GB2335853A - Inhibition of Surgical Adhesions - Google Patents

Abstract

There is disclosed the use of naturally occurring surface active phospholipids (SAPLs, dipalmitoylphosphatidylcholine and phosphatidyl glycerol), preferably as a commercially available mixture ALEC (RTM), for the prevention of adhesions following surgery. A suitable dispersion device for the powdered medicament (figs 2 and 3) comprises a casing (10) containing a propellant canister (14) and a drug vial (15). A valve arrangement (16) operated by depression of the inverted end (18) of the canister allows the introduction of propellant by a tube (19, 21) into the vial. A second tube (22, 24) provides exit means from the vial to the site of delivery.

Description

1 MEDICAMENTS 2335853 This invention relates to medicamerfs for and

methods of reducing the probability of surgical adhesions.

Following surgery, membranes which have been severed may 'cross-heal'. For example the abdominal wall can heal with the peritoneum and adhere to it. This is known as an adhesion. A very serious complication of adhesions inside the peritoneum is intestinal obstruction. Unless corrected surgically this can rapidly be fatal. It has been estimated that in the US in 1988 the cost of correcting lower abdominal pelvic adhesions was of the order of US$ 1180 million (AH De Cherney and GS diZeregram Surgical Clinics of North America 17L3), 671). Attempts have been made to reduce adhesions by providing physical barriers such as sheets of hyaluronic acid and carboxymethylcellulose. While providing an initial barrier the sheets degrade.

It has now been unexpectedly found that natural occurring surface active phospholipids and enantiomers thereof can substantially reduce the likelihood of adhesions forming.

According to the invention there is provided a method of reducing the probability of surgical adhesion comprising administering SAPI, to mesothical membranes during surgery.

According to the invention there is provided the use of a SAPI, in the manufacture of a medicament for use in reducing the probability of surgical adhesions following surgery.

Embodiments of the invention will be described by way of non-limiting example by reference to the Figure which shows the length of adhesion formed under various conditions.

A physical or chemical binding of the surfactant to the membrane is highly desirable. Examples of suitable phospholipids include diacyl phosphatidyl cholines (DAPC's) such as dipalrnitoyl phosphatidyl choline (DPPC), dioleyl phosphatidyl 2 choline (DOPC) and distearyl phosphatidyl choline (DSPC). It is also preferred to include a spreading agent in the composition to assist the DPPC or analogous compound rapidly to form a thin film over the surface of the membrane. A number of agents are capable of acting in this way including other phosphoupids, such as phosphatidylglycerols (PG); phosphatidylethanolan-dnes (PE); phosphatidylserines (PS) and phosphatidylinositols (PI). Another useful spreading agent is cholesteryl paln-dtate (CP). We prefer to use dipalmitoyl phosphatidyl choline (DPPC) and unsaturated phosphatidyl glycerol (PG) either alone or in combination. A mixture comprising DPPC 70 wt% and PG 30 wt% can be used. This material is commercially available as ALEC'm from Britannia Pharmaceutical Limited. ALEC is known for use in treating respiratory distress syndrome see for example British Medical Journal 294 (1984) 991- 996.

A widely accepted theory on the mechanism of action of ALEC in the lungs of neonates is that it functions principally by lowering surface tension. Since there is no air-water interface in the normal peritoneal cavity one would not expect ALEC and other SAPL's to be efFective in preventing the formation of or reduction the probability of forming adhesions. It has however been experimentally found that SAPL's do, in fact reduce the frequency of adhesion formation as will become apparent from the experimental data set forth below.

rabbits were taken. A surgical opening was made in the peritoneum. Opposing peritoneal surfaces were subjected to a sterilised 50 mm abrasion. In 10 cases the opening was simply closed. In a finiher 10 cases the abrasion was perfused with dialysate prior to closure. In a still further 10 cases the abrasion was perflased with a suspension of ALEC in dialysate and the opening closed. In a final 10 cases powdered ALEC was blown into the abrasion prior to closure. Following healing the peritoneum was reopened and the presence of adhesions noted. Where adhesions were noted their length was measured. The results are shown in Table 3 Table 1

