Showing posts with label las adherencias. Show all posts
Showing posts with label las adherencias. Show all posts
Thursday, February 02, 2012
Wednesday, December 28, 2011
CONFLUENT SPRAYSHIELD MAUDE Adverse Event Report
Another one!
CONFLUENT SPRAYSHIELD POLYMER KIT WITH SPRAYER SPRAYSHIELD KIT
Catalog Number SP10S01
Event Date 01/21/2011
Event Type Injury Patient Outcome Other;
Manufacturer Narrative
(b)(4).
Event Description
According to the reporter: the pt experienced heavy underbelly pains two days post-operatively. The pains were described as burning. At the fourth post-operative day, the stomach had to be re-opened. There were syrinxes that were discovered where the product had been applied, which were operated upon. The pt was released from the hospital free of pain.
Search Alerts/Recalls
New Search | Submit an Adverse Event Report
Brand Name SPRAYSHIELD POLYMER KIT WITH SPRAYER
Type of Device SPRAYSHIELD KIT
Manufacturer (Section F) CONFLUENT
101a first ave.
waltham MA 02451
Manufacturer (Section D) CONFLUENT
101a first ave.
waltham MA 02451
Manufacturer (Section G) CONFLUENT
101a first ave.
waltham MA 02451
Manufacturer Contact terry callahan
60 middletown ave.
north haven , CT 06473
(203) 492 -6273
Device Event Key 2070451
MDR Report Key 2037782
Event Key 1934758
Report Number 3003157248-2011-00007
Device Sequence Number 1
Product Code NQR
Report Source Manufacturer
Source Type Health Professional,User facility
Reporter Occupation Other
Type of Report Initial
Report Date 01/24/2011
1 Device Was Involved in the Event
1 Patient Was Involved in the Event
Date FDA Received 03/23/2011
Is This An Adverse Event Report? Yes
Is This A Product Problem Report? Yes
Device Operator Health Professional
Device Catalogue Number SP10S01
Was Device Available For Evaluation? No
Is The Reporter A Health Professional? Yes
Was The Report Sent To Manufacturer? No
Date Manufacturer Received 01/24/2011
Was Device Evaluated By Manufacturer? Device Not Returned To Manufacturer
Is The Device Single Use? Yes
Is the Device an Implant? No
Is this an Explanted Device?
Type of Device Usage Unkown
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=2037782
CONFLUENT SPRAYSHIELD POLYMER KIT WITH SPRAYER SPRAYSHIELD KIT
Catalog Number SP10S01
Event Date 01/21/2011
Event Type Injury Patient Outcome Other;
Manufacturer Narrative
(b)(4).
Event Description
According to the reporter: the pt experienced heavy underbelly pains two days post-operatively. The pains were described as burning. At the fourth post-operative day, the stomach had to be re-opened. There were syrinxes that were discovered where the product had been applied, which were operated upon. The pt was released from the hospital free of pain.
Search Alerts/Recalls
New Search | Submit an Adverse Event Report
Brand Name SPRAYSHIELD POLYMER KIT WITH SPRAYER
Type of Device SPRAYSHIELD KIT
Manufacturer (Section F) CONFLUENT
101a first ave.
waltham MA 02451
Manufacturer (Section D) CONFLUENT
101a first ave.
waltham MA 02451
Manufacturer (Section G) CONFLUENT
101a first ave.
waltham MA 02451
Manufacturer Contact terry callahan
60 middletown ave.
north haven , CT 06473
(203) 492 -6273
Device Event Key 2070451
MDR Report Key 2037782
Event Key 1934758
Report Number 3003157248-2011-00007
Device Sequence Number 1
Product Code NQR
Report Source Manufacturer
Source Type Health Professional,User facility
Reporter Occupation Other
Type of Report Initial
Report Date 01/24/2011
1 Device Was Involved in the Event
1 Patient Was Involved in the Event
Date FDA Received 03/23/2011
Is This An Adverse Event Report? Yes
Is This A Product Problem Report? Yes
Device Operator Health Professional
Device Catalogue Number SP10S01
Was Device Available For Evaluation? No
Is The Reporter A Health Professional? Yes
Was The Report Sent To Manufacturer? No
Date Manufacturer Received 01/24/2011
Was Device Evaluated By Manufacturer? Device Not Returned To Manufacturer
Is The Device Single Use? Yes
Is the Device an Implant? No
Is this an Explanted Device?
Type of Device Usage Unkown
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=2037782
Tuesday, November 08, 2011
Diagnosis and management of chronic radiation enteritis
Diagnosis and management of chronic radiation enteritis
http://www.aboutcancer.com/radiation_enteritis_utd_807.htm
INTRODUCTION — Chronic radiation enteritis is a complication of radiation therapy for cancer, most commonly for rectal, prostate and pelvic malignancies. It can affect both the large and small intestine, is often progressive, and may lead to a variety of clinical consequences (such as diarrhea, nausea, weight loss, abdominal pain, intestinal obstruction, and perforation) depending upon the extent of the injury. It usually develops six or more months after radiation therapy (mean approximately 5 years, range two months to as long as 30 years. This contrasts with the timing of acute radiation enteritis (characterized by diarrhea and abdominal pain), which develops during or shortly after radiation therapy and resolves within two to six weeks.
The incidence has not been well defined, in part because of the large number of patients who died or were lost to follow-up in major studies involving radiation therapy, and because of the variability in the field size and dose of radiation. One literature review estimated that the incidence ranged from 1.2 to as high as 15 percent in patients with rectal cancer
This topic review will focus on the diagnosis and management of chronic radiation injury to the small intestines and proximal colon. Issues related to the prevention and treatment of chronic radiation proctitis (usually encountered following treatment of cancers of the rectum, cervix, uterus, prostate, urinary bladder, and testes) are presented separately.
PATHOGENESIS — Chronic radiation enteritis usually develops only after large doses of radiation therapy have been delivered (4500 to 5500 cGY); it is uncommon at lower doses. In addition to the dose of radiation, several other predisposing conditions have been described including:
Older age
Combined chemotherapy
Poor radiation technique
Postoperative radiation; in this setting, bowel loops fixed together by adhesions may prolapse into the pelvis, leading them to receive excessive radiation exposure. Adhesions due to past surgical procedures can have the same effect.
Intestinal injury is believed to be related to oxidative damage caused by the formation of free radicals. The end result is an obliterative endarteritis that leads to intestinal ischemia resulting in stricturing with ulceration and fibrosis and occasionally fistula formation. The physiologic consequences may include altered intestinal transit, reduced bile acid absorption, increased intestinal permeability, bacterial overgrowth and lactose malabsorption The resulting clinical manifestations may include nausea, vomiting, lactose intolerance, obstructive symptoms, diarrhea, weight loss, malnutrition, and bleeding (usually in patients with colonic involvement).
The prominent histopathologic features are those of an occlusive vasculitis with diffuse collagen deposition and fibrosis. The arteriolar walls may show a hyaline ring-like thickening and large foams cells beneath the intima. Mucosal ulceration, necrosis and perforation may develop as the disease progresses. Progressive fibrosis leads to stricturing with dilation of proximal segments. The intestinal segments and their associated serosa appear grossly thickened. Telangiectasias may be seen.
The precise mechanisms leading from oxidative damage to the histologic and morphologic abnormalities described above are incompletely understood. Several theories have been proposed, all of which are probably interrelated:
One model suggests that fibrosis develops from the initial mucosal injury
Another theory suggests that fibrosis develops in connective tissues where radiation has caused a decrease in cell turnover and a low rate of proliferation.
A third model focuses on the cellular responses to vascular damage caused by paracrine mediators. The signals leading to the developing of fibrosis are a topic of intensive ongoing investigation.
One study found that intestinal webs forming after radiation therapy demonstrated an impaired vasodilatory response in vitro to acetylcholine treatment. This microvascular dysfunction may lead to the formation of the abnormal tissue response seen in the wall of the intestine post-radiation therapy.
CLINICAL MANIFESTATIONS — The classical features of radiation enteritis are abdominal pain, nausea, vomiting, and diarrhea. Patients with severe disease may develop intermittent, partial, or complete small bowel obstruction
As noted above, bacterial overgrowth may lead to malabsorption and contribute to the nausea, abdominal pain and diarrhea. Bacterial overgrowth should be suspected in patients with intestinal strictures. Another clue may be the development of new lactose intolerance. Nonspecific symptoms include diarrhea, bloating, excessive gas, borborygmi, and nausea. Most such patients have only subtle laboratory or clinical findings pointing toward the diagnosis; thus a high index of suspicion is required. Rare patients with severe malabsorption may present with a more fulminant clinical and laboratory profile
DIAGNOSIS — The diagnosis is usually established by suggestive radiologic findings in patients with compatible clinical features who have a history of prior radiation exposure. The patient's previous radiation treatment record should be reviewed to determine the total dose and distribution of the radiation field. This may help to determine which intestinal segments may have received excessive radiation exposure, information that can be correlated with the radiologic findings and the clinical presentation.
We usually obtain an abdominal CT scan followed by an upper gastrointestinal series with small bowel follow through in patients with suspected small bowel disease. Additional imaging is reserved for patients in whom the diagnosis remains unclear. We generally perform a colonoscopy in patients with suspected colonic involvement.
Upper gastrointestinal series — An upper gastrointestinal series with small bowel follow-through is a useful initial test for evaluating the extent of disease although it is not as sensitive as enteroclysis.
Enteroclysis — Enteroclysis involves the instillation of contrast material (usually administered through a nasoenteric tube) into the small bowel using a pump (making it considerably less comfortable than a standard small bowel follow-through). It provides more detailed visualization of the small bowel compared with a standard upper gastrointestinal series. Suggestive findings include submucosal thickening, single or multiple stenoses, adhesions, and sinus or fistula formation. Its sensitivity and specificity for radiation enteritis have not been well-defined.
CT scan — Computed tomography may show thickening of bowel segments, but the findings are nonspecific. CT may be helpful in narrowing the differential diagnosis, particularly in distinguishing strictures due to radiation enteritis from those arising from abdominal metastases or a local recurrence
CT enteroclysis (in which a CT is performed after instilling contrast into the intestine using a nasoenteric tube) produces superior bowel opacification compared with conventional CT, and may therefore be useful for identifying low-grade or intermittent obstruction (reported sensitivity and specificity of approximately 88 and 82 percent, respectively). However, the technique is still used only in a few specialized centers. Similarly, other improvements in CT imaging of the small bowel (such as three-dimensional imaging) will likely also have a role in diagnosis of radiation enteritis but are not yet widely available
Magnetic resonance enteroclysis — Magnetic resonance enteroclysis permits visualization of the small bowel using similar principles as described above for CT enteroclysis. Initial studies suggest the results are comparable to (and possibly more sensitive than) CT enteroclysis. However, only small numbers of patients have been studied and the technique is not yet widely available.
Enteroscopy — Enteroscopy (peroral endoscopy of the small bowel using specialized endoscopes) has a limited role in the diagnosis of radiation enteritis although it may help to narrow the differential diagnosis. Enteroclysis can be performed following enteroscopy by leaving a tube inserted in the intestine upon withdrawal of the enteroscope.
Capsule endoscopy — There is no published experience with capsule endoscopy specifically for diagnosing radiation enteritis, although there is some clinical experience. However, it should probably not be performed in patients in whom there is a strong clinical suspicion for radiation enteritis because the capsule may become lodged in a strictured segment, requiring surgical removal.
Colonoscopy — Colonoscopy is helpful in evaluating colonic involvement and can also visualize the terminal ileum. Mucosal features consistent with radiation injury include pallor with friability and telangiectasias, which can be multiple, large, and serpiginous; these changes tend to be continuous. Although mucosal biopsies are not diagnostic, they can help to exclude other causes of proctitis such as infection or inflammatory bowel disease.
