What is the effect of Seprafilm (hyaluronic acid and carboxymethylcellulose) on bowel anastomosis?

Effect of Seprafilm on Bowel Anastomosis

Seprafilm should not be placed directly on bowel anastomosis sites as it may increase the risk of anastomotic leak and related complications. 1

Mechanism and General Effects of Seprafilm

Seprafilm (hyaluronic acid and carboxymethylcellulose) is a bioresorbable adhesion barrier designed to separate tissues during healing to prevent adhesion formation. It works as a physical spacer between injured peritoneal surfaces, allowing them to heal without forming fibrinous attachments that lead to adhesions 2.

Effects on Bowel Anastomosis

Negative Effects

• Anastomotic Leak Risk: When Seprafilm is wrapped around fresh bowel anastomoses, it significantly increases the risk of leak-related events, including:

  • Anastomotic leak
  • Fistula formation (2% vs <1% in control groups)
  • Peritonitis (2% vs <1% in control groups)
  • Abscess
  • Sepsis 1

• Meta-analysis Evidence: A 2022 meta-analysis of randomized controlled trials confirmed that while Seprafilm reduces small bowel obstruction risk, it significantly increases anastomotic leak rates (RR 1.85,95% CI 1.15-3.00, P = 0.01) 3

Neutral Effects on Anastomotic Healing

• When not directly wrapped around the anastomosis, Seprafilm does not interfere with normal healing of bowel anastomoses 4
• Burst pressures of anastomoses with Seprafilm applied nearby (but not directly on the anastomosis) were nearly identical to control anastomoses at all time points in animal studies 4

Proper Use in Abdominal Surgery

Recommendations for Use

• Seprafilm should be applied to adhesiogenic tissues throughout the abdomen, but not directly on anastomotic sites 5
• It is most suitable for open surgery, though laparoscopic placement has been described 2
• Optimal use is in surgeries without bowel anastomosis or when placed away from anastomotic sites 3

Benefits When Properly Used

• Reduces incidence of reoperations for adhesive small bowel obstruction (RR 0.49,95% CI 0.28–0.88) 2
• Reduces severity of adhesions and increases the number of adhesion-free patients 3
• May reduce chronic abdominal complaints in the long term 6

Clinical Decision Algorithm

1. For surgeries without bowel anastomosis:

   • Seprafilm can be safely used throughout the abdomen
   • Apply to areas most likely to form adhesions

2. For surgeries with bowel anastomosis:

   • Do not wrap Seprafilm directly around fresh anastomotic sites
   • Can still apply Seprafilm to other areas of the abdomen away from anastomoses
   • Consider alternative adhesion barriers if concerned about anastomotic sites

3. Special considerations:

   • For colorectal surgery: Seprafilm reduces reoperation rates for adhesive small bowel obstruction when properly used 2
   • For emergency surgery for adhesive small bowel obstruction: Icodextrin 4% may be an alternative option 2

Conclusion Points

• Seprafilm is effective at reducing adhesions and subsequent small bowel obstruction when used correctly
• The key safety concern is increased anastomotic leak risk when placed directly on fresh bowel anastomoses
• Proper placement technique is critical to balance adhesion prevention benefits against anastomotic risks