A randomized, controlled pilot study of the safety and efficacy of 4% icodextrin solution in the reduction of adhesions following laparoscopic gynaecological surgery

BACKGROUND: Adhesion-related readmissions are frequent sequelae to gynaecological surgery. Attempts to prevent adhesions by separating healing peritoneal surfaces include site-specific barriers and hydroflotation by instilled solutions. Rapid absorption limits the effectiveness of solutions such as Ringer's lactated saline (RLS). This pilot study assessed the safety, tolerability and preliminary effectiveness of a non-viscous, iso-osmolar solution of 4% icodextrin, an alpha-1,4 glucose polymer with prolonged intraperitoneal residence, in reducing adhesions after laparoscopic gynaecological surgery. METHODS: Women aged > or = 18 years, requiring laparoscopic adnexal surgery (n = 62), were entered into a randomized, open-label, assessor-blinded, multicentre study to compare 4% icodextrin with RLS. Treatments were coded in blocks of four with equal randomization to each group, and pre-allocated to consecutively numbered patients. At least 100 ml per 30 min was used for intra-operative lavage, with 1 l instilled post-operatively. Per protocol analysis included all eligible patients (n = 53); reformation analysis required one or more baseline adhesion (n = 42). Incidence, extent and severity of post-operative adhesions were assessed at second-look laparoscopy after 6-12 weeks. Procedures were video-taped for third party, blinded assessment. RESULTS: Safety and tolerability (laboratory variables, adverse events, clinical follow-up) were good with no difference between treatments. A shift analysis of incidence-ranked adhesions (n = 53) showed apparent improvements in more patients with icodextrin than RLS (37 versus 15%; not significant). Adhesion score reduction (n = 42) was more frequent in icodextrin- than RLS-treated patients: incidence (52 versus 32%), extent (52 versus 47%), and severity (65 versus 37%). Despite greater baseline adhesions, median reformation was less after icodextrin (24%) than RLS (60%). The pilot study group sizes were not powered for statistical significance. CONCLUSIONS: In this preliminary study, 4% icodextrin lavage plus instillation was well tolerated and reduced adhesion formation and reformation following laparoscopic gynaecological surgery. A Phase III pivotal study is currently in progress.     

Prevention of post-surgical adhesion formation using aspirin in a rodent model: a preliminary report

Pelvic adhesions are one of the major factors which significantlyand adversely affect surgery outcome due to intra-and postoperativemorbidity and reduce future female fertility. Using a rodentmodel, we evaluated the efficacy of aspirin, a non-steroidalanti-inflammatory drug, in the prevention of adhesion formation.A total of 72 female Wistar rats received a standardized primarytraumatic lesion to the right uterine horn. They were randomlydivided into eight groups: group I (control) had no treatmentand group II received a single pre-operative 0.70 mg aspirin.All the succeeding groups (III-VIII) received aspirin in dosesof 0.35, 0.70, or 1.40 mg every 6 h for either 48 or 96 h inaddition to the pre-operative aspirin (0.70 mg). All animalswere killed 4 weeks later and adhesions were assessed usinga modified adhesion scoring scale. The lowest adhesion scorewas found in the group treated with 0.35 mg of aspirin for 96h, and the highest was found among the groups treated with either0.70 or 1.40 mg for 48–96 h respectively (P < 0.05).These results are in line with the hypothesis that administrationof a low dose of aspirin selectively inhibits the productionof thromboxane A₂, whereas basal prostacyclin biosynthesis ispreserved. This phenomenon might contribute to reducing postoperativeadhesion formation in a rat model. Thus, future studies intothe prevention of adhesion formation may require the additionaluse of a non-steroidal anti-inflammatory drug, for which aspirindeserves further attention, before extrapolation into humantherapy.     