DIFFERENTIAL DIAGNOSIS — The differential diagnosis of chronic radiation enteritis is broad. Other diagnostic possibilities include post-surgical adhesions, malabsorption syndromes, abdominal metastases, lymphoma, Crohn's disease, infectious, ischemic or ulcerative colitis, and intestinal pseudo-obstruction.
MEDICAL MANAGEMENT — Prevention is the key to avoiding chronic radiation enteritis. Once established, treatment should be as conservative as possible focusing on relief of symptoms. Experience with specific medical treatments has been derived largely from small clinical trials and case series. Approaches used to treat small bowel disease will be summarized below while specific treatments aimed at radiation proctitis are discussed separately.
Dietary recommendations — There does not appear to be a clear-cut diet that reliably alleviates symptoms. A high fiber diet should probably not be recommended specifically since it may worsen diarrhea and urgency. Some patients may develop lactose intolerance, which may be due to bacterial overgrowth, and may improve following antibiotic treatment (see below). Others may require avoidance of lactose. Enteral formulas supplemented with glutamine may have a benefit but studies are limited
Antidiarrheal agents — Judicious use of antidiarrheal agents (such as loperamide) can help improve diarrhea, although it should not be used in patients with suspected small or large bowel obstruction. The efficacy of loperamide was evaluated in a crossover trial involving 18 patients with diarrhea due to radiation enteritis who were randomly assigned to loperamide or placebo for 14 days separated by a 14 day washout period. Loperamide was associated with a significant reduction in the frequency of bowel movements, slower intestinal transit, and improvement in the absorption of bile acids.
Antibiotics — Antibiotics may reduce symptoms in patients in whom bacterial overgrowth has developed. Specific testing for bacterial overgrowth is preferable to empiric therapy. A major drawback to empiric therapy is that treatment may require more than one antibiotic, and repeated and sometimes cyclic treatment. Because antibiotics may be associated with adverse effects, some of which may mimic symptoms of bacterial overgrowth (such as diarrhea and abdominal discomfort), establishing a firm diagnosis is important. This can usually be accomplished with a breath test.
5-ASA drugs — A case report (published nearly three decades ago) suggested a possible benefit from sulfasalazine with or without oral prednisone. There is no large published experience with either of these drugs. Discordant results have been obtained from controlled clinical trials evaluating mesalazine or sulfasalazine in the prevention of acute radiation enteritis
Hyperbaric oxygen — HBO has been used for treatment of refractory foot ulcers in diabetes and in other conditions [39]. The theoretical benefit of hyperbaric oxygen therapy (HBO) may be via inhibition of bacterial growth [40], preservation of marginally perfused tissue, and inhibition of toxin production [41].
A benefit in chronic radiation enteritis was suggested in a case report of a patient in whom 20 treatments over a one month period brought about objective improvements in symptoms and absorption of D-xylose. However, this anecdote did not give the results of long-term follow-up. Other reports have also suggested a benefit for patients with chronic radiation proctitis.
The equipment needed for hyperbaric oxygen treatment is expensive and not widely available. Thus, at the present time, it is not a practical means of treating chronic radiation enteritis outside of centers specializing in this approach, particularly since its effectiveness has not been well-studied.
Parenteral nutrition — A mainstay of the medical therapy of severe chronic radiation enteritis has been total parenteral nutrition (TPN), the success of which is similar for other intestinal disorders requiring TPN. One of the largest series included 54 patients who required home TPN mostly because of intestinal obstruction (27 patients), short bowel syndrome (17 patients), malabsorption (five patients), fistula formation (three patients), and dysmotility (two patients). TPN was initiated a median of 20 months after radiation therapy and was administered for a median of 20 months. Cumulative 5-year survival was 64 percent. Most early deaths were due to recurrent cancer. Similar survival estimates were reached in other series .
SURGERY — As noted above, surgery for radiation enteritis should be avoided if possible because of several inherent difficulties in operating on patients with chronic radiation injury
Diffuse fibrosis and adhesions between bowel loops can make resection technically challenging.
The risk of a leak is high when creating an anastomosis between irradiated tissues. Furthermore, it can be difficult to distinguish healthy tissue for irradiated tissue by gross inspection alone; intraoperative endoscopy may be helpful in this setting, but experienced is limited.
Extensive resection may be required, potentially leading to short bowel syndrome.
Despite attempts at conservative management, approximately one-third of patients progress to the point where surgery is required. Most surgical series of patients treated for radiation enteritis are small; the most common indications for surgery have been persistent ileus, intestinal fistulization, and massive adhesions. Surgical mortality rates are as high as 10 to 22 percent and many patients require more than one laparotomy
An illustrative series focused on 109 patients who underwent surgery during a 10 year period. Five patients died postoperatively (all of whom had undergone resection) while 33 (30 percent) had postoperative complications. Complications were more likely in patients who underwent emergency surgery. Repeat surgery was required in 40 percent of patients during a 40 month follow-up period. Overall survival in patients without a cancer recurrence was 85 percent at year one, and 69 percent at year five.
Strictureplasty may offer a less invasive approach to the management of strictures, but experience is limited. The role of small bowel transplantation in this setting is still being determined; its role, if any, will probably be only in children
SUMMARY AND RECOMMENDATIONS — Chronic radiation enteritis may lead to a variety of clinical consequences (such as diarrhea, nausea, weight loss, abdominal pain, intestinal obstruction and perforation) depending upon the extent of the injury. It usually develops six or more months after radiation therapy (mean approximately 5 years, range two months to as long as 30 years).
The diagnosis is usually established by suggestive radiologic findings in patients with compatible clinical features who have a history of prior radiation exposure. The patient's previous radiation treatment record should be reviewed to determine the total dose and distribution of the radiation field. This may help to determine which intestinal segments may have received excessive radiation exposure, information that can be correlated with the radiologic findings and the clinical presentation. We usually obtain an abdominal CT scan and an upper gastrointestinal series with small bowel follow-through. Further testing with an enteroclysis (standard, CT, or MRI depending upon local expertise) can be performed if the above is unrevealing and clinical suspicion remains.
Management should be conservative, addressing the predominant symptoms.
Patients with diarrhea, abdominal pain, nausea or bloating should undergo breath testing for bacterial overgrowth and treated with antibiotics if bacterial overgrowth is confirmed. Avoidance of lactose may benefit other patients while antidiarrheal agents (such as loperamide) may also be helpful. Loperamide should be avoided in patients with obstructive symptoms.
Patients with intermittent obstructive symptoms may benefit from a low residue diet, although dietary tolerance is variable. Radiologic evaluation may help to identify the strictured segment, information which may be critical should strictureplasty or surgery be ultimately required. The narrowed segment may not always be visible with an upper gastrointestinal series, particularly in patients with intermittent symptoms. Such patients may require enteroclysis as described above.
Despite conservative measures, surgery will be required in approximately 30 percent of patients. This is usually due to persistent ileus, intestinal fistulization, and massive adhesions.
Prognosis is variable since the disease is progressive. Early mortality is usually due to cancer recurrence. Five-year survival is approximately 70 percent in those without cancer recurrence, although many patients continue to have troubling digestive symptoms for the remainder of their lives.
Intensive, ongoing research on mechanisms related to fibrogenesis may eventually produce effective means to prevent or reverse disease progression once it has been established. However, at the present time, prevention during radiation therapy is central to reducing the risk of developing chronic radiation enteritis.
http://www.aboutcancer.com/radiation_enteritis_utd_807.htm
INTRODUCTION — Chronic radiation enteritis is a complication of radiation therapy for cancer, most commonly for rectal, prostate and pelvic malignancies. It can affect both the large and small intestine, is often progressive, and may lead to a variety of clinical consequences (such as diarrhea, nausea, weight loss, abdominal pain, intestinal obstruction, and perforation) depending upon the extent of the injury. It usually develops six or more months after radiation therapy (mean approximately 5 years, range two months to as long as 30 years. This contrasts with the timing of acute radiation enteritis (characterized by diarrhea and abdominal pain), which develops during or shortly after radiation therapy and resolves within two to six weeks.
The incidence has not been well defined, in part because of the large number of patients who died or were lost to follow-up in major studies involving radiation therapy, and because of the variability in the field size and dose of radiation. One literature review estimated that the incidence ranged from 1.2 to as high as 15 percent in patients with rectal cancer
This topic review will focus on the diagnosis and management of chronic radiation injury to the small intestines and proximal colon. Issues related to the prevention and treatment of chronic radiation proctitis (usually encountered following treatment of cancers of the rectum, cervix, uterus, prostate, urinary bladder, and testes) are presented separately.
PATHOGENESIS — Chronic radiation enteritis usually develops only after large doses of radiation therapy have been delivered (4500 to 5500 cGY); it is uncommon at lower doses. In addition to the dose of radiation, several other predisposing conditions have been described including:
Older age
Combined chemotherapy
Poor radiation technique
Postoperative radiation; in this setting, bowel loops fixed together by adhesions may prolapse into the pelvis, leading them to receive excessive radiation exposure. Adhesions due to past surgical procedures can have the same effect.
Intestinal injury is believed to be related to oxidative damage caused by the formation of free radicals. The end result is an obliterative endarteritis that leads to intestinal ischemia resulting in stricturing with ulceration and fibrosis and occasionally fistula formation. The physiologic consequences may include altered intestinal transit, reduced bile acid absorption, increased intestinal permeability, bacterial overgrowth and lactose malabsorption The resulting clinical manifestations may include nausea, vomiting, lactose intolerance, obstructive symptoms, diarrhea, weight loss, malnutrition, and bleeding (usually in patients with colonic involvement).
The prominent histopathologic features are those of an occlusive vasculitis with diffuse collagen deposition and fibrosis. The arteriolar walls may show a hyaline ring-like thickening and large foams cells beneath the intima. Mucosal ulceration, necrosis and perforation may develop as the disease progresses. Progressive fibrosis leads to stricturing with dilation of proximal segments. The intestinal segments and their associated serosa appear grossly thickened. Telangiectasias may be seen.
The precise mechanisms leading from oxidative damage to the histologic and morphologic abnormalities described above are incompletely understood. Several theories have been proposed, all of which are probably interrelated:
One model suggests that fibrosis develops from the initial mucosal injury
Another theory suggests that fibrosis develops in connective tissues where radiation has caused a decrease in cell turnover and a low rate of proliferation.
A third model focuses on the cellular responses to vascular damage caused by paracrine mediators. The signals leading to the developing of fibrosis are a topic of intensive ongoing investigation.
One study found that intestinal webs forming after radiation therapy demonstrated an impaired vasodilatory response in vitro to acetylcholine treatment. This microvascular dysfunction may lead to the formation of the abnormal tissue response seen in the wall of the intestine post-radiation therapy.
CLINICAL MANIFESTATIONS — The classical features of radiation enteritis are abdominal pain, nausea, vomiting, and diarrhea. Patients with severe disease may develop intermittent, partial, or complete small bowel obstruction
As noted above, bacterial overgrowth may lead to malabsorption and contribute to the nausea, abdominal pain and diarrhea. Bacterial overgrowth should be suspected in patients with intestinal strictures. Another clue may be the development of new lactose intolerance. Nonspecific symptoms include diarrhea, bloating, excessive gas, borborygmi, and nausea. Most such patients have only subtle laboratory or clinical findings pointing toward the diagnosis; thus a high index of suspicion is required. Rare patients with severe malabsorption may present with a more fulminant clinical and laboratory profile
DIAGNOSIS — The diagnosis is usually established by suggestive radiologic findings in patients with compatible clinical features who have a history of prior radiation exposure. The patient's previous radiation treatment record should be reviewed to determine the total dose and distribution of the radiation field. This may help to determine which intestinal segments may have received excessive radiation exposure, information that can be correlated with the radiologic findings and the clinical presentation.
