Thursday, January 04, 2007

About adhesions

Adhesions are a type of scar tissue that forms a connection between two organs or surfaces that are normally separate in the body. Adhesions are sometimes associated with endometriosis and pelvic inflammatory disease, and often form after abdominal or pelvic surgery. Over 93% of patients who have had one or more procedures may have adhesions.
Why adhesions form after surgery is not well understood, but the trauma of tissue handling during surgery is a key factor. Even the most delicate surgical techniques, like the use of very fine sutures, can injure the peritoneal surface. This normally smooth surface covers most of the internal organs and walls of the abdomen and pelvis.

During surgery, bleeding often occurs. This free blood and plasma form filmy strands of fibrin between tissues in as little as three hours. These delicate bridges often mature within days into permanent tissue bands. The bands interfere with normal organ function and can lead to serious complications.
Patient PerspectiveAdhesions are quite common, and form in as many as 60 to more than 90 % of women undergoing gynecologic surgery. They commonly form in the pelvis or abdomen, and often involve the ovaries, pelvic sidewall, and/or intestines. When present, adhesions can prevent the normal orientation or movement of organs in the pelvis or abdomen. This restriction can cause chronic pelvic pain, infertility, urinary tract problems, sexual dysfunction, and bowel obstruction. Oncethe adhesions form, the risk of suffering from one or more of these associated problems is life-long 1-5.
Physician Perspective In spite of careful surgical techniques to minimize trauma, complications from post-surgical adhesions remain a significant problem 1, 2, 5-10. It has been estimated that the presence of pelvic or abdominal adhesions may prolong subsequent abdomino-pelvic surgeries by an average of 24 minutes, having been reported to extend OR time by as much as 17 hours 11, 12. Adhesions may also necessitate any subsequent procedures to convert from laparoscopic to open, and have been associated with inadvertent enterotomy, resulting in the attendant higher complication rates associated with bowel perforation 12-16. It is obvious that prevention of post-surgical adhesions has a direct bearing on improved patient outcomes.
Hospital Perspective The incidence of adhesion-related complications is high and well-recognized. The annual economic costs for adhesiolysis alone have been conservatively estimated to be $1.3 billion in the US, and that figure only includes hospitalization and surgeon fees - excluding laboratory tests, radiology, and other medical management that would normally be associated with such treatment 10. This figure also does not include management and treatment for the 60 to 70 % of small bowel obstructions acknowledged to result from adhesions, or the cost of any outpatient medical care, which for chronic pain alone has been estimated to be over $800 million per year 6, 17. Adhesiolysis has been shown to increase the time for surgical procedures by an average of 24 minutes 11, and the adhesiolysis procedure itself carries a 19% increased risk of iatrogenic enterotomy 14. A very large retrospective analysis conducted in the UK revealed that 50% of hospital admissions for adhesion-related problems are actually re-admissions for complications due to adhesions 5, 8, 9. Therefore, reducing the incidence of post-surgical adhesions will improve patient outcomes while reducing healthcare costs.
References 1. Monk, B. J., Berman, M. L. and Montz, F. J. Adhesions after extensive gynecologic surgery: clinical significance, etiology and prevention. Am J Obstet Gynecol 170: 1396-1403, 1994.2. Diamond, M. P., et al. Adhesion reformation and de novo adhesion formation after reproductive pelvic surgery. Fertil Steril 47: 864-866, 1987.3. Diamond, M. P. and DeCherney, A. H. Pathogenesis of adhesion formation/reformation: application to reproductive pelvic surgery. Microsurgery 8: 103-107, 1987.4. Stricker, B., Blanco, J. and Fox, H. E.. The gynecologic contribution to intestinal obstruction in females. J Am Coll Surg 178: 617-620, 1994.5. Lower, A. M., et al. The impact of adhesions on hospital readmissions over ten years after 8849 open gynecological operations: an assessment from the Surgical and Clinical Adhesions Research Study. Bjog 107: 855-862, 2000.6. Ellis, H. The clinical significance of adhesion: focus on intestinal obstruction Eur. J. Surg. 163 (Suppl 557) 5-9, 1997.7. Ellis, H. The magnitude of adhesion related problems. Ann Chir Gynaecol 87: 9-11, 1998.8. Ellis, H., et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study [see comments]. Lancet 353: 1476-1480, 1999.9. Parker MC, Postoperative adhesions: ten year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum 2001; 44: 822-830.10. Ray, N. F., et al. Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994. K Am Coll Surg 186: 1-9, 1998.11. Coleman, M. G., McLain, A. D., and Moran, B., J. The impact of previous surgery in the time it takes for incision and division of adhesions during laparotomy. Dis. Colon Rectum in press.12. Presented at the Department of Health and Human Services, Food and Drug Administration Center for Devices and Radiological Health: Obstetrics and Gynecology Devices Panel. Bethesda, MD. January 25, 2000. 13. Svigetvari, I., et al. Association of previous abdominal surgery and significant adhesions in laparoscopic sterilization patients. J Reprod Med 34: 465-466, 1989.14. Van Der Krabben, et al. Morbidity and mortality of inadvertent enerotomy during adhesiotomy. Br J Surg 87: 467-471, 2000.15. Alwan, M. H., van Rij, A. M. and Grieg, S. F. Postoperative adhesive small bowel obstruction: the resources impacts. N Z Med J 112: 421-423, 1999.16. Holmadahl, L. and Risberg, B. Adhesions: Prevention and complications in general surgery. Eur. J. Surg. 163: 169-174, 1997.17. Matthias S, et al. Chronic pelvic pain:prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996; 87: 321-7.

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