The correlation of adhesions and peritoneal fluid cytokine concentrations: a pilot study

BACKGROUND: Intra-abdominal adhesion formation and reformation after surgery is a significant cause of morbidity. The greatest problem after the surgical removal of adhesions is their reformation. We examined the concentrations of interleukin (IL)-1, IL-6 and tumour necrosis factor (TNF)-alpha in the peritoneal fluid throughout the 48 h post-operative period following adhesiolysis, and correlated the results to the extent of adhesion reformation. METHODS: Peritoneal fluid, collected from eight patients following laparoscopy and again at 12, 36 and 48 h after surgery, was analysed using enzyme-linked immunosorbent assay (IL-1 and IL-6) and bioassay (TNF-alpha). At 48 h, a second look laparoscopy was performed to inspect the pelvis for adhesion formation/reformation. RESULTS: Three patients had adhesion reformation >10% at 48 h after surgery. The mean adhesion score 48 h after adhesiolysis was 5 (range 0-17). The mean reduction in adhesion score was 88% (range 83-100%). Newly formed adhesions were filmy, relatively soft and avascular in nature. Adhesion reformation of >10% was associated with (i) high concentrations of IL-6 at 12 h (P < 0.01) and (ii) high concentrations of IL-1 at 48 h (P < 0.001). CONCLUSIONS: Results from this preliminary study suggest that future treatment strategies for adhesion prevention could be aimed at the control of cellular mediators in the peritoneal fluid during the initial adhesion formation period.     

Hypoxaemia induced by CO(2) or helium pneumoperitoneum is a co-factor in adhesion formation in rabbits

A prospective randomized trial in a rabbit model was performed to test the hypothesis that the increase in adhesion formation following prolonged pneumoperitoneum is mediated by peritoneal hypoxaemia. Laparoscopic standardized opposing lesions were performed in uterine horns and pelvic sidewalls by bipolar coagulation and CO(2) laser in six groups of eight animals. Pure CO(2) or helium pneumoperitoneum was used for 10 (groups I and IV) or 45 min (groups II and V) to confirm the effect of duration of pneumoperitoneum and 96% of CO(2) or helium with 4% of oxygen (group III and VI) for 45 min to assess the effect of the addition of oxygen. After 7 days, adhesion formation was scored by laparoscopy. By two-way analysis of variance, total, extent, type and tenacity of adhesion scores increased (P = 0.0003, P = 0.0004, P = 0.0004 and P = 0.004) with increasing duration of pneumoperitoneum and decreased (P = 0.02, P = 0.03, P = 0.01 and P = 0.05) with the addition of oxygen. No differences were found between CO(2) and helium. In conclusion these data confirm the effect of pneumoperitoneum upon adhesions and demonstrate its reduction by oxygen, strongly suggesting that the main cause of adhesion formation is the relatively superficial hypoxaemia produced by the pneumoperitoneum.     

聚合物/液晶细胞模型的构建及其表面弹性对大鼠骨髓干细胞黏附的影响

目的:构建聚合物/液晶细胞模型,探究其表面弹性对大鼠骨髓干细胞黏附情况的影响。方法:溶剂挥发致相分离方法构建聚合物/液晶细胞模型,通过偏光显微镜、扫描式电子显微镜及X射线衍射观察细胞模型的表面特征。全骨髓细胞贴壁培养法分离大鼠骨髓间充质干细胞(BMSCs),通过表面因子检测和诱导其成骨成脂分化进行鉴定。培养3代后分4组:纯PU空白对照组,10%膜组,30%膜组和50%膜组。接种细胞密度为5×107/L,待细胞贴壁24h后作细胞骨架染色处理,激光共聚焦显微镜观察细胞附着在材料上的情况并拍照。结果:溶剂挥发致相分离方法成功构建3种不同硬度的聚合物/液晶细胞模型;表面因子检测显示CD29、CD44、CD90呈阳性表达,而CD34和CD45呈阴性表达;经过茜素红S染色和油红O染色,成骨成脂分化形成的钙结节和脂滴都显而易见;细胞骨架染色拍摄结果显示,纯PU对照组、10%膜组和30%膜组上的细胞铺展面积较广,肌动蛋白微丝和细胞核清晰明显;而50%膜组的细胞铺展面积较小,细胞核虽较清晰,但是肌动蛋白微丝却模糊不清。结论:合适液晶含量的聚合物/液晶生物膜能支持大鼠骨髓干细胞的贴壁生长,而液晶含量过高则抑制细胞的贴壁生长。     

Effectiveness of auto-cross-linked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic adhesiolysis: a prospective,randomized, controlled study