We usually obtain an abdominal CT scan followed by an upper gastrointestinal series with small bowel follow through in patients with suspected small bowel disease. Additional imaging is reserved for patients in whom the diagnosis remains unclear. We generally perform a colonoscopy in patients with suspected colonic involvement.
Upper gastrointestinal series — An upper gastrointestinal series with small bowel follow-through is a useful initial test for evaluating the extent of disease although it is not as sensitive as enteroclysis.
Enteroclysis — Enteroclysis involves the instillation of contrast material (usually administered through a nasoenteric tube) into the small bowel using a pump (making it considerably less comfortable than a standard small bowel follow-through). It provides more detailed visualization of the small bowel compared with a standard upper gastrointestinal series. Suggestive findings include submucosal thickening, single or multiple stenoses, adhesions, and sinus or fistula formation. Its sensitivity and specificity for radiation enteritis have not been well-defined.
CT scan — Computed tomography may show thickening of bowel segments, but the findings are nonspecific. CT may be helpful in narrowing the differential diagnosis, particularly in distinguishing strictures due to radiation enteritis from those arising from abdominal metastases or a local recurrence
CT enteroclysis (in which a CT is performed after instilling contrast into the intestine using a nasoenteric tube) produces superior bowel opacification compared with conventional CT, and may therefore be useful for identifying low-grade or intermittent obstruction (reported sensitivity and specificity of approximately 88 and 82 percent, respectively). However, the technique is still used only in a few specialized centers. Similarly, other improvements in CT imaging of the small bowel (such as three-dimensional imaging) will likely also have a role in diagnosis of radiation enteritis but are not yet widely available
Magnetic resonance enteroclysis — Magnetic resonance enteroclysis permits visualization of the small bowel using similar principles as described above for CT enteroclysis. Initial studies suggest the results are comparable to (and possibly more sensitive than) CT enteroclysis. However, only small numbers of patients have been studied and the technique is not yet widely available.
Enteroscopy — Enteroscopy (peroral endoscopy of the small bowel using specialized endoscopes) has a limited role in the diagnosis of radiation enteritis although it may help to narrow the differential diagnosis. Enteroclysis can be performed following enteroscopy by leaving a tube inserted in the intestine upon withdrawal of the enteroscope.
Capsule endoscopy — There is no published experience with capsule endoscopy specifically for diagnosing radiation enteritis, although there is some clinical experience. However, it should probably not be performed in patients in whom there is a strong clinical suspicion for radiation enteritis because the capsule may become lodged in a strictured segment, requiring surgical removal.
Colonoscopy — Colonoscopy is helpful in evaluating colonic involvement and can also visualize the terminal ileum. Mucosal features consistent with radiation injury include pallor with friability and telangiectasias, which can be multiple, large, and serpiginous; these changes tend to be continuous. Although mucosal biopsies are not diagnostic, they can help to exclude other causes of proctitis such as infection or inflammatory bowel disease.
DIFFERENTIAL DIAGNOSIS — The differential diagnosis of chronic radiation enteritis is broad. Other diagnostic possibilities include post-surgical adhesions, malabsorption syndromes, abdominal metastases, lymphoma, Crohn's disease, infectious, ischemic or ulcerative colitis, and intestinal pseudo-obstruction.
MEDICAL MANAGEMENT — Prevention is the key to avoiding chronic radiation enteritis. Once established, treatment should be as conservative as possible focusing on relief of symptoms. Experience with specific medical treatments has been derived largely from small clinical trials and case series. Approaches used to treat small bowel disease will be summarized below while specific treatments aimed at radiation proctitis are discussed separately.
Dietary recommendations — There does not appear to be a clear-cut diet that reliably alleviates symptoms. A high fiber diet should probably not be recommended specifically since it may worsen diarrhea and urgency. Some patients may develop lactose intolerance, which may be due to bacterial overgrowth, and may improve following antibiotic treatment (see below). Others may require avoidance of lactose. Enteral formulas supplemented with glutamine may have a benefit but studies are limited
Antidiarrheal agents — Judicious use of antidiarrheal agents (such as loperamide) can help improve diarrhea, although it should not be used in patients with suspected small or large bowel obstruction. The efficacy of loperamide was evaluated in a crossover trial involving 18 patients with diarrhea due to radiation enteritis who were randomly assigned to loperamide or placebo for 14 days separated by a 14 day washout period. Loperamide was associated with a significant reduction in the frequency of bowel movements, slower intestinal transit, and improvement in the absorption of bile acids.
Antibiotics — Antibiotics may reduce symptoms in patients in whom bacterial overgrowth has developed. Specific testing for bacterial overgrowth is preferable to empiric therapy. A major drawback to empiric therapy is that treatment may require more than one antibiotic, and repeated and sometimes cyclic treatment. Because antibiotics may be associated with adverse effects, some of which may mimic symptoms of bacterial overgrowth (such as diarrhea and abdominal discomfort), establishing a firm diagnosis is important. This can usually be accomplished with a breath test.
5-ASA drugs — A case report (published nearly three decades ago) suggested a possible benefit from sulfasalazine with or without oral prednisone. There is no large published experience with either of these drugs. Discordant results have been obtained from controlled clinical trials evaluating mesalazine or sulfasalazine in the prevention of acute radiation enteritis
Hyperbaric oxygen — HBO has been used for treatment of refractory foot ulcers in diabetes and in other conditions [39]. The theoretical benefit of hyperbaric oxygen therapy (HBO) may be via inhibition of bacterial growth [40], preservation of marginally perfused tissue, and inhibition of toxin production [41].
A benefit in chronic radiation enteritis was suggested in a case report of a patient in whom 20 treatments over a one month period brought about objective improvements in symptoms and absorption of D-xylose. However, this anecdote did not give the results of long-term follow-up. Other reports have also suggested a benefit for patients with chronic radiation proctitis.
The equipment needed for hyperbaric oxygen treatment is expensive and not widely available. Thus, at the present time, it is not a practical means of treating chronic radiation enteritis outside of centers specializing in this approach, particularly since its effectiveness has not been well-studied.
Parenteral nutrition — A mainstay of the medical therapy of severe chronic radiation enteritis has been total parenteral nutrition (TPN), the success of which is similar for other intestinal disorders requiring TPN. One of the largest series included 54 patients who required home TPN mostly because of intestinal obstruction (27 patients), short bowel syndrome (17 patients), malabsorption (five patients), fistula formation (three patients), and dysmotility (two patients). TPN was initiated a median of 20 months after radiation therapy and was administered for a median of 20 months. Cumulative 5-year survival was 64 percent. Most early deaths were due to recurrent cancer. Similar survival estimates were reached in other series .
SURGERY — As noted above, surgery for radiation enteritis should be avoided if possible because of several inherent difficulties in operating on patients with chronic radiation injury
Diffuse fibrosis and adhesions between bowel loops can make resection technically challenging.
The risk of a leak is high when creating an anastomosis between irradiated tissues. Furthermore, it can be difficult to distinguish healthy tissue for irradiated tissue by gross inspection alone; intraoperative endoscopy may be helpful in this setting, but experienced is limited.
Extensive resection may be required, potentially leading to short bowel syndrome.
Despite attempts at conservative management, approximately one-third of patients progress to the point where surgery is required. Most surgical series of patients treated for radiation enteritis are small; the most common indications for surgery have been persistent ileus, intestinal fistulization, and massive adhesions. Surgical mortality rates are as high as 10 to 22 percent and many patients require more than one laparotomy
An illustrative series focused on 109 patients who underwent surgery during a 10 year period. Five patients died postoperatively (all of whom had undergone resection) while 33 (30 percent) had postoperative complications. Complications were more likely in patients who underwent emergency surgery. Repeat surgery was required in 40 percent of patients during a 40 month follow-up period. Overall survival in patients without a cancer recurrence was 85 percent at year one, and 69 percent at year five.
Strictureplasty may offer a less invasive approach to the management of strictures, but experience is limited. The role of small bowel transplantation in this setting is still being determined; its role, if any, will probably be only in children
SUMMARY AND RECOMMENDATIONS — Chronic radiation enteritis may lead to a variety of clinical consequences (such as diarrhea, nausea, weight loss, abdominal pain, intestinal obstruction and perforation) depending upon the extent of the injury. It usually develops six or more months after radiation therapy (mean approximately 5 years, range two months to as long as 30 years).
The diagnosis is usually established by suggestive radiologic findings in patients with compatible clinical features who have a history of prior radiation exposure. The patient's previous radiation treatment record should be reviewed to determine the total dose and distribution of the radiation field. This may help to determine which intestinal segments may have received excessive radiation exposure, information that can be correlated with the radiologic findings and the clinical presentation. We usually obtain an abdominal CT scan and an upper gastrointestinal series with small bowel follow-through. Further testing with an enteroclysis (standard, CT, or MRI depending upon local expertise) can be performed if the above is unrevealing and clinical suspicion remains.
Management should be conservative, addressing the predominant symptoms.
Patients with diarrhea, abdominal pain, nausea or bloating should undergo breath testing for bacterial overgrowth and treated with antibiotics if bacterial overgrowth is confirmed. Avoidance of lactose may benefit other patients while antidiarrheal agents (such as loperamide) may also be helpful. Loperamide should be avoided in patients with obstructive symptoms.
Patients with intermittent obstructive symptoms may benefit from a low residue diet, although dietary tolerance is variable. Radiologic evaluation may help to identify the strictured segment, information which may be critical should strictureplasty or surgery be ultimately required. The narrowed segment may not always be visible with an upper gastrointestinal series, particularly in patients with intermittent symptoms. Such patients may require enteroclysis as described above.
Despite conservative measures, surgery will be required in approximately 30 percent of patients. This is usually due to persistent ileus, intestinal fistulization, and massive adhesions.
Prognosis is variable since the disease is progressive. Early mortality is usually due to cancer recurrence. Five-year survival is approximately 70 percent in those without cancer recurrence, although many patients continue to have troubling digestive symptoms for the remainder of their lives.
Intensive, ongoing research on mechanisms related to fibrogenesis may eventually produce effective means to prevent or reverse disease progression once it has been established. However, at the present time, prevention during radiation therapy is central to reducing the risk of developing chronic radiation enteritis.
Saturday, November 05, 2011
Scientists uncover the secrets behind rapid tissue repair
10 October 2011
UK researchers have discovered how cells detect and respond to tissue damage. Their findings could open up new opportunities for improving tissue repair in patients after illness or surgery. When a tissue is wounded, cells detect damage via changes in their environment. Plasma leaking from broken blood vessels causes fibroblast cells to migrate into the damaged tissue, making the wound contract and plugging it by depositing substances such as collagen, which gives structural support to the tissue.
Now, researchers at the University of Bristol and the Wellcome Trust Centre for Cell-Matrix Research, University of Manchester - funded by the Wellcome Trust - have examined the signalling process that occurs in damaged tissues and identified the cellular mechanisms responsible for activating repair.
Lead author Dr Mark Bass said: "Each of these processes requires the turnover of cellular adhesions [repeated sticking and unsticking of cells], and the challenge has been to determine how cells detect tissue damage and modify their adhesive properties accordingly."
Using an imaging technique known as atomic force microscopy, the team were able to show how a protein, syndecan-4, triggers the uptake and redeployment of adhesive molecules. This novel sequence of signals enables fibroblasts and other cells to respond to changes in tissue structure and migrate along the matrix fibres which make up the skin. By moving towards a damage signal, cells are able to arrive at the wound far more quickly than if they searched for it randomly. This results in a very efficient healing response.
