Hyaluronate Does Not Prevent Adhesions

In the March issue of the ARCHIVES, Kramer et al¹ suggest using a bioresorbant hyaluronic membrane to reduce intestinal adhesion to mesh. This idea was first reported by Loury and Chevrel² in 1983 and was based on the hypothesis that while the bioresorbant layer is being absorbed, a layer of mesothelium covers the nonresorbant mesh and prevents adhesions. Since then, various bioresorbant materials such as fibrin glue, collagen, polyglycolic acid, polyglactin, hyaluronate sodium, and carboxymethylcellulose combined with hyaluronic acid have been used by different investigators and have demonstrated that a bioresorbant barrier can only reduce adhesion, without its complete elimination. Baptista et al³ conducted a study in a rat model using the implantation of polypropylene mesh covered by a layer of hyaluronate sodium combined with carboxymethylcellulose (Sepramesh; Genzyme Biomedical, Cambridge, Mass) to increase its longevity. Serial laparoscopic observations and electron microscopic studies demonstrated that although it takes a week for the mesothelium to cover the polypropylene mesh, the bioresorbant layer disappears from the peritoneal cavity after 3 days; it reduces the number of adhesions but does not eliminate adhesion formation. In 1994, our rabbit model experimentation⁴ as well as a rat model experimentation and clinical observations by Soler et al⁵ demonstrated that combining nonresorbant mesh even with a long-lasting resorbant membrane did not prevent intestinal adhesion, bowel obstruction, or intestinal fistula formation.