Control Dialysate ALEC & Dialysate ALEC Number of adhesion 1 5 4 5 free cases Total length of 320 197 151 91 adhesion (mm) Reduction in adhesion 38% 53% 72% length relative to control Mean Adhesive Length 32 19.7 15.1 9.1 (M1n) Standard Deviation 5 10.5 9 5 One can say therefore with a high degree of confidence (even with a very limited number of samples) that ALEC powder markedly reduces both the likelihood of adhesion formation and the length of the adhesions which do form. There is also evidence that a suspension of ALEC is more effective than either no treatment or treatment with dialysate.

Preferably the SAPL is used in the form of a dry powder aerial dispersion.

Phosphatidyl glycerol (PG) is believed to be capable of binding to the surface of the animal tissue and is, therefore, a preferred component of the SAPL. DipaIrffitoyl phosphatidyl choline (DPPC) may function also in this way and is also a preferred compound of the SAPL. PG has a finiher important function in 4 I- medicaments employed in the present invention which is its ability to cause the DPPC to form a dry powder. The particle size of such powders is not critical and the controlling factor is that the size is preferably such that medicament can be readily instilled into the surgical site. Generally, the particle size is within the range of 0.5 to 1 00im. Particles which are more readily conveyed in a gas stream have a particle size of from 0.5 to 20VLrri, preferably 0.5 to 1Ogm and more preferably 0. 5 to 2VwL Finely-divided dry powders of this kind are believed to be absorbed very rapidly onto the surfaces of mesothical membranes, i.e. bound to the epithelium. Preferably, the SAPL compositions employed in the present invention are blends of dipalmitoyl phosphatidyl choline (DPPC) and PG, although as indicated above, other phospholipids may be employed.

The medicament should generally be essentially free from animal protein in order to avoid the danger of patient sensitivity to animal proteins. Also, animal proteins may become adhesive and, for this reason, should preferably be excluded from the compositions.

DPPC is commercially available from Sigma Chemical Co. Ltd. or can be prepared synthetically by the use of acyl chlorides using the method of Baer & Bachrea - Can. J. Of Biochem. Physiol 1959; 37, page 953 and is available commercially from Sigma (London) Ltd. The PG may be prepared from egg phosphatidyl choline by the methods of Comfurions et al and Dawson, Biochem. Biophys Acta 1977; 488; pages 36-42 and Biochem J. 1947; 192; pages 205-210.

The medicaments employed in the present invention are generally finelydivided dry powders having a particle size distribution which is small enough to be introduced into the surgical site in a gas stream from a dispersion device. The material available commercially as 'Alec' has a particle size distribution such that a major proportion is between 0.5 and 2gm with a median particle diameter of about 1.2 gm. However, as mentioned above, larger particle size powders can be satisfactorily used in accordance with the invention. The medicament of the present invention may be introduced into the surgical site through a cannula, e.g. connected to a syringe.

However, we prefer to employ a dispersion device which utilises a propeflant. These may employ a propellant such as a halocarbon to form a gas stream and may include a tapered discharge nozzle, baffle or venturi to accelerate particles through a discharge nozzle. Suitable halocarbons include hydrolluorocarbons, hydrofluorochlorocarbons and fluorocldorocarbons having a low boiling point, such as those marketed by DuPont under the trade marks "Freon" and "SUVK'. Pharniaceutically acceptable hydro fluoroalkanes are available as BFA- 1 34a and 227.

One suitable design of dispensing device for administering the powdered material to a surgical site is shown in Figures 2 and 3 in which:- Figure 2 is a side elevation of the dispenser; and Figure 3 is a similar view, but shows its interior.