Dr Bass added: "We find that this signalling cascade is essential for efficient healing; this opens up considerable opportunities for improving tissue repair in patients."
Image: A scanning electron micrograph of the underside of a sticking plaster used to treat a razor blade cut. Credit: Anne Weston, LRI, CRUK, Wellcome Images.
Reference
Bass MD et al. A syndecan-4 hair trigger initiates wound healing through caveolin- and RhoG-regulated integrin endocytosis. Developmental Cell 2011 (epub ahead of print).
http://www.wellcome.ac.uk/News/2011/News/WTVM053022.htm
UK researchers have discovered how cells detect and respond to tissue damage. Their findings could open up new opportunities for improving tissue repair in patients after illness or surgery. When a tissue is wounded, cells detect damage via changes in their environment. Plasma leaking from broken blood vessels causes fibroblast cells to migrate into the damaged tissue, making the wound contract and plugging it by depositing substances such as collagen, which gives structural support to the tissue.
Now, researchers at the University of Bristol and the Wellcome Trust Centre for Cell-Matrix Research, University of Manchester - funded by the Wellcome Trust - have examined the signalling process that occurs in damaged tissues and identified the cellular mechanisms responsible for activating repair.
Lead author Dr Mark Bass said: "Each of these processes requires the turnover of cellular adhesions [repeated sticking and unsticking of cells], and the challenge has been to determine how cells detect tissue damage and modify their adhesive properties accordingly."
Using an imaging technique known as atomic force microscopy, the team were able to show how a protein, syndecan-4, triggers the uptake and redeployment of adhesive molecules. This novel sequence of signals enables fibroblasts and other cells to respond to changes in tissue structure and migrate along the matrix fibres which make up the skin. By moving towards a damage signal, cells are able to arrive at the wound far more quickly than if they searched for it randomly. This results in a very efficient healing response.
Dr Bass added: "We find that this signalling cascade is essential for efficient healing; this opens up considerable opportunities for improving tissue repair in patients."
Image: A scanning electron micrograph of the underside of a sticking plaster used to treat a razor blade cut. Credit: Anne Weston, LRI, CRUK, Wellcome Images.
Reference
Bass MD et al. A syndecan-4 hair trigger initiates wound healing through caveolin- and RhoG-regulated integrin endocytosis. Developmental Cell 2011 (epub ahead of print).
http://www.wellcome.ac.uk/News/2011/News/WTVM053022.htm
Wednesday, October 19, 2011
Intra-abdominal adhesions: Cellular mechanisms and strategies for prevention.
Int J Surg. 2011 Sep 23. [Epub ahead of print]
Intra-abdominal adhesions: Cellular mechanisms and strategies for prevention.
Maciver AH, McCall M, James Shapiro AM.
SourceDepartment of Surgery, University of Alberta Hospitals, 2000 College Plaza, 8215 112th Street, Edmonton, Alberta, Canada T6G 2C8.
Abstract
Postoperative intra-abdominal adhesions represent a serious clinical problem. In this review, we have focused on recent progress in the cellular and humoral mechanisms underpinning adhesion formation, and have reviewed strategies that interfere with these pathways as a means to prevent their occurrence. Current and previous English-language literature on the pathogenesis of adhesion formation was identified. As the burden of surgical disease in the world population increases, and the frequency of reoperation increases, prevention of adhesion formation has become a pressing goal in surgical research.
Copyright © 2011. Published by Elsevier Ltd.
http://www.ncbi.nlm.nih.gov/pubmed/21964216
Intra-abdominal adhesions: Cellular mechanisms and strategies for prevention.
Maciver AH, McCall M, James Shapiro AM.
SourceDepartment of Surgery, University of Alberta Hospitals, 2000 College Plaza, 8215 112th Street, Edmonton, Alberta, Canada T6G 2C8.
Abstract
Postoperative intra-abdominal adhesions represent a serious clinical problem. In this review, we have focused on recent progress in the cellular and humoral mechanisms underpinning adhesion formation, and have reviewed strategies that interfere with these pathways as a means to prevent their occurrence. Current and previous English-language literature on the pathogenesis of adhesion formation was identified. As the burden of surgical disease in the world population increases, and the frequency of reoperation increases, prevention of adhesion formation has become a pressing goal in surgical research.
Copyright © 2011. Published by Elsevier Ltd.
http://www.ncbi.nlm.nih.gov/pubmed/21964216
Tuesday, October 04, 2011
The inpatient burden of abdominal and gynecological adhesiolysis in the US
Vanja Sikirica1 , Bela Bapat2 , Sean D Candrilli2 , Keith L Davis2 , Malcolm Wilson3 and Alan Johns4
1 Shire Pharmaceuticals, Wayne, PA 19087 USA
2 RTI Health Solutions, 200 Park Offices, Research Triangle Park, NC 27709 USA
3 The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
4 Texas Health Care, Fort Worth, TX 76109 USA
author email corresponding author email
BMC Surgery 2011, 11:13doi:10.1186/1471-2482-11-13
The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2482/11/13
Received: 5 January 2011
Accepted: 9 June 2011
Published: 9 June 2011
© 2011 Sikirica et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background
Adhesions are fibrous bands of scar tissue, often a result of surgery, that form between internal organs and tissues, joining them together abnormally. Postoperative adhesions frequently occur following abdominal surgery, and are associated with a large economic burden. This study examines the inpatient burden of adhesiolysis in the United States (i.e., number and rate of events, cost, length of stay [LOS]).
Methods
Hospital discharge data for patients with primary and secondary adhesiolysis were analyzed using the 2005 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Procedures were aggregated by body system.
Results
We identified 351,777 adhesiolysis-related hospitalizations: 23.2% for primary and 76.8% for secondary adhesiolysis. The average LOS was 7.8 days for primary adhesiolysis. We found that 967,332 days of care were attributed to adhesiolysis-related procedures, with inpatient expenditures totaling $2.3 billion ($1.4 billion for primary adhesiolysis; $926 million for secondary adhesiolysis). Hospitalizations for adhesiolysis increased steadily by age and were higher for women. Of secondary adhesiolysis procedures, 46.3% involved the female reproductive tract, resulting in 57,005 additional days of care and $220 million in attributable costs.
Conclusions
Adhesiolysis remain an important surgical problem in the United States. Hospitalization for this condition leads to high direct surgical costs, which should be of interest to providers and payers.
Keywords: Adhesions; adhesiolysis; abdominal; gynecological; burden of illness; hospitalizationsBackground
Adhesions are fibrous bands of scar tissue, often result of surgery, that form between internal organs and tissues, joining them together abnormally [1]. Postoperative adhesions frequently occur following abdominal surgery and are a leading cause of intestinal obstruction. It has been estimated that more than 90% of patients who undergo abdominal operations will develop postoperative adhesions [2].
The most severe complication of postoperative adhesions is small bowel obstruction (SBO), which has a 10% risk of mortality [3,4]. Recent research has demonstrated that readmission episodes averaged 2.7 per patient for SBO or nonspecific abdominal pain (when adhesions were considered likely). Inpatient readmissions accounted for 87% of episodes; 47% of those required repeat surgery [5]. Additionally, in the large retrospective study Surgical and Clinical Adhesions Research, surgical procedures performed on the bowel or the female reproductive system were associated with an increased chance of adhesion development, termed adhesiolysis [6-8]. Ray and colleagues found that 47% of adhesiolysis-related inpatient hospitalizations were for procedures involving the female reproductive tract [2]. Postoperative adhesiolysis-related SBO occurred in 2.8% of patients undergoing hysterectomy for benign conditions and in 5% of those undergoing radical hysterectomy [4,9].
A number of studies have shown that the economic burden of adhesiolysis is significant [2,5,10]. It was estimated that adhesiolysis procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient care, and nearly $1.3 billion in health care expenditures in the United States (US) in 1994 [2]. This cost has decreased when compared with similar data from 1988,[10] due in part to laparoscopic surgery. Despite the decrease in costs associated with laparoscopic surgery, increased use of such techniques did not lead to a decreased rate of overall hospitalizations [2].
Utilizing more recent data, we estimated the current burden of inpatient treatment of adhesiolysis in the US. This study examined the number and rate of adhesiolysis-related hospitalizations, days of care attributable to adhesiolysis, and length of stay (LOS) for adhesiolysis-related hospitalizations, with primary and secondary procedures considered separately. Additionally, we assessed total inpatient costs attributable to adhesiolysis.
Methods
Data Source
Data were taken from the 2005 Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS)[11]. The NIS is the largest all-payer inpatient care database in the US and contains data from approximately 8 million hospital stays in 2005. The database also contains clinical and resource use information, including patient demographics, International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes, diagnosis-related group (DRG) codes, LOS, charges, discharge status, payer source, and hospital-specific characteristics. Using the survey design elements provided with the NIS, data can be weighted to produce nationally representative estimates [12]. All financial information in the NIS database is presented as charges rather than costs. To convert hospital charges to costs, facility-specific cost-to-charge ratios were used. Finally, the medical care component of the Consumer Price Index was applied to inflate all financial data to 2007 US dollars [13].
RTI International's Institutional Review Board determined that this study met all criteria for exemption.
Study Sample
From the NIS, all hospitalizations containing a DRG code of peritoneal adhesiolysis with or without complications (i.e., DRG 150, 151) were defined as primary adhesiolysis-related hospitalizations. Hospitalizations containing a primary or nonprimary ICD-9-CM procedure code for adhesiolysis, but without DRG 150 or 151, were defined as secondary adhesiolysis-related hospitalizations (Table 1). Hospitalizations related to secondary adhesiolysis were stratified by body system, using the following DRG coding:
(1) Digestive system (i.e., DRG 148, 149, 154, or 468),
(2) Hepatobiliary system (i.e., DRG 197, 493, or 494),
(3) Female reproductive system (i.e., DRG 358, 359, 361, or 365),
(4) Pregnancy with evidence of Cesarean section (i.e., DRG 370, 371, or 378).
Table 1. Description of Procedure (ICD-9-CM) Codes Used to Identify Adhesiolysis-Related Surgical Procedures
.Study Measures
Study measures included the number of inpatient hospitalizations involving adhesiolysis, adhesiolysis-related hospitalization rates, days of care, and costs attributable to adhesiolysis.
Hospitalization rates per 100,000 persons were assessed using the US Census Bureau's 2005 total US civilian population projection. The total days of care attributable to adhesiolysis were estimated using methods presented by Ray and colleagues that then were adapted for the HCUP NIS [2]. When DRG 150 or 151 (i.e., primary adhesiolysis) was the primary reason for admission, the attributed LOS was simply the mean LOS for this group. For records without a DRG of 150 or 151, excess days attributed to adhesiolysis were calculated as the difference between the mean LOS for those same procedures with adhesiolysis and those procedures without adhesiolysis within each DRG. The total number of adhesiolysis-related days then was estimated as the product of the attributed LOS for the group and the number of adhesiolysis-related hospitalizations within the group.
This study utilized the methodology from Ray and colleagues to estimate the per-day cost attributable to adhesiolysis [2]. Cost per day was estimated by dividing the total cost of adhesiolysis-related hospitalizations divided by the total number of adhesiolysis-related inpatient days. The total inpatient expenditures attributable to adhesiolysis were estimated by multiplying the estimated cost per day attributable to adhesiolysis by the number of days attributed to adhesiolysis.
Average expenditures for surgeon's services were estimated using the Resource-Based Relative Value Scale (RBRVS). The RBRVS value was estimated for Current Procedural Terminology codes related to adhesiolysis (Table 2) and then multiplied by a fixed conversion factor to determine the average surgeon expenditures for each specific procedure. These figures then were inflated to 2007 dollars using the medical care component of the Consumer Price Index.
