ACADEMIC RESEARCH IN MODERN SCIENCE
International scientific-online conference
53
EVALUATION OF THE EFFECTIVENESS OF SODIUM
CARBOXYMETHYLCELLULOSE IN THE PREVENTION OF
POSTOPERATIVE ADHESION FORMATION USING
HYDROXYPROLINE AND MATRIX METALLOPROTEINASES AS
BIOMARKERS OF FIBROGENESIS
Сапаев А.Д.
https://doi.org/10.5281/zenodo.15689536
Keywords:
postoperative adhesions, sodium carboxymethylcellulose,
hydroxyproline, matrix metalloproteinases, fibrosis, peritoneal surgery,
biochemical monitoring
Abstract
Postoperative intra-abdominal adhesions remain a critical challenge in
abdominal and pelvic surgery, with significant clinical and economic
implications. Adhesions can lead to chronic pelvic pain, female infertility,
intestinal obstruction, and complicate reoperations due to anatomical distortion.
The development of adhesions is a multifactorial process involving peritoneal
injury, local inflammation, oxidative stress, and dysregulated collagen
metabolism. Despite preventive surgical techniques, the incidence of adhesions
remains high, highlighting the need for effective adjunctive strategies.
This study aims to evaluate the efficacy of sodium carboxymethylcellulose
(Na-CMC), a bioresorbable barrier agent, in preventing postoperative adhesion
formation, and to determine the role of hydroxyproline and matrix
metalloproteinases (MMP-2 and MMP-9) as molecular biomarkers of peritoneal
fibrogenesis and adhesion activity.
Introduction
Adhesion formation occurs in up to 90% of patients undergoing abdominal
surgery and represents a form of aberrant tissue repair characterized by
excessive deposition of extracellular matrix components, particularly collagen.
Hydroxyproline, a major component of collagen, serves as a reliable indicator of
collagen turnover and fibrogenic activity. Additionally, MMP-2 and MMP-9,
members of the gelatinase family, play central roles in extracellular matrix
remodeling and are implicated in both adhesion formation and resolution. Their
measurement may provide insight into the dynamic fibrotic processes during
the postoperative period.
Sodium carboxymethylcellulose is a cellulose derivative with proven
biocompatibility and resorbable film-forming properties. When applied locally
ACADEMIC RESEARCH IN MODERN SCIENCE
International scientific-online conference
54
during surgery, it creates a temporary physical barrier between injured
peritoneal surfaces, thereby reducing the likelihood of fibrous adhesions.
Materials and Methods
A prospective, comparative clinical study was conducted in 218 patients
undergoing elective or emergency abdominal surgery. Patients were stratified
into two groups:
Main group (n = 110):
received intraoperative application of Na-CMC film
(sterile sheets or gel), positioned between at-risk peritoneal surfaces.
Control group (n = 108):
underwent standard surgical treatment without
use of anti-adhesion barriers.
Venous blood and daily urine samples were collected on postoperative days
3, 7, and 14. Hydroxyproline concentrations were measured using the Weber–
Collman colorimetric assay, while plasma levels of MMP-2 and MMP-9 were
quantified via sandwich-type ELISA kits validated for human samples.
Additional clinical parameters included:
Incidence and severity of postoperative pain (VAS scale)
Duration of postoperative ileus
Time to first bowel movement
Total length of hospitalization
Early postoperative complications (e.g., fever, seroma, wound infection)
Instrumental assessment (ultrasound or laparoscopy) was performed
selectively to evaluate adhesion formation in cases of recurrent symptoms or
diagnostic uncertainty.
Results
Patients in the Na-CMC group demonstrated a significant reduction in
adhesion-related complications and faster clinical recovery. On biochemical
analysis:
By day 14,
serum hydroxyproline
levels in the treatment group were
reduced by
27%
compared to controls (p = 0.031), suggesting attenuated
collagen deposition.
MMP-9 activity
was significantly lower in the Na-CMC group by
34%
(p =
0.008), and
MMP-2
levels showed a downward trend, though not statistically
significant.
The
duration of postoperative ileus
was shortened by an average of 1.2
days, and the average
length of stay
was reduced by 2.4 days in the Na-CMC
group (p < 0.05).
ACADEMIC RESEARCH IN MODERN SCIENCE
International scientific-online conference
55
No adverse reactions to Na-CMC were recorded, indicating favorable
safety and biocompatibility.
These findings suggest that Na-CMC not only provides a mechanical
separation of tissues but may also modulate the local inflammatory and fibrotic
responses through indirect molecular pathways.
Discussion
The reduction in hydroxyproline and MMP-9 in the barrier group highlights
the dual role of Na-CMC as both a physical and potentially biochemical
modulator of fibrogenesis. MMPs, particularly MMP-9, are upregulated during
peritoneal injury and contribute to matrix remodeling. Elevated levels of MMPs
can paradoxically promote fibrosis by stimulating the release of latent TGF-β
and enhancing fibroblast activation.
The observed suppression of MMP-9 activity in this study may reflect a
more regulated healing environment, possibly through reduced tissue trauma
and inflammation in the presence of the barrier film. Similarly, lower
hydroxyproline levels indicate downregulation of excessive collagen synthesis, a
hallmark of adhesion formation.
These insights support the incorporation of biochemical monitoring into
future clinical protocols for adhesion prevention and may pave the way for
personalized anti-adhesion strategies based on biomarker profiles.
Conclusions
Sodium carboxymethylcellulose is an effective and safe barrier agent for
reducing postoperative adhesion formation. Its use is associated with improved
clinical outcomes and favorable modulation of fibrogenic biomarkers.
Hydroxyproline and MMP-9 may serve as promising candidates for early
identification of patients at high risk of adhesion-related complications and for
evaluating the efficacy of prophylactic interventions. A combination of localized
physical protection and systemic biochemical assessment represents a novel
integrative approach in modern abdominal surgery.