Referring to Figures 2 and 3, a casing (10) is formed from two plastic mouldings (12 & 13) which snap together to form a container for a pressurised canister (14) and a vial (15). Canister (14) contains a low boiling liquid, preferably a hydrofluorocarbon such as I1FA-134a or FEC227, under sufficient pressure to maintain the propellant liquid at normal room temperature. Vial (15) contains the powdered medicament, such as "Alec". Canister (14) has a release valve (16) which is received in a recess (17) so that finger pressure on the inverted end (18) of the canister will cause propellant to be released into a tube (19). Tube (19) is typically a hard plastics, e.g. pvc or polypropylene, tube of about 23 mm outside diameter and about 0.5 to 2 mm inside diameter. Tube (19) connects valve (16) with a fitting (20) and thence to a tube or needle (21) which extends into the vial (15). Vial(15)maybe closed with a rubber seal which is penetrated by the tube or needle (21) and self-seals around the tube or needle. A second needle or tube (22) extends part way into the vial through the rubber seal in the neck of the vial and connects with a fitting (23). Fitting (23) discharges into a catheter (4) from which the powder can be directed to the desired area of the surgical site. The advantage of the dispenser shown in Figures 2 and 3 is that it can be operated 'one-handed' while the doctor or nurse ensures that the catheter is correctly positioned to distribute powder into the surgical site. A 6 /I- catheter may not be necessary. The powder may simply be sprayed onto the area of the surgical wound.

in general, the DPPC and PG may be present in a weight ratio of from 9:1 to 1:9. Compositions employed in current formulations have been in the weight ratio of from about 6:4 to 82.

It is desirable that the SAPI, (or its active component) should not break down rapidly in the environment of the surgical wound. One of the factors which will reduce the life of a release fining or coating will be the presence of enzymes capable of digesting DPPC and/or PG. Such enzymes only attack the laevo rotatory (L) form, which constitutes the naturally occurring form. Therefore, the anti-adhesion medicament should preferably contain the dextro rotatory (D form) or at least comprise a racemic mixture which is obtained by synthetic preparation routes. This also applies to the other SAPL/s mentioned above.

As an alternative to use as a powder dispersion, the medicament may be used as a dispersion in an inert liquid, for example, in sterile saline, preferably isotonic saline, which is approximately 0.9% aqueous sodium chloride.

The SAPL may comprise phosphatidyl glycerol (PG) either alone or in admixture with other components. PG has a useful additional function of forn-dng very finely divided dispersions.

The SAPL may comprise dipalmitoyl phosphatidyl choline (DPPC) either alone or in admixture with other components such as PG.

In preferred embodiments the medicament is essentially free of animal protein to avoid patient sensitivity and also to aid the formation of finely divided particle.

When PG and DPPC are co-precipitated from a common solvent a fine powder is formed. At a weight ratio DPPC: PG of about 7:3 the mixture spreads rapidly at body temperature.

In general the weight ratio DPPC:PG lies in the range 9:1 to 1:9 preferably 6:4 to 8:1 7 It may be advantageous to include other active substances into the medicament, such as anti-fungal or anti-bacterial agents.

8

Claims (8)

1. The use of surface active phospholipids (SAPL) in the manufacture of a medicament for use in reducing the probability of adhesions following surgery.

2. A use as claimed in claim 1 wherein the SAPL is selected to bind to tissue at a surgical site.

3. A use as claimed in claim 1 or claim 2 wherein the SAPL is in powder form.

4. A use as claimed in claim 1 or claim 2 wherein the SAPL is a dispersion m aqueous saline.

A use as claimed in any one of the preceding claims wherein the SAPL comprises dipalmitoylphosphatidyl choline, (DPPC).

5.

6. A use as claimed in any one of the preceding claims wherein the SAPL comprises unsaturated phosphatidyl glycerol (PG).

7. A use as claimed in claim 5 wherein the SAPL comprises a mixture of DPPC and PG at a weight ratio of 1:9 to 9: 1.

8. A use as claimed in claim 7 wherein the weight ratio of DPPC: PG is 6:4 to 8:2.