A role for the fibrinolytic system in postsurgical adhesion formation.

OBJECTIVE: To look for evidence of a fibrinolytic insufficiency as a cause of adhesion formation.
DESIGN: Retrospective and prospective study.
SETTING: University medical center. PATIENT(S): Retrospective study: 50 patients undergoing laparoscopy, divided into patients with and without endometriosis. Prospective study: 18 patients undergoing infertility surgery involving a second-look laparoscopy. INTERVENTION(S): During all surgical procedures, adhesions were scored, and peritoneal fluid and plasma were collected. MAIN OUTCOME MEASURE(S): Parameters of the fibrinolytic system were measured to establish a possible relation with the presence and formation of adhesions. RESULT(S): In patients with endometriosis and adhesions, significantly higher peritoneal fluid concentrations were found for plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA), and plasminogen, compared with patients with endometriosis but without adhesions. In the prospective study, initial peritoneal PAI-1 concentrations correlated significantly with the extent of adhesion formation (r(s) = 0.49) and adhesion-improvement scores (r(s) = -0.52). Also, the change in concentration of tPA and fibrinogen from the initial surgical procedure to the second-look laparoscopy correlated significantly with adhesion-improvement scores (DeltatPA: r(s)= 0.50; Deltafibrinogen: r(s) = -0.64). CONCLUSION(S): This first prospective study in humans adds further weight to the hypothesis that adhesions are caused by an insufficiency in peritoneal fibrinolytic activity. Plasminogen activator inhibitor-1 is a potential marker for the identification of patients at risk for developing adhesions.