Achieving Efficient Anti-Adhesion in Re-Mediastinoscopy: An Experimental Study in Rats

Abstract

Objective: Re-mediastinoscopy can be a difficult procedure due to fibrosis in the mediastinum. We have investigated the effect of an anti-adhesive barrier agent “hylan B gel” on the formation of adhesions after dissection in the superior mediastinum in a rat model. Methods: The study was conducted in 70 male Sprague-Dawley rats weighing 300 g. The strap muscles were divided by a midline cervical incision. The anterior and lateral aspects of the trachea were dissected to the level of the carina. Hylan B gel (Sepragel Sinus, Genzyme Company, Redgefield, NJ, USA) was used to create an anti-adhesive barrier. The rats who were subjected to surgery were sacrificed on postoperative days 14 and 28. All rats were previously divided into 5 groups: Sham group (n = 10); Group 1 (n = 15) surgery alone, sacrificed on day 14; Group 2 (n = 15) surgery and Sepragel, sacrificed on day 14; Group 3 (n = 15) surgery alone, sacrificed on day 28; Group 4 (n = 15) surgery and Sepragel, sacrificed on day 28. Histopathological analysis was performed to study the effect of the anti-adhesive agent. Scores were calculated based on collagen fibrosis, fibroblasts, granulation tissue, muscle alterations/inflammation, histiocytes, mononuclear giant cells, inflammation and vascular proliferation. Results: Collagen fibrosis and fibroblast scores, which represent adhesions, were significantly higher in Groups 1, 2, 3, 4 than in the Sham group (p < 0.01). The degree of adhesions on day 14 was found to be higher in Group 1 compared to Group 2 (p < 0.01). Adhesions on day 28 were higher in Group 3 compared to Group 4 (p < 0.01). There were no differences between groups with regard to foreign body reactions (p > 0.05). Conclusion: Adhesions causing technical difficulty during re-mediastinoscopy can be reduced by the application of anti-adhesive agents during the primary procedure.

Key words

thoracic surgery - anti‐adhesive agent - re‐mediastinoscopy - lung cancer

References

• 1 Bocage J P, Mackenzie J W, Nosher J L. Invasive diagnostic procedures. Shields TW, LeCicero J, Ponn RB General Thoracic Surgery. Philadelphia; Lippincott Williams-Wilkins 2000: 273-284
• 2 Meersschaut D, Vermassen F, Brutel de la Riviere A, Knaepen P J, Van den Bosch J M, Vanderschueren R. Repeat mediastinoscopy in the assessment of new and recurrent lung neoplasm.  Ann Thorac Surg. 1992;  53 120-122
• 3 Deutch A A, Evitar E, Gutman H, Reiss R. Small bowel obstruction: a review of 264 cases and suggestions for management.  Postgrad Med J. 1989;  65 463-467
• 4 Ellis H, Moran B J, Thompson J N, Parker M C, Wilson M S, Menzies D, McGuire A, Lower A M, Hawthorn R J, O'Brien F, Buchan S, Crowe A M. Adhesion related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study.  Lancet. 1999;  353 1476-1480
• 5 Chapron C, Pierre F, Harchaoui Y, Lacroix S, Bequin S, Querleu D, Lansac J, Dubuisson J B. Gastrointestinal injuries during gynaecological laparoscopy.  Hum Reprod. 1999;  14 333-337
• 6 Terzi C, Sevinc I A, Kocdor H, Oktay G, Alanyali H, Kupelioglu A, Ergor G, Fuzun M. Improvement of colonic healing by preoperative rectal irrigation with short-chain fatty acids in rats given radiotherapy.  Dis Colon Rectum. 2004;  47 2184-2194
• 7 Van Schil P, van der Schoot J, Poniewierski J, Pauwels M, Carp L, Germonpre P, De Backer W. Remediastinoscopy after neoadjuvant therapy for non small cell lung cancer.  Lung Cancer. 2002;  37 281-285
• 8 Mateu-Navarro M, Rami-Porta R, Bastus-Piulats R, Cirera-Nogueras L, Gonzalez-Pont G. Remediastinoscopy after induction chemotherapy in nonsmall cell lung cancer.  Ann Thorac Surg. 2000;  70 391-395
• 9 Balle V H, Bretlau P. Remediastinoscopy.  J Laryngol Otol. 1985;  99 267-281
• 10 Milligan D W, Raftery A T. Observations on the pathogenesis of peritoneal adhesions: a light and electron microscopical study.  Br J Surg. 1974;  61 274-280
• 11 Lewis R J, Sisler G, Mackenzie J W. Repeat mediastinoscopy.  Ann Thorac Surg. 1984;  37 147-149
• 12 Olsen P S, Stentoft P, Ellefsen B, Pettersson G. Remediastinoscopy in the assessment of resectability of lung cancer.  Eur J Cardiothorac Surg. 1997;  11 661-663
• 13 Hellebrekers B W, Trimbos-Kember G C, Van Blitterswijk C A, Bakkum E A, Trimbos J B. Effects of five different barrier materials on postsurgical adhesion formation in the rat.  Hum Reprod. 2000;  15 1358-1363
• 14 Osada H, Minai M, Tsunoda I, Fujii T K, Tsubata K, Satoh K. The effect of hyaluronic acid-carboxymethylcellulose in reducing adhesion reformation in rabbits.  J Int Med Res. 1999;  27 292-296
• 15 Yoldemir T, Sagol S, Adakan S, Oztekin K, Ozsener S, Karadadas N. Comparison of the reduction of postoperative adhesions by two barriers, one solution, and two pharmacologic agents in the rat uterine model.  Fertil Steril. 2002;  78 335-339
• 16 Alponat A, Lakshminarasappa S R, Yavuz N, Goh P M. Prevention of adhesions by Seprafilm, an absorbable adhesion barrier: an incisional hernia model in rats.  Am Surg. 1997;  63 818-819
• 17 Yigit O, Uslu Coskun B, Coskun H, Yilmaz B, Alkan S, Cinar U, Dadas B. Efficacy of anti-adhesive barriers in secondary thyroidectomy: an experimental study.  Laryngoscope. 2004;  114 1668-1673
• 18 Trimbos-Kemper T CM, Trimbos J B, van Hall E V. Adhesion formation after tubal surgery: results of eighth-day laparoscopy in 188 patients.  Fertil Steril. 1985;  43 395-400
• 19 Diamond M P, Daniell J F, Feste J, Surrey M W, McLaughlin D S, Friedman S, Vaughn W K, Martin D C. Adhesion reformation and de novo adhesion formation after reproductive pelvic surgery.  Fertil Steril. 1987;  47 864-866