Objective
We sought to evaluate postsurgical adhesions in women of different races with or without keloids.
Study Design
This was a prospective study evaluating postsurgical adhesions after a cesarean delivery in 429 women with or without keloids. The outcome measures were the prevalence and extent of adhesions in women of different races with or without keloids.
Results
There was no difference in the prevalence of adhesions and adhesion score in various sites among women of different races. Compared with whites (0.5%), keloids were significantly more common in African Americans (7.1%; P = .007; odds ratio, 16.5) and in Asians (5.2%; P = .02; odds ratio, 11.9). Women with keloids were found to have more dense adhesions between the uterus and the bladder ( P = .028; 95% confidence interval, 0–12) and between the uterus and the anterior abdominal wall ( P < .0001; 95% confidence interval, 8–12).
Conclusion
The prevalence and degree of postsurgical adhesions in women of different races are comparable. Women with keloids on the cesarean scar have increased adhesions between the uterus and the bladder and between the uterus and the abdominal wall.
Keloids are an overgrowth of dense fibrous tissue, usually at the site of a healed skin wound. Unlike hypertrophic scars, keloids extend beyond the borders of the original injury. Keloids develop less commonly in whites than in African Americans. Similar to postsurgical adhesions, they do not regress spontaneously and tend to recur after excision. In addition, keloids display a histologic similarity with intraperitoneal adhesions. There is also excess production and deposition of extracellular matrix, such as collagens, in keloids, as well as in adhesions. Compared to normal tissue, they express a number of genes that regulate cell growth and apoptosis, inflammation, angiogenesis, and tissue turnover. Despite the similarities between keloids and postsurgical adhesions, there has not been any clinical study evaluating their relationship.
The purpose of our study was to examine the prevalence and extent of adhesions in women of different races with or without keloids.
Materials and Methods
We conducted a prospective study evaluating postsurgical adhesions after a cesarean delivery in 429 women with or without keloids in 2008 through 2009 at the Sir Mortimer B. Davis Jewish General Hospital, a McGill University teaching hospital in Montreal. All patients underwent the second cesarean within 1-2 years after the primary surgery. We excluded patients who had had a laparotomy other than a cesarean, >1 previous cesarean, cesarean with classic or T incision, pelvic infection, adhesions at primary surgery, or endometriosis stage III or IV. The research and ethics board of the hospital approved the study entitled “Adhesion development and morbidity after repeat cesarean delivery.”
The site and nature of adhesions were evaluated at the second cesarean delivery using an adhesion scoring system ( Table 1 ). The degree of enclosure referred to the part of the previous cesarean scar that was covered by adhesions. The outcome measures were the prevalence and extent of adhesions. We also evaluated the relationship among racial origin, keloids, and adhesions. Thick operation scars that did not extend beyond the original injury were not considered as keloids.
| Adhesions | Consistency of adhesions | None | 1/3 enclosure | 1/3-2/3 enclosure | >2/3 enclosure |
|---|---|---|---|---|---|
| Between uterus and bladder | Filmy | 0 | 1 | 2 | 4 |
| Dense | 0 | 4 | 8 | 16 | |
| Between uterus and abdominal wall | Filmy | 0 | 1 | 2 | 4 |
| Dense | 0 | 4 | 8 | 16 | |
| Between uterus and intestine | Filmy | 0 | 1 | 2 | 4 |
| Dense | 0 | 4 | 8 | 16 | |
| Between uterus and omentum | Filmy | 0 | 1 | 2 | 4 |
| Dense | 0 | 4 | 8 | 16 |
The normality of data distribution was tested using the Shapiro-Wilks test. For continuous variables, inferential testing was conducted using the Student t test for normally distributed data and Mann-Whitney test for skewed data. Proportions were compared using χ 2 test or Fisher’s exact test when appropriate. The differences were considered to be statistically significant if P was < .05.
Results
Of 429 women, 218 women were white; 77, Asian; 56, African American; 62, Hispanic; and 16, of mixed race. There was no difference in the prevalence of adhesions and adhesion score in various sites among women of different races ( Table 2 ).
| Variable | Whites | Asians | African Americans | Hispanics | P value | ||||
|---|---|---|---|---|---|---|---|---|---|
| No. | 218 | 77 | 56 | 62 | |||||
| Age, y | 35.0 ± 4.1 | 36.1 ± 3.9 | 33.6 ± 4.8 | 32.4 ± 5.7 | |||||
| Adhesions | Adhesions, n (%) | Adhesion score | Adhesions, n (%) | Adhesion score | Adhesions, n (%) | Adhesion score | Adhesions, n (%) | Adhesion score | |
| Uterus and bladder | |||||||||
| Filmy | 124 (56.9) | 1 (1-4) | 45 (58.4) | 1 (1-4) | 35 (62.5) | 1 (1-4) | 27 (43.5) | 1 (1-4) | NS |
| Dense | 66 (30.3) | 8 (4-16) | 23 (29.9) | 4 (4-16) | 18 (32.1) | 8 (4-16) | 18 (29.0) | 4 (4-16) | NS |
| Uterus and abdominal wall | |||||||||
| Filmy | 80 (36.7) | 1 (1-4) | 26 (33.8) | 1 (1-4) | 21 (37.5) | 1 (1-2) | 18 (29.0) | 2 (1-4) | NS |
| Dense | 59 (27.1) | 4 (1-16) | 20 (26.0) | 6 (4-16) | 17 (20.4) | 8 (4-16) | 11 (17.7) | 8 (4-8) | NS |
| Uterus and intestines | |||||||||
| Filmy | 24 (11.0) | 1 (1-2) | 7 (9.1) | 1 (1-2) | 16 (28.6) | 1 (1-4) | 6 (9.7) | 1 (1-1) | < .001 whites vs African Americans; = .007 Asians vs African Americans |
| Dense | 8 (3.7) | 4 (4-8) | 4 (5.2) | 8 (4-8) | 6 (10.7) | 12 (4-16) | 2 (3.2) | 4 (4-4) | NS |
| Uterus and omentum | |||||||||
| Filmy | 42 (19.3) | 1 (1-4) | 17 (22.1) | 1 (1-2) | 16 (28.6) | 1 (1-4) | 8 (12.9) | 1 (1-2) | NS |
| Dense | 30 (13.8) | 4 (4-8) | 5 (6.5) | 8 (4-8) | 16 (28.6) | 6 (4-16) | 3 (4.8) | 4 (4-4) | < .05 whites vs Hispanics; = .001 Asians vs African Americans; < .001 Asians vs Hispanics |
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