BACKGROUND: A prospective, randomized, controlled study was performed to assess the efficacy of auto-cross-linked hyaluronic acid (ACP) gel in preventing the development of intrauterine adhesions following hysteroscopic adhesiolysis. METHODS: Ninety-two patients with irregular menses and intrauterine adhesions referred to the Hysteroscopic Unit of the University of Naples "Federico II". Patients were randomized to two different groups. Group A were randomized to hysteroscopic adhesiolysis plus intrauterine application of ACP gel (10 ml) and group B were randomized to operative hysteroscopy alone (control group). Baseline adhesion scores were calculated for each patient and at 3 months after surgery. RESULTS: Group A showed a significant decrease in intrauterine adhesions at 3 months follow-up in comparison with the control group. Staging of adhesions showed a significant decrease in adhesion severity in patients treated with ACP gel. CONCLUSIONS: ACP gel significantly reduces the development of intrauterine adhesions postoperatively and its use is likely to be associated with a reduction of severe adhesions.     

Multifunctional cationic polymer decorated and drug intercalated layered silicate (NLS) for early gastric cancer prevention

A multifunctional compound that can prevent early gastric cancer is produced by intercalating 3.20% and 1.64% of 5-FU into the interlayer of montmorillonite (MMT) and attapulgite (At), respectively. A low molecular weight cationic polymer, polyethylenimine (PEI1200), is incorporated into the surface of the 5-FU-MMT and 5-FU-At to form the multifunctional layered silicate (NLS). The chemical structure and surface morphology of the NLS are characterized and the model drug of 5-FU is intercalated into the MMT and At. The cell viability determined by the MTT assay on the BGC-823 cell lines show that over 80% of the cells are live under the experimental conditions. The PEI-5-FU-MMT and PEI-5-FU-At can carry the report gene to the BGC-823 and COS-7 cell lines efficiently. Western blotting assay shows that the pTrail protein of the BGC-823 cell lines treated with PEI-5-FU-MMT/pTrail and PEI-5-FU-At/pTrail is up-regulated, whereas the cFLIP protein is down-regulated at 48 h compared to free 5-FU, PEI1200, MMT, and At, providing evidence that the NLS can increase the sensitivity of pTrail gene and improve the effects of pTrail gene therapy. Moreover, the Helicobacter pylori (HP) bacteria are adsorbed and immobilized efficiently on the surface of the NLS according to the LIVE/DEAD^® BacLight™ Bacterial Viability Kit in the confocal fluorescence analysis. The histochemical analyses provide evidence that NLS/pTrail can prevent early gastric mucosa effectively.     

Effectiveness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study

BACKGROUND: A prospective, randomized, controlled study was performed to assess the efficacy of auto-crosslinked hyaluronic acid (ACP) gel to prevent the development of de-novo intrauterine adhesions following hysteroscopic surgery. METHODS: One hundred and thirty-two patients with a single surgically remediable intrauterine lesion (myomas, polyps and uterine septa, subgroups I-III) completed the study. Patients were randomized to two different groups: group A underwent hysteroscopic surgery plus intrauterine application of ACP gel (10 ml) while group B underwent hysteroscopic surgery alone (control group). The rate of adhesion formation and the adhesion score was calculated for each group and subgroup 3 months after surgery. RESULTS: Group A showed a significant reduction in the development of de-novo intrauterine adhesions at 3 months follow-up in comparison with the control group. Furthermore, the staging of adhesions showed a significant decrease in adhesion severity in patients treated with ACP gel. CONCLUSIONS: ACP gel significantly reduces the incidence and severity of de-novo formation of intrauterine adhesions after hysteroscopic surgery.     

Enhanced hydrogel adhesion by polymer interdiffusion: Use of linear poly(ethylene glycol) as an adhesion promoter

The fracture energy required to separate layers of hydrogel films was investigated to evaluate the impact of bulk polymer diffusion on hydrogel/hydrogel adhesion and to obtain molecular information on the fracture energy in polymer mucoadhesion. Poly(ethylene glycol) (PEG) was incorporated in a hydrogel and was used as an adhesion promoter. The influence of PEG molecular weight and contact time on PEG diffusion across the hydrogel/hydrogel interface was investigated by using tensiometric studies and near-field FTIR microscopy. These experiments indicated that linear PEG diffusion enhanced the adhesion between the two hydrogel layers. The enhanced adhesion could not be explained by surface wetting phenomena alone. These results indicated that bulk diffusion of linear polymers such as PEG (adhesion promoter) incorporated into polymer networks (hydrogels) was an effective technique for enhancing gel/gel adhesion in various applications including polymer/mucus interactions in mucoadhesion and development of mucoadhesive controlled drug delivery systems.     