Table 2. Description of Procedure (CPT) Codes Used to Identify Adhesiolysis-Related Surgical Procedures to Estimate Expenditures for Surgeons' Servicesa
.Total inpatient costs attributable to adhesiolysis consisted of inpatient costs and costs for the surgeon's services. Estimates were made separately for primary and secondary adhesiolysis. These also were examined by body system and then aggregated to estimate a total cost. Additionally, inpatient expenditures were summarized to compare Cesarean section deliveries with and without adhesiolysis.
Statistical Analyses
Descriptive analyses were conducted to display the mean, standard deviation, median, and range of continuous variables, as well as the frequency distribution of categorical variables. All data management and analyses were conducted with SAS and SUDAAN statistical software packages [14,15].
Results and Discussion
Table 3 illustrates that there were 351,777 adhesiolysis-related hospitalizations in the US in 2005, representing 119 adhesiolysis hospitalizations per 100,000 persons. There were 898 adhesiolysis hospitalizations per 100,000 hospitalizations and 3,549 per 100,000 surgical hospitalizations of any kind (3.5%). Primary adhesiolysis (i.e., DRG 150 or 151) was found in 23.2% of these hospitalizations, while the remaining 76.8% were classified as secondary adhesiolysis (i.e., evidence of the procedure but with a DRG other than 150 or 151).
Table 3. Rate of Adhesiolysis-Related Hospitalizations
.Table 4 presents background characteristics for the study sample. For primary adhesiolysis, the number of hospitalizations increased steadily by age; for secondary adhesiolysis, the number increased for most age categories. The lowest rate was in patients who were younger than 25 years (5.2 per 100,000 persons for primary adhesiolysis; 13.8 per 100,000 persons for secondary adhesiolysis), and the highest rate was in patients who were older than 65 years (88.4 per 100,000 persons for primary adhesiolysis; 176.7 per 100,000 persons for secondary adhesiolysis). Women had a higher hospitalization rate than men (34.9 vs. 19.7 per 100,000 persons for primary adhesiolysis; 153.1 vs. 13.4 per 100,000 persons for secondary adhesiolysis). Among primary adhesiolysis hospitalizations, almost half (48%) of the patients were admitted via the emergency department, whereas only 20.5% of the secondary adhesiolysis hospitalizations were via the emergency department. Primary adhesiolysis-related hospitalizations were evenly distributed between private insurance and governmental coverage, i.e., Medicaid and Medicare (44% and 48%, respectively), whereas more than half (56%) of the patients with secondary adhesiolysis hospitalizations had private insurance and 37.4% had government-sponsored health care coverage.
Table 4. Demographics and Other Patient- and Facility-Specific Characteristics of Interest Among Adhesiolysis-Related Hospitalizations (i.e., DRG 150 or 151) in the US in 2005
.A total of 967,332 inpatient days of care were attributed to primary and secondary adhesiolysis (Table 5). There were 81,532 hospitalizations and an average LOS of 7.8 days per stay, totaling 632,688 inpatient days of care for primary adhesiolysis. An estimated 334,644 days of care were attributed to secondary adhesiolysis. For hospitalizations in which adhesiolysis was a secondary procedure, we compared the LOS between adhesiolysis and nonadhesiolysis procedures to estimate the LOS attributable to adhesiolysis by each DRG. The majority of DRGs showed an increase in LOS for adhesiolysis hospitalizations versus nonadhesiolysis hospitalizations. On average, hospitalizations related to secondary adhesiolysis resulted in an additional 1.24 hospitalized days compared with nonadhesiolysis-related hospitalizations.
Table 5. Inpatient Care Attributable to Abdominal Adhesiolysis by Surgical Procedure in the US in 2005
.The difference in mean LOS was greatest for extensive operation room procedures unrelated to principal diagnosis (i.e., DRG 468), with 4.9 days attributable to adhesiolysis. For stomach, esophageal, and duodenal procedures with complications of comorbid conditions (i.e., DRG 154), 4.6 days were attributable to adhesiolysis. Almost half (46.3%) of all secondary adhesiolysis procedures (125,069) were female reproductive tract related, resulting in 57,005 days of care. Thus, 0.46 day of additional stay were attributable to adhesiolysis. The longest LOS for female reproductive system procedures was for DRG 358 (uterine and adnexa procedures for nonmalignancy), which resulted in an additional day of inpatient stay (0.90 day).
Table 6 shows that total inpatient expenditures for adhesiolysis-related hospitalizations were $2.25 billion: of this amount, primary adhesiolysis-related hospitalizations accounted for $1.35 billion and secondary adhesiolysis-related hospitalizations accounted for $902 million. Of the total secondary adhesiolysis expenditures, $622 million (69%) were related to procedures for the digestive system and $220 million (24.3%) were related to procedures for the female reproductive system. Adhesiolysis related to the hepatobiliary system and pancreas and Cesarean sections accounted for $41 million and $18 million, respectively.
Table 6. Inpatient Expenditures Attributable to Abdominal Adhesiolysis in the US in 2005
.The rate of adhesiolysis-related hospitalizations in the US has remained fairly constant from 1998 to 2005: from 115.5 in 1988 [10] to 117.3 in 1994 [2] and ultimately 118.6 per 100,000 persons in 2005. In these same time periods, the average LOS for primary adhesiolysis-related hospitalizations has steadily decreased from 11.2 days to 9.7 days and 7.8 days, respectively. The costs for such hospitalizations, when inflated to reflect 2007 dollars, indicated an increase of $112 million between 1988 and 2005, despite the 3.4-day (or 30%) decrease in LOS--this represented a 5% increase in medical care costs. This increase suggested that costs of treating adhesiolysis have increased substantially.
Primary adhesiolysis contributed 23% of all adhesiolysis procedures (81,532) but represented more than half of the total cost burden ($1.3 billion). Secondary adhesiolysis was substantially higher in volume, representing 77% of procedures (270,245) but less half of the total cost burden ($902 million). The greatest number of procedures was to the female reproductive tract (125,069) while procedures to the digestive tract yielded the highest overall costs ($622 million).
Potentially mitigating this growth in the cost of adhesiolysis may be the continuing trend in the US toward minimally invasive and laparoscopic approaches, which may lessen the occurrence of postoperative adhesions [2]. Although laparoscopy reduces surgical trauma, the procedure has not been show to reduce the incidence of adhesion-related readmissions [16].
This study is subject to potential limitations consistent with retrospective database studies. Conditions and events of interest were identified by diagnosis codes. Previous research has suggested that the condition may be underreported [17]. This may mean that the actual cost of adhesiolysis-related disease is greater than the estimate provided by our study. The database used for this study was not specifically designed to assess inpatient burden. Like all administrative billing databases, the data contained in the HCUP NIS are dependent upon the quality of coding, which may be influenced by reimbursement incentives. However, we do not feel it likely that such incentives greatly affected our results since the majority of overall adhesiolysis costs were a part of secondary adhesiolysis procedures and not the more costly primary adhesiolysis. Moreover, even if such incentives exist and are reflected in the data used for this study, these data are indicative of real world practice. Additionally, with such a large sample, the effect of any coding errors or anomalies would likely be minimized.
Furthermore, due to the nature of the database, detailed clinical characteristics could not be ascertained; therefore, the results could not be adjusted for disease severity or other clinical parameters. However, it is unlikely that these factors would have had a large impact on the results, as this study focused on those patients receiving inpatient care. Additionally, since the database contains US data only, the results may not be generalizable to other populations outside of the US. Lastly, because the focus of this study was on direct cost measures, the results do not account for productivity loss for the patient or caregiver and potential future societal contributions that may be lost due to death resulting from or related to adhesiolysis. Because we examined only the direct health care costs associated with inpatient adhesiolysis, we have not examined any adhesiolysis-related surgeries performed at other sites of care, such as ambulatory surgical centers. Further, our study does not capture direct costs relating to but occurring before or after surgery, including pain medications, cost of work-up visits, and procedures related to diagnosis. Similarly, patient work-ups and diagnostic laparoscopic procedures that may have occurred at separate visits and prior to the adhesiolysis surgery were not captured if specific DRG codes were not listed for those hospitalizations [6,7,9]. Hence, this study's estimates of costs are likely to be conservative.
Conclusions
Adhesions remain an important surgical problem, and hospitalization for adhesiolysis leads to a high direct cost burden in the US. Despite a trend of decreasing LOS for adhesiolysis-related hospitalizations from 2001 to 2005, adhesiolysis-related costs continue to rise even while the overall rate of adhesiolysis procedures remains constant. Consistent with previous research, the distribution of inpatient care and costs across the diagnostic categories remained steady from 2001 to 2005, with only a slight increase in primary adhesiolysis procedures over time. From 2001 to 2005, hospitalizations for adhesiolysis related to the digestive system and to the female reproductive tract had the largest number of inpatient days and accounted for the majority of costs related to secondary adhesiolysis procedures.
Adhesiolysis remains a substantial economic burden to the US health care system, which should be of interest to providers and commercial and government payers. Further research incorporating detailed clinical data and indirect costs would aid in a greater understanding of the overall burden of adhesiolysis.
Competing interests
VS was an employee of Ethicon, Inc. at the time that this manuscript was prepared; he is currently an employee of Shire Pharmaceuticals. BB, SDC, and KLD are employees of RTI Health Solutions, the research organization contracted by Ethicon to conduct this study. AJ is an employee of Texas Healthcare; MW is an employee of Christie NHS Foundation Trust.
Authors' contributions
VS was responsible for developing the study design, interpreting the analysis results, and drafting the manuscript text; he is the primary author of this manuscript. BB, SDC, and KLD were responsible for the acquisition, management, interpretation, and analysis of all study data. BB, SDC, and KLD also assisted with developing the study design, interpreting the analysis results, and drafting the manuscript. AJ and MW contributed clinical expertise and guidance and assisted in interpreting the analysis results and drafting the manuscript text.
All authors confirm that they have read the journal's position on issues involved in ethical publication and affirm that this research report is consistent with those guidelines. Finally, all authors have read and approved the final manuscript.
Funding
This study and the preparation of this manuscript were funded by Ethicon, Inc. The authors acknowledge that Ethicon, Inc. is the maker of GYNECARE INTERCEED, a product that is marketed to prevent pelvic adhesions.
Acknowledgements
Portions of the study data presented in this paper were previously presented as a podium presentation at the VIIIth PAX Meeting; Clermont-Ferrand, France; September 18-20, 2008, as well as a poster presentation at the 57th Annual Clinical Meeting of the American College of Obstetricians and Gynecologists; Chicago, Illinois; May 2-6, 2009.
The authors wish to thank Ms. Gail Zona of RTI Health Solutions and Ms. Heidi Waters of Ethicon, Inc., for assistance with preparing this manuscript.
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2482/11/13/prepub
http://www.biomedcentral.com/1471-2482/11/13
1 Shire Pharmaceuticals, Wayne, PA 19087 USA
2 RTI Health Solutions, 200 Park Offices, Research Triangle Park, NC 27709 USA
3 The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
4 Texas Health Care, Fort Worth, TX 76109 USA
author email corresponding author email
BMC Surgery 2011, 11:13doi:10.1186/1471-2482-11-13
The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2482/11/13
Received: 5 January 2011
Accepted: 9 June 2011
Published: 9 June 2011
© 2011 Sikirica et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background
Adhesions are fibrous bands of scar tissue, often a result of surgery, that form between internal organs and tissues, joining them together abnormally. Postoperative adhesions frequently occur following abdominal surgery, and are associated with a large economic burden. This study examines the inpatient burden of adhesiolysis in the United States (i.e., number and rate of events, cost, length of stay [LOS]).
Methods
Hospital discharge data for patients with primary and secondary adhesiolysis were analyzed using the 2005 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Procedures were aggregated by body system.
