been effective in reducing and preventing adhesions in rabbits. Phosphatidylcholine, given i.p. or orally, also has shown promise in animal studies. Barriers, by separating traumatized surfaces for the critical first five to seven days of peritoneal re-epithelialization, are useful adjuvants, and include macromolecular solutions and mechanical devices. Dextran, a macromolecular solution, has been studied widely, but has not demonstrated consistent clinical efficacy and has been largely abandoned as an anti-adhesion barrier. A newly developed hyaluronic acid-phosphate-buffered saline solution applied intraoperatively to protect peritoneal surfaces from indirect surgical trauma effectively and safely reduced adhesions in a large multicenter study of women undergoing gynecological laparotomy. Three recently developed mechanical barriers also have demonstrated clinical progress in adhesion prevention. A bioresorbable membrane consisting of hyaluronic acid and CMC has gained regulatory approval for clinical use in both general and gynecological surgery following demonstration of efficacy and safety in reducing adhesions. A barrier made of expanded polytetrafluoroethylene and another developed from oxidized regenerated cellulose are currently available for gynecological surgery. With continued research, new and improved approaches hopefully will become available to prevent adhesion formation.

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