Transvaginal hydrolaparoscopy compared with laparoscopy for the evaluation of infertile women: a prospective comparative blind study

Standard diagnostic laparoscopy is considered the gold standard to investigate tubo-peritoneal infertility. It requires general anaesthesia and full operative facilities. Due to the risk of complications, laparoscopy is frequently postponed to the final stage of infertility evaluation or even after treatment trials have failed. Transvaginal hydrolaparoscopy (THL) is based on vaginal access using a needle puncture technique and saline for distention. THL can be performed on an outpatient basis under local anaesthesia. However, little data exist concerning the accuracy of THL in comparison with laparoscopy. We conducted a prospective comparative blind trial to assess the feasibility and accuracy of THL compared with diagnostic laparoscopy in infertile women. Sixty women were assigned to undergo THL immediately prior to laparoscopy. Different operators evaluated the findings of the two procedures. In order to evaluate the accuracy of THL, findings in terms of tubal pathology, endometriosis and adhesions were analysed. The success rate of accessing the pouch of Douglas was 90.2%. Complication rate was 1.6%. THL diagnosis was correlated with that of laparoscopy in 92.3% of cases. In cases of abnormal findings by THL, there were no normal laparoscopies. Our pilot study suggests that THL is a safe and reproducible method. Retroverted uterus should be considered as a relative contraindication to THL. When a complete evaluation by THL is available, it is a highly accurate technique in comparison with the laparoscopy.     

Induced regeneration of endometrium following curettage for abortion: a comparative study

A significant increase in endometrial thickness and volume wasobserved in 30 patients given oestrogen and progestin supplementationfollowing curettage for first trimester abortions, comparedwith 30 women who received no treatment. This indicates an enhancedregeneration of the endometrium following treatment. The abilityto induce this response, creating a space between the intra-cavitysurface area a short time after abortion, may theoreticallybe suggested as preventative treatment to reduce the risk ofintrauterine adhesions.     

Development of novel submicron textured polyether(urethane urea) for decreasing platelet adhesion

Ventricular assist devices have proven to be a useful clinical option for providing circulatory support as a bridge to transplantation and a mode of destination therapy. Thromboembolism is prevented by designing devices that use blood interfaces that either encourage biological material deposition and strong adhesion, or discourage deposition via surface chemistry, surface finish, and fluid flow fields. Minimum continuous or periodic wall shear forces and maximum time at reduced shear are important, and sometimes difficult-to-satisfy, design constraints. We present an approach to reducing platelet adhesion via surface topography, reducing surface area for platelet-material interaction. Large areas of polyether(urethane urea) were textured with two different sizes of ordered pillar arrays via two-stage replication molding without affecting surface chemistry. Pillars had subplatelet dimensions designed to reduce the surface area a platelet may contact. Platelet adhesion was assessed in a physiologically relevant shear stress range from 0-10 dyn/cm2 using a rotating disk and compared to smooth control. Adhesion was highest from 0-5 dyn/cm2. Surface texturing reduced platelet adhesion without increasing platelet activation in bulk suspension. This study demonstrates that material surface texture is an additional variable that may be used to reduce platelet adhesion under low shear stresses potentially reducing thromboembolism.     