Results
We identified 351,777 adhesiolysis-related hospitalizations: 23.2% for primary and 76.8% for secondary adhesiolysis. The average LOS was 7.8 days for primary adhesiolysis. We found that 967,332 days of care were attributed to adhesiolysis-related procedures, with inpatient expenditures totaling $2.3 billion ($1.4 billion for primary adhesiolysis; $926 million for secondary adhesiolysis). Hospitalizations for adhesiolysis increased steadily by age and were higher for women. Of secondary adhesiolysis procedures, 46.3% involved the female reproductive tract, resulting in 57,005 additional days of care and $220 million in attributable costs.
Conclusions
Adhesiolysis remain an important surgical problem in the United States. Hospitalization for this condition leads to high direct surgical costs, which should be of interest to providers and payers.
Keywords: Adhesions; adhesiolysis; abdominal; gynecological; burden of illness; hospitalizationsBackground
Adhesions are fibrous bands of scar tissue, often result of surgery, that form between internal organs and tissues, joining them together abnormally [1]. Postoperative adhesions frequently occur following abdominal surgery and are a leading cause of intestinal obstruction. It has been estimated that more than 90% of patients who undergo abdominal operations will develop postoperative adhesions [2].
The most severe complication of postoperative adhesions is small bowel obstruction (SBO), which has a 10% risk of mortality [3,4]. Recent research has demonstrated that readmission episodes averaged 2.7 per patient for SBO or nonspecific abdominal pain (when adhesions were considered likely). Inpatient readmissions accounted for 87% of episodes; 47% of those required repeat surgery [5]. Additionally, in the large retrospective study Surgical and Clinical Adhesions Research, surgical procedures performed on the bowel or the female reproductive system were associated with an increased chance of adhesion development, termed adhesiolysis [6-8]. Ray and colleagues found that 47% of adhesiolysis-related inpatient hospitalizations were for procedures involving the female reproductive tract [2]. Postoperative adhesiolysis-related SBO occurred in 2.8% of patients undergoing hysterectomy for benign conditions and in 5% of those undergoing radical hysterectomy [4,9].
A number of studies have shown that the economic burden of adhesiolysis is significant [2,5,10]. It was estimated that adhesiolysis procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient care, and nearly $1.3 billion in health care expenditures in the United States (US) in 1994 [2]. This cost has decreased when compared with similar data from 1988,[10] due in part to laparoscopic surgery. Despite the decrease in costs associated with laparoscopic surgery, increased use of such techniques did not lead to a decreased rate of overall hospitalizations [2].
Utilizing more recent data, we estimated the current burden of inpatient treatment of adhesiolysis in the US. This study examined the number and rate of adhesiolysis-related hospitalizations, days of care attributable to adhesiolysis, and length of stay (LOS) for adhesiolysis-related hospitalizations, with primary and secondary procedures considered separately. Additionally, we assessed total inpatient costs attributable to adhesiolysis.
Methods
Data Source
Data were taken from the 2005 Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS)[11]. The NIS is the largest all-payer inpatient care database in the US and contains data from approximately 8 million hospital stays in 2005. The database also contains clinical and resource use information, including patient demographics, International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes, diagnosis-related group (DRG) codes, LOS, charges, discharge status, payer source, and hospital-specific characteristics. Using the survey design elements provided with the NIS, data can be weighted to produce nationally representative estimates [12]. All financial information in the NIS database is presented as charges rather than costs. To convert hospital charges to costs, facility-specific cost-to-charge ratios were used. Finally, the medical care component of the Consumer Price Index was applied to inflate all financial data to 2007 US dollars [13].
RTI International's Institutional Review Board determined that this study met all criteria for exemption.
Study Sample
From the NIS, all hospitalizations containing a DRG code of peritoneal adhesiolysis with or without complications (i.e., DRG 150, 151) were defined as primary adhesiolysis-related hospitalizations. Hospitalizations containing a primary or nonprimary ICD-9-CM procedure code for adhesiolysis, but without DRG 150 or 151, were defined as secondary adhesiolysis-related hospitalizations (Table 1). Hospitalizations related to secondary adhesiolysis were stratified by body system, using the following DRG coding:
(1) Digestive system (i.e., DRG 148, 149, 154, or 468),
(2) Hepatobiliary system (i.e., DRG 197, 493, or 494),
(3) Female reproductive system (i.e., DRG 358, 359, 361, or 365),
(4) Pregnancy with evidence of Cesarean section (i.e., DRG 370, 371, or 378).
Table 1. Description of Procedure (ICD-9-CM) Codes Used to Identify Adhesiolysis-Related Surgical Procedures
.Study Measures
Study measures included the number of inpatient hospitalizations involving adhesiolysis, adhesiolysis-related hospitalization rates, days of care, and costs attributable to adhesiolysis.
Hospitalization rates per 100,000 persons were assessed using the US Census Bureau's 2005 total US civilian population projection. The total days of care attributable to adhesiolysis were estimated using methods presented by Ray and colleagues that then were adapted for the HCUP NIS [2]. When DRG 150 or 151 (i.e., primary adhesiolysis) was the primary reason for admission, the attributed LOS was simply the mean LOS for this group. For records without a DRG of 150 or 151, excess days attributed to adhesiolysis were calculated as the difference between the mean LOS for those same procedures with adhesiolysis and those procedures without adhesiolysis within each DRG. The total number of adhesiolysis-related days then was estimated as the product of the attributed LOS for the group and the number of adhesiolysis-related hospitalizations within the group.
This study utilized the methodology from Ray and colleagues to estimate the per-day cost attributable to adhesiolysis [2]. Cost per day was estimated by dividing the total cost of adhesiolysis-related hospitalizations divided by the total number of adhesiolysis-related inpatient days. The total inpatient expenditures attributable to adhesiolysis were estimated by multiplying the estimated cost per day attributable to adhesiolysis by the number of days attributed to adhesiolysis.
Average expenditures for surgeon's services were estimated using the Resource-Based Relative Value Scale (RBRVS). The RBRVS value was estimated for Current Procedural Terminology codes related to adhesiolysis (Table 2) and then multiplied by a fixed conversion factor to determine the average surgeon expenditures for each specific procedure. These figures then were inflated to 2007 dollars using the medical care component of the Consumer Price Index.
Table 2. Description of Procedure (CPT) Codes Used to Identify Adhesiolysis-Related Surgical Procedures to Estimate Expenditures for Surgeons' Servicesa
.Total inpatient costs attributable to adhesiolysis consisted of inpatient costs and costs for the surgeon's services. Estimates were made separately for primary and secondary adhesiolysis. These also were examined by body system and then aggregated to estimate a total cost. Additionally, inpatient expenditures were summarized to compare Cesarean section deliveries with and without adhesiolysis.
Statistical Analyses
Descriptive analyses were conducted to display the mean, standard deviation, median, and range of continuous variables, as well as the frequency distribution of categorical variables. All data management and analyses were conducted with SAS and SUDAAN statistical software packages [14,15].
Results and Discussion
Table 3 illustrates that there were 351,777 adhesiolysis-related hospitalizations in the US in 2005, representing 119 adhesiolysis hospitalizations per 100,000 persons. There were 898 adhesiolysis hospitalizations per 100,000 hospitalizations and 3,549 per 100,000 surgical hospitalizations of any kind (3.5%). Primary adhesiolysis (i.e., DRG 150 or 151) was found in 23.2% of these hospitalizations, while the remaining 76.8% were classified as secondary adhesiolysis (i.e., evidence of the procedure but with a DRG other than 150 or 151).
Table 3. Rate of Adhesiolysis-Related Hospitalizations
.Table 4 presents background characteristics for the study sample. For primary adhesiolysis, the number of hospitalizations increased steadily by age; for secondary adhesiolysis, the number increased for most age categories. The lowest rate was in patients who were younger than 25 years (5.2 per 100,000 persons for primary adhesiolysis; 13.8 per 100,000 persons for secondary adhesiolysis), and the highest rate was in patients who were older than 65 years (88.4 per 100,000 persons for primary adhesiolysis; 176.7 per 100,000 persons for secondary adhesiolysis). Women had a higher hospitalization rate than men (34.9 vs. 19.7 per 100,000 persons for primary adhesiolysis; 153.1 vs. 13.4 per 100,000 persons for secondary adhesiolysis). Among primary adhesiolysis hospitalizations, almost half (48%) of the patients were admitted via the emergency department, whereas only 20.5% of the secondary adhesiolysis hospitalizations were via the emergency department. Primary adhesiolysis-related hospitalizations were evenly distributed between private insurance and governmental coverage, i.e., Medicaid and Medicare (44% and 48%, respectively), whereas more than half (56%) of the patients with secondary adhesiolysis hospitalizations had private insurance and 37.4% had government-sponsored health care coverage.
Table 4. Demographics and Other Patient- and Facility-Specific Characteristics of Interest Among Adhesiolysis-Related Hospitalizations (i.e., DRG 150 or 151) in the US in 2005
.A total of 967,332 inpatient days of care were attributed to primary and secondary adhesiolysis (Table 5). There were 81,532 hospitalizations and an average LOS of 7.8 days per stay, totaling 632,688 inpatient days of care for primary adhesiolysis. An estimated 334,644 days of care were attributed to secondary adhesiolysis. For hospitalizations in which adhesiolysis was a secondary procedure, we compared the LOS between adhesiolysis and nonadhesiolysis procedures to estimate the LOS attributable to adhesiolysis by each DRG. The majority of DRGs showed an increase in LOS for adhesiolysis hospitalizations versus nonadhesiolysis hospitalizations. On average, hospitalizations related to secondary adhesiolysis resulted in an additional 1.24 hospitalized days compared with nonadhesiolysis-related hospitalizations.
Table 5. Inpatient Care Attributable to Abdominal Adhesiolysis by Surgical Procedure in the US in 2005
.The difference in mean LOS was greatest for extensive operation room procedures unrelated to principal diagnosis (i.e., DRG 468), with 4.9 days attributable to adhesiolysis. For stomach, esophageal, and duodenal procedures with complications of comorbid conditions (i.e., DRG 154), 4.6 days were attributable to adhesiolysis. Almost half (46.3%) of all secondary adhesiolysis procedures (125,069) were female reproductive tract related, resulting in 57,005 days of care. Thus, 0.46 day of additional stay were attributable to adhesiolysis. The longest LOS for female reproductive system procedures was for DRG 358 (uterine and adnexa procedures for nonmalignancy), which resulted in an additional day of inpatient stay (0.90 day).
Table 6 shows that total inpatient expenditures for adhesiolysis-related hospitalizations were $2.25 billion: of this amount, primary adhesiolysis-related hospitalizations accounted for $1.35 billion and secondary adhesiolysis-related hospitalizations accounted for $902 million. Of the total secondary adhesiolysis expenditures, $622 million (69%) were related to procedures for the digestive system and $220 million (24.3%) were related to procedures for the female reproductive system. Adhesiolysis related to the hepatobiliary system and pancreas and Cesarean sections accounted for $41 million and $18 million, respectively.
Table 6. Inpatient Expenditures Attributable to Abdominal Adhesiolysis in the US in 2005
.The rate of adhesiolysis-related hospitalizations in the US has remained fairly constant from 1998 to 2005: from 115.5 in 1988 [10] to 117.3 in 1994 [2] and ultimately 118.6 per 100,000 persons in 2005. In these same time periods, the average LOS for primary adhesiolysis-related hospitalizations has steadily decreased from 11.2 days to 9.7 days and 7.8 days, respectively. The costs for such hospitalizations, when inflated to reflect 2007 dollars, indicated an increase of $112 million between 1988 and 2005, despite the 3.4-day (or 30%) decrease in LOS--this represented a 5% increase in medical care costs. This increase suggested that costs of treating adhesiolysis have increased substantially.