Development of a highly responsive needle-type glucose sensor using polyimide for a wearable artificial endocrine pancreas

To produce a long-life, stable, miniature glucose sensor for a wearable artificial endocrine pancreas (WAEP), we developed a novel microneedle-type glucose sensor using polyimide, designated the PI sensor (outer diameter, 0.3 mm; length, 16 mm), and investigated its characteristics in vitro and in vivo. In the in vitro study, we tested the sensor in 0.9% NaCl solution with varying glucose concentrations and observed an excellent linear relationship between the sensor output and glucose concentration (range: 0–500 mg/100 ml). In in vivo experiments, the PI sensor was inserted into the abdominal subcutaneous tissue of beagle dogs (n = 5), and interstitial fluid glucose concentrations were monitored after sensor calibration. Simultaneously, blood glucose concentrations were also monitored continuously with another PI sensor placed intravenously. The correlation and time delay between subcutaneous tissue glucose (Y) and blood glucose concentrations (X: 30–350 mg/100 ml) were Y = 1.03X + 7.98 (r = 0.969) and 6.6 ± 1.2 min, respectively. We applied the new WAEP system/PI sensor and an intravenous insulin infusion algorithm developed previously for glycemic control in diabetic dogs. The use of the WAEP system resulted in excellent glycemic control after an oral glucose challenge of 1.5 g/kg (post-challenge blood glucose levels: 176 ± 18 mg/100 ml at 65 min and 93 ± 23 mg/100 ml at 240 min), without any hypoglycemia. Thus, we confirmed that our new PI sensor has excellent sensor characteristics in vitro and in vivo. The new WAEP using this sensor is potentially suitable for clinical application.     

The macrophage stimulating protein/RON system: a potential novel target for prevention and treatment of endometriosis

Our recent DNA microarray analysis using tissue obtained by laser capture microdissection (LCM) identified up-regulation of RON (a tyrosine kinase receptor) during the late secretory phase in eutopic endometrial epithelial cells from patients with deep endometriosis compared with control endometrium from women with macroscopically normal pelvic cavities. In the present study, we further investigated mRNA expression of RON and its ligand, macrophage stimulating protein (MSP), in deep endometriotic lesions, eutopic endometrium from patients with deep endometriosis and control endometrium by using LCM and quantitative real-time RT-PCR. MSP mRNA expression in endometrial epithelial cells was significantly up-regulated in endometriosis patients during the late secretory phase compared with expression in controls. Furthermore, we detected up-regulation of MSP mRNA in ectopic endometrial epithelial cells compared with matched eutopic endometrial epithelial cells within the same patients regardless of the menstrual phase. MSP has an intrinsically dual functional nature through its receptor RON-it is a trophic cytokine preventing apoptosis and a scatter factor promoting invasion, both of which may be necessary for the initial development and growth of endometriosis. The present findings suggest that the MSP/RON system may be involved in the pathophysiology of endometriosis.     

Post-operative adhesions after laparoscopic electrosurgical treatment for polycystic ovarian syndrome with the application of Interceed to one ovary: a prospective randomized controlled study

In this prospective, randomized, controlled clinical study,21 women underwent a second-look laparoscopy 2–11 weeksafter standardized laparoscopic electrosurgical treatment forpolycystic ovarian syndrome (PCOS). Following bilateral ovariantreatment, one ovary was randomly chosen to have Interceed appliedto its surface using a specially designed applicator, with theother ovary serving as a control. Peri-adnexal adhesions ofsignificant extent and severity developed in 57% of the womenand 38% of the adnexa. The incidence of adhesions on the Interceed-treatedside was 43%, while on the control side it was 33%. In addition,the extent and severity of the adhesions appeared to be similaron the Interceed-treated and the control side. However, largernumbers would be required to determine statistically the effectsof Interceed on de-novo adhesion formation after laparoscopicelectro-surgical treatment of PCOS, as described here.     

Comparison of hyaluronate/carboxymethylcellulose membrane and melatonin for prevention of adhesion formation in a rat model

BACKGROUND: To investigate the effectiveness of melatonin in preventing post-operative adhesion formation and to compare it with the efficacy of hyaluronate/carboxymethylcellulose membrane in a rat model. MATERIALS and METHODS: Following pilot studies, 35 rats were operated on in the full study. In 15 animals (group one), 10 standard lesions were inflicted in each uterine horn (total 30 horns) and melatonin was applied before closure of the abdomen. In the second group, 20 animals were operated on and one of the uterine horns (total 20 horns) with standard lesions was treated with hyaluronate/carboxymethylcellulose membrane and the other uterine horn served as a control. Second-look operations were performed 1 week later and adhesion scores were compared. RESULTS: The adhesion scores of uterine horns treated with melatonin and of uterine horns treated with hyaluronate/carboxymethylcellulose membrane were significantly lower than the scores of the controls (P < 0.001). There was no statistically significant difference between the adhesion scores of uterine horns treated with melatonin and of uterine horns treated with hyaluronate/carboxymethylcellulose membrane (P > 0.05). CONCLUSIONS: Both melatonin and hyaluronate/carboxymethylcellulose membrane were effective in prevention of adhesion formation in a rat uterine horn model.     