Primary adhesiolysis contributed 23% of all adhesiolysis procedures (81,532) but represented more than half of the total cost burden ($1.3 billion). Secondary adhesiolysis was substantially higher in volume, representing 77% of procedures (270,245) but less half of the total cost burden ($902 million). The greatest number of procedures was to the female reproductive tract (125,069) while procedures to the digestive tract yielded the highest overall costs ($622 million).
Potentially mitigating this growth in the cost of adhesiolysis may be the continuing trend in the US toward minimally invasive and laparoscopic approaches, which may lessen the occurrence of postoperative adhesions [2]. Although laparoscopy reduces surgical trauma, the procedure has not been show to reduce the incidence of adhesion-related readmissions [16].
This study is subject to potential limitations consistent with retrospective database studies. Conditions and events of interest were identified by diagnosis codes. Previous research has suggested that the condition may be underreported [17]. This may mean that the actual cost of adhesiolysis-related disease is greater than the estimate provided by our study. The database used for this study was not specifically designed to assess inpatient burden. Like all administrative billing databases, the data contained in the HCUP NIS are dependent upon the quality of coding, which may be influenced by reimbursement incentives. However, we do not feel it likely that such incentives greatly affected our results since the majority of overall adhesiolysis costs were a part of secondary adhesiolysis procedures and not the more costly primary adhesiolysis. Moreover, even if such incentives exist and are reflected in the data used for this study, these data are indicative of real world practice. Additionally, with such a large sample, the effect of any coding errors or anomalies would likely be minimized.
Furthermore, due to the nature of the database, detailed clinical characteristics could not be ascertained; therefore, the results could not be adjusted for disease severity or other clinical parameters. However, it is unlikely that these factors would have had a large impact on the results, as this study focused on those patients receiving inpatient care. Additionally, since the database contains US data only, the results may not be generalizable to other populations outside of the US. Lastly, because the focus of this study was on direct cost measures, the results do not account for productivity loss for the patient or caregiver and potential future societal contributions that may be lost due to death resulting from or related to adhesiolysis. Because we examined only the direct health care costs associated with inpatient adhesiolysis, we have not examined any adhesiolysis-related surgeries performed at other sites of care, such as ambulatory surgical centers. Further, our study does not capture direct costs relating to but occurring before or after surgery, including pain medications, cost of work-up visits, and procedures related to diagnosis. Similarly, patient work-ups and diagnostic laparoscopic procedures that may have occurred at separate visits and prior to the adhesiolysis surgery were not captured if specific DRG codes were not listed for those hospitalizations [6,7,9]. Hence, this study's estimates of costs are likely to be conservative.
Conclusions
Adhesions remain an important surgical problem, and hospitalization for adhesiolysis leads to a high direct cost burden in the US. Despite a trend of decreasing LOS for adhesiolysis-related hospitalizations from 2001 to 2005, adhesiolysis-related costs continue to rise even while the overall rate of adhesiolysis procedures remains constant. Consistent with previous research, the distribution of inpatient care and costs across the diagnostic categories remained steady from 2001 to 2005, with only a slight increase in primary adhesiolysis procedures over time. From 2001 to 2005, hospitalizations for adhesiolysis related to the digestive system and to the female reproductive tract had the largest number of inpatient days and accounted for the majority of costs related to secondary adhesiolysis procedures.
Adhesiolysis remains a substantial economic burden to the US health care system, which should be of interest to providers and commercial and government payers. Further research incorporating detailed clinical data and indirect costs would aid in a greater understanding of the overall burden of adhesiolysis.
Competing interests
VS was an employee of Ethicon, Inc. at the time that this manuscript was prepared; he is currently an employee of Shire Pharmaceuticals. BB, SDC, and KLD are employees of RTI Health Solutions, the research organization contracted by Ethicon to conduct this study. AJ is an employee of Texas Healthcare; MW is an employee of Christie NHS Foundation Trust.
Authors' contributions
VS was responsible for developing the study design, interpreting the analysis results, and drafting the manuscript text; he is the primary author of this manuscript. BB, SDC, and KLD were responsible for the acquisition, management, interpretation, and analysis of all study data. BB, SDC, and KLD also assisted with developing the study design, interpreting the analysis results, and drafting the manuscript. AJ and MW contributed clinical expertise and guidance and assisted in interpreting the analysis results and drafting the manuscript text.
All authors confirm that they have read the journal's position on issues involved in ethical publication and affirm that this research report is consistent with those guidelines. Finally, all authors have read and approved the final manuscript.
Funding
This study and the preparation of this manuscript were funded by Ethicon, Inc. The authors acknowledge that Ethicon, Inc. is the maker of GYNECARE INTERCEED, a product that is marketed to prevent pelvic adhesions.
Acknowledgements
Portions of the study data presented in this paper were previously presented as a podium presentation at the VIIIth PAX Meeting; Clermont-Ferrand, France; September 18-20, 2008, as well as a poster presentation at the 57th Annual Clinical Meeting of the American College of Obstetricians and Gynecologists; Chicago, Illinois; May 2-6, 2009.
The authors wish to thank Ms. Gail Zona of RTI Health Solutions and Ms. Heidi Waters of Ethicon, Inc., for assistance with preparing this manuscript.
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2482/11/13/prepub
http://www.biomedcentral.com/1471-2482/11/13
Monday, October 03, 2011
Abdominal/Pelvic Pain Can Occur After Surgery.
Abdominal/Pelvic pain can occur after surgery. Post surgical pain can present shortly following your surgery, and usually resolves over the following days and weeks as you recover from that surgery. But some pain may linger for months or years following a surgical procedure. The question is, what is the source of this pain?
In some cases, the answer is Adhesions!
Adhesions are bands of scar tissue intra-abdominal and/or pelvic cavity that bind your internal organs together, causing them to stick to each other. The result of these bands of scar tissue can lead to:
Adhesion Related Disorder or ARD.
The symptoms of ARD include:
Chronic pain
Infertility
Bowel obstruction
Gastro-esophageal reflux disease, (GERD)
Urinary Bladder dysfunction
Pain and difficulty having a bowel movement
Pain on movement such as: Walking, sitting or laying in certain positions.
Loss of Nutrients due to poor eating habits or loss of appetite.
Loss of employment due to lost work days
Loss of family and social life
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness
If you are experiencing pelvic pain, it’s important to see your doctor. Pain in the pelvic or abdominal area can be caused by a variety of conditions, some of which may be serious. Your doctor will be able to perform tests to determine the cause of your pain. Do not assume all pelvic or abdominal is caused by adhesion even if your post adhesiolysis, as adhesions do reform following surgery.
It is important to ask for and allow diagnostic tests to rule out other sources of pathology as being the cause for your symptoms…while some adhesion do cause pain, not all adhesions cause pain and not all pain is caused by adhesions!
If all diagnostic tests result in negative findings, one cause of pain that your doctor might consider is adhesions, particularly if you have had abdominal or pelvic surgery. Adhesions are commonly associated with pelvic pain. In fact, an estimated 38 percent of women suffering from pelvic pain have adhesions.
The better news is that there are things that your doctor can do to reduce the incidence post-operative adhesions – and maybe even prevent them altogether. Educate yourself to “Adhesion Related Disorder” as the informed patient can make informed decisions when you discuss your symptoms and medical care needs with your doctor.
Always request and keep a personal file of all your medical interventions!
Adhesions Can Cause Pain:
Adhesions can cause pain by binding normally separate organs and tissues together - essentially “tying them down.” The stretching and pulling of everyday movements can irritate the nerves involved. Some adhesions can cause pain during intercourse. Ask your medical care provide to order an “ESR = Erythrocyte Sedimentation Rate” ‘ blood test for inflammatory reaction in your body. Inflammation at the adhesion attachment sites become agitated due to the pulling and tugging on the tissues of the attached organs. This inflammation creates pain and must be taken into consideration by the Doctor when treating the ARD sufferer for pain.
While pelvic pain can be an obvious symptom of adhesions, there are other serious complications of which you should be aware. Two of the more common complications of adhesions are infertility and bowel obstruction.
Adhesion can and do cause disabling pain and loss of productivity. You will want to resent substantiating information on this issue when you meet with your Doctor.
Be prepared, be your own best Doctor!
Bowel obstruction:
Adhesion formation involving the bowel (intestine) is particularly common following hysterectomy. These adhesions occasionally they can cause the bowel to kink and not allow the passage of digested food. This causes a “back-up.” Bowel obstruction can occur shortly after surgery or many years later. Symptoms of bowel obstruction may include pain, nausea, and vomiting. Bowel obstruction is a serious illness and requires immediate medical attention.
Even though the overall incidence of bowel obstruction is low, you should be aware of the possibility of its occurrence. If left untreated, obstruction can lead to serious complications, even death. Symptoms of bowel obstruction include:
Abdominal pain
Nausea
Vomiting
Diarrhea (early)
Constipation (late)
Fever
You should talk to your doctor if you have any of these symptoms.
Endometriosis.
One of the more common non-surgical causes of pelvic pain is endometriosis.
If you have been trying unsuccessfully to conceive, you are probably searching for the cause. Your search may have led you to this site. It’s important to understand that there are many conditions that can cause infertility, and you should talk to your doctor to determine whether your situation requires medical attention.
Adhesions that form as a result of certain types of gynecologic surgery, especially tubal surgeries and myomectomies (surgery to remove fibroids), are a common cause of infertility. Adhesions can form between the ovaries, fallopian tubes or pelvic walls.
These adhesions can block the passage of ovum (an egg) from the ovaries into and through the fallopian tubes.
Adhesions around the fallopian tubes can also interfere with sperm transport to the ovum.
Ovarian Surgery
Surgical Treatment of Endometriosis
Myomectomy
Reconstructive Tubal Surgery
The good news is that infertility due to pelvic adhesions can be successfully treated in approximately 40% to 60% of women. However, the surgical procedure, adhesiolysis, can often lead to more adhesions. The best way to reduce the chances of adhesions forming and/or reforming is for your surgeon to learn the best procedure used in the attempt to reduce adhesion formation. The more a surgeon practices the procedure, the more skilled he will become in performing it. As he develops his technique over time along with the use of an effective adhesion barrier, the better the results for improvement in the symptoms of the adhesion patient!
Talk to your doctor if you have pelvic pain of any kind.
Although adhesions often form after gynecologic surgery, they are not inevitable. And, even if adhesions do form, they usually don’t cause pain or other problems.
Although there is no way to eliminate the risk of adhesions completely, there are steps your surgeon can take to reduce the likelihood of adhesion formation. The most effective methods of adhesion prevention involve meticulous surgical technique and the use of a physical barrier to separate tissue surfaces while they heal.
Surgeons have developed minimally invasive techniques such as the laparoscopy, that are designed to minimize trauma, blood loss, infection, and the introduction of foreign bodies, all of which can lead to inflammation and adhesion formation. Good surgical technique involves minimizing tissue handling, using delicate instruments, and keeping the tissues moist when they are exposed to the air.
While good surgical technique is important, but it is often not sufficient to prevent adhesions. There are also other preventive steps that can be taken:
Surgical techniques that can help decrease adhesion formation
Not simply the surgical procedure used, but in combination with these techniques and the lesser of invasive surgery, a laporoscopy, one has the best chance of adhesion reduction when these are used together in a surgery!
Achieve meticulous hemostasis
Maintain vascularity
Moisten tissues
Avoid dry sponges
Minimize tissue handling
Use fine, non-reactive sutures
Avoid peritoneal grafts
Minimize foreign bodies
Even though the most meticulous surgical and microsurgical techniques cannot eliminate the formation of adhesions, the following steps can be taken to reduce adhesion formation:
Achieve meticulous hemostasis: Inadequate hemostasis and the resultant fibrin deposition promote adhesion formation.