缺氧条件下葡萄糖对成年神经干细胞体外增殖影响的研究

目的　探讨不同浓度的葡萄糖对氧/糖剥夺条件下体外成年大鼠神经干细胞活力和增殖的影响。 方法　无血清培养成年Fisher 344大鼠海马神经干细胞系,用Nestin和DAPI免疫荧光双染以确认其生物学特性。将三气培养箱氧气浓度调至1%以制备缺氧环境,将培养基换为无糖Earle’s平衡盐溶液缺氧培养6 h后更换为含有不同浓度葡萄糖（7.5、17.5、27.75、41.75、83.75 mmol/L）的培养基恢复正常条件继续培养后,检测神经干细胞的活力和形态学改变。同时设置常氧常糖为正常对照组和甘露醇为渗透压对照组。 结果　CCK-8检测显示,常糖常氧正常对照组细胞吸光度值较缺氧模型组高,7.5 mmol/l糖培养组以及41.75 mmol/L和83.75 mmol/L糖培养组吸光度值均较正常糖缺氧组（17.5 mmol/L）低,差异有统计学意义（P<0.05）;而27.75 mmol/L糖培养组吸光度值较正常糖缺氧组低,差异无统计学意义,且排除了高糖培养基引起的渗透压力的影响。各组细胞形态学改变与CCK-8检测结果一致。 结论　缺氧后轻度升高的糖对体外缺氧成年神经干细胞的损伤可能有保护作用,而较低浓度和更高浓度的葡萄糖则加重其损伤。     

Development of a novel electrophoretic system for the isolation of human spermatozoa

BACKGROUND: Optimization of assisted conception outcomes involves the development of rapid, safe, effective techniques for the isolation of functional human spermatozoa free from significant DNA damage. In this study we describe a novel electrophoretic sperm isolation technique that achieves these objectives. METHODS: The separation system consisted of a cassette comprising two 400 mul chambers separated by a polycarbonate filter containing 5 micromol/l pores and bounded by a 15 kDa polyacrylamide membrane to allow the free circulation of buffer. Semen was introduced into one chamber, current applied (75 mA at variable voltage) and within seconds a purified suspension of spermatozoa could be collected from the adjacent chamber. These cells were assessed for their count, viability, motility, morphology and DNA integrity. RESULTS: The suspensions generated by the electrophoretic separation technique contained motile, viable, morphologically normal spermatozoa and exhibited low levels of DNA damage. Moreover, these cell suspensions were free from contaminating cells, including leukocytes. The technique was comparable to discontinuous gradient centrifugation except that it took a fraction of the time and generated cells with significantly less DNA damage. CONCLUSION: Electrophoretic separation represents a highly effective, novel approach for the isolation of spermatozoa for assisted conception purposes.     

Development and pre-clinical analysis of a Plasmodium falciparum Merozoite Surface Protein-1(42) malaria vaccine

Merozoite Surface Protein-1(42) (MSP-1(42)) is a leading vaccine candidate against erythrocytic malaria parasites. We cloned and expressed Plasmodium falciparum MSP-1(42) (3D7 clone) in Escherichia coli. The antigen was purified to greater than 95% homogeneity by using nickel-, Q- and carboxy-methyl (CM)-substituted resins. The final product, designated Falciparum Merozoite Protein-1 (FMP1), had endotoxin levels significantly lower than FDA standards. It was structurally correct based on binding conformation-dependent mAbs, and was stable. Functional antibodies from rabbits vaccinated with FMP1 in Freund's adjuvant inhibited parasite growth in vitro and also inhibited secondary processing of MSP-1(42). FMP1 formulated with GlaxoSmithKline Biologicals (GSK) adjuvant, AS02A or alum was safe and immunogenic in rhesus (Macaca mulatta) monkeys.