Maintain vascularity: Limiting ischemia supports fibrinolysis.
Moisten tissues: Frequent irrigation and the use of moist sponges prevent desiccation of tissue. Ringer's lactate or other irrigating solutions also eliminate any residual talc, lint, or blood clots, which may provide a nidus for a foreign body reaction, inflammation, and adhesion formation.
Avoid dry sponges: Use of gauze and dry sponges should be avoided because they may damage the peritoneal surface and leave a foreign body behind.
Minimize tissue handling: Manipulating tissue increases the possibility of vascular and tissue damage. When direct manipulation of the peritoneum is necessary, use either atraumatic instruments or fingers. In addition, cutting and coagulating should be kept to a minimum to reduce the possibility of trauma and maintain vascularity.
Use fine, nonreactive sutures: To minimize foreign body reactions use the smallest size of suture composed of synthetic material.
Avoid peritoneal grafts: Grafting increases the risk of peritoneal trauma while decreasing vascularity.
Minimize foreign bodies: Foreign bodies may damage the peritoneal surface, lead to inflammation, and ultimately result in adhesion formation.
CONSIDERING SURGERY
If surgery is recommended for you, it's important to know what your options are and what questions to ask your primary-care physician and surgeon. If you learn all you can, you'll be sure that you're making the right decision.
Jason Bodzin, M.D., F.A.C.S., director of the Inflammatory Bowel Disease (IBD) Institute at Sinai Hospital in Detroit, advises you to follow a four-step process:
Examine your options.
Talk to your surgeon.
Talk to patients who have had the operation.
Weigh all the factors in making your decision.
Knowing What to Ask
Before consenting to surgery, the first question you should ask is: "Is this surgery necessary, or are there other medical options that I can try?" For instance, many people with IBD have avoided surgery by combining total parenteral nutrition (intravenous feeding) with medications. 6-MP, an immunomodulator drug, often successfully heals fistulas that once required surgery.
You'll also want to know:
Are there other surgical options?
What risks will I face by having the operation?
How will the operation improve my condition?
How long will my recovery take?
Will I require medications following surgery?
Whom do you recommend as a surgeon? As anesthesiologist?
Choosing a Surgeon
Many sources can help you find a surgeon:
Friends, relatives, neighbors
Your primary-care physician
American Board of Medical Specialties (ABMS): (800) 776-CERT. (The ABMS can tell you whether a surgeon is board-certified.)
American College of Surgeons: (312) 664-4050, Ext. 391
The American Society of Colon and Rectal Surgeons: (708) 290-9184
Your local CCFA chapter
Your health insurance carrier
Your local hospital, or your state or county medical association -- all can provide lists of board-certified surgeons.
Once you've compiled a list of two or three possible surgeons, ask the following questions about each one:
Is he experienced with the particular operation you need? (This is particularly important if you are undergoing a fairly new procedure, such as an ileoanal anastomosis.)
Does she treat many IBD patients?
Is he affliated with the hospital you want to be in?
Is she affiliated with a medical school or is she a member of its clinical faculty?
You'll also want to know:
Where the surgeon trained, what his specialization is, and whether he belongs to any professional organizations or has published any professional articles. (To get this information, ask the surgeon directly or go to the library.)
Whether the hospital frequently performs your kind of surgery and whether the staff is well-versed in IBD.
Getting a Second Opinion:
It is always wise to get a second opinion. In fact, many insurance companies require it. Before seeking a second opinion, you may want to get copies of all your medical records. However, any physician can request these for you.
If you receive conflicting opinions, visit a third surgeon or review the situation with your primary-care physician. Though this process can be frustrating and time-consuming, it will give you peace of mind.
http://www.adhesionrelateddisorder.com/adhesion3.html
In some cases, the answer is Adhesions!
Adhesions are bands of scar tissue intra-abdominal and/or pelvic cavity that bind your internal organs together, causing them to stick to each other. The result of these bands of scar tissue can lead to:
Adhesion Related Disorder or ARD.
The symptoms of ARD include:
Chronic pain
Infertility
Bowel obstruction
Gastro-esophageal reflux disease, (GERD)
Urinary Bladder dysfunction
Pain and difficulty having a bowel movement
Pain on movement such as: Walking, sitting or laying in certain positions.
Loss of Nutrients due to poor eating habits or loss of appetite.
Loss of employment due to lost work days
Loss of family and social life
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness
If you are experiencing pelvic pain, it’s important to see your doctor. Pain in the pelvic or abdominal area can be caused by a variety of conditions, some of which may be serious. Your doctor will be able to perform tests to determine the cause of your pain. Do not assume all pelvic or abdominal is caused by adhesion even if your post adhesiolysis, as adhesions do reform following surgery.
It is important to ask for and allow diagnostic tests to rule out other sources of pathology as being the cause for your symptoms…while some adhesion do cause pain, not all adhesions cause pain and not all pain is caused by adhesions!
If all diagnostic tests result in negative findings, one cause of pain that your doctor might consider is adhesions, particularly if you have had abdominal or pelvic surgery. Adhesions are commonly associated with pelvic pain. In fact, an estimated 38 percent of women suffering from pelvic pain have adhesions.
The better news is that there are things that your doctor can do to reduce the incidence post-operative adhesions – and maybe even prevent them altogether. Educate yourself to “Adhesion Related Disorder” as the informed patient can make informed decisions when you discuss your symptoms and medical care needs with your doctor.
Always request and keep a personal file of all your medical interventions!
Adhesions Can Cause Pain:
Adhesions can cause pain by binding normally separate organs and tissues together - essentially “tying them down.” The stretching and pulling of everyday movements can irritate the nerves involved. Some adhesions can cause pain during intercourse. Ask your medical care provide to order an “ESR = Erythrocyte Sedimentation Rate” ‘ blood test for inflammatory reaction in your body. Inflammation at the adhesion attachment sites become agitated due to the pulling and tugging on the tissues of the attached organs. This inflammation creates pain and must be taken into consideration by the Doctor when treating the ARD sufferer for pain.
While pelvic pain can be an obvious symptom of adhesions, there are other serious complications of which you should be aware. Two of the more common complications of adhesions are infertility and bowel obstruction.
Adhesion can and do cause disabling pain and loss of productivity. You will want to resent substantiating information on this issue when you meet with your Doctor.
Be prepared, be your own best Doctor!
Bowel obstruction:
Adhesion formation involving the bowel (intestine) is particularly common following hysterectomy. These adhesions occasionally they can cause the bowel to kink and not allow the passage of digested food. This causes a “back-up.” Bowel obstruction can occur shortly after surgery or many years later. Symptoms of bowel obstruction may include pain, nausea, and vomiting. Bowel obstruction is a serious illness and requires immediate medical attention.
Even though the overall incidence of bowel obstruction is low, you should be aware of the possibility of its occurrence. If left untreated, obstruction can lead to serious complications, even death. Symptoms of bowel obstruction include:
Abdominal pain
Nausea
Vomiting
Diarrhea (early)
Constipation (late)
Fever
You should talk to your doctor if you have any of these symptoms.
Endometriosis.
One of the more common non-surgical causes of pelvic pain is endometriosis.
If you have been trying unsuccessfully to conceive, you are probably searching for the cause. Your search may have led you to this site. It’s important to understand that there are many conditions that can cause infertility, and you should talk to your doctor to determine whether your situation requires medical attention.
Adhesions that form as a result of certain types of gynecologic surgery, especially tubal surgeries and myomectomies (surgery to remove fibroids), are a common cause of infertility. Adhesions can form between the ovaries, fallopian tubes or pelvic walls.
These adhesions can block the passage of ovum (an egg) from the ovaries into and through the fallopian tubes.
Adhesions around the fallopian tubes can also interfere with sperm transport to the ovum.
Ovarian Surgery
Surgical Treatment of Endometriosis
Myomectomy
Reconstructive Tubal Surgery
The good news is that infertility due to pelvic adhesions can be successfully treated in approximately 40% to 60% of women. However, the surgical procedure, adhesiolysis, can often lead to more adhesions. The best way to reduce the chances of adhesions forming and/or reforming is for your surgeon to learn the best procedure used in the attempt to reduce adhesion formation. The more a surgeon practices the procedure, the more skilled he will become in performing it. As he develops his technique over time along with the use of an effective adhesion barrier, the better the results for improvement in the symptoms of the adhesion patient!
Talk to your doctor if you have pelvic pain of any kind.
Although adhesions often form after gynecologic surgery, they are not inevitable. And, even if adhesions do form, they usually don’t cause pain or other problems.
Although there is no way to eliminate the risk of adhesions completely, there are steps your surgeon can take to reduce the likelihood of adhesion formation. The most effective methods of adhesion prevention involve meticulous surgical technique and the use of a physical barrier to separate tissue surfaces while they heal.
Surgeons have developed minimally invasive techniques such as the laparoscopy, that are designed to minimize trauma, blood loss, infection, and the introduction of foreign bodies, all of which can lead to inflammation and adhesion formation. Good surgical technique involves minimizing tissue handling, using delicate instruments, and keeping the tissues moist when they are exposed to the air.
While good surgical technique is important, but it is often not sufficient to prevent adhesions. There are also other preventive steps that can be taken:
Surgical techniques that can help decrease adhesion formation
Not simply the surgical procedure used, but in combination with these techniques and the lesser of invasive surgery, a laporoscopy, one has the best chance of adhesion reduction when these are used together in a surgery!
Achieve meticulous hemostasis
Maintain vascularity
Moisten tissues
Avoid dry sponges
Minimize tissue handling
Use fine, non-reactive sutures
Avoid peritoneal grafts
Minimize foreign bodies
Even though the most meticulous surgical and microsurgical techniques cannot eliminate the formation of adhesions, the following steps can be taken to reduce adhesion formation:
Achieve meticulous hemostasis: Inadequate hemostasis and the resultant fibrin deposition promote adhesion formation.
Maintain vascularity: Limiting ischemia supports fibrinolysis.
Moisten tissues: Frequent irrigation and the use of moist sponges prevent desiccation of tissue. Ringer's lactate or other irrigating solutions also eliminate any residual talc, lint, or blood clots, which may provide a nidus for a foreign body reaction, inflammation, and adhesion formation.
Avoid dry sponges: Use of gauze and dry sponges should be avoided because they may damage the peritoneal surface and leave a foreign body behind.
Minimize tissue handling: Manipulating tissue increases the possibility of vascular and tissue damage. When direct manipulation of the peritoneum is necessary, use either atraumatic instruments or fingers. In addition, cutting and coagulating should be kept to a minimum to reduce the possibility of trauma and maintain vascularity.
Use fine, nonreactive sutures: To minimize foreign body reactions use the smallest size of suture composed of synthetic material.
Avoid peritoneal grafts: Grafting increases the risk of peritoneal trauma while decreasing vascularity.
Minimize foreign bodies: Foreign bodies may damage the peritoneal surface, lead to inflammation, and ultimately result in adhesion formation.
CONSIDERING SURGERY
If surgery is recommended for you, it's important to know what your options are and what questions to ask your primary-care physician and surgeon. If you learn all you can, you'll be sure that you're making the right decision.
Jason Bodzin, M.D., F.A.C.S., director of the Inflammatory Bowel Disease (IBD) Institute at Sinai Hospital in Detroit, advises you to follow a four-step process:
Examine your options.
Talk to your surgeon.
Talk to patients who have had the operation.
Weigh all the factors in making your decision.
Knowing What to Ask
Before consenting to surgery, the first question you should ask is: "Is this surgery necessary, or are there other medical options that I can try?" For instance, many people with IBD have avoided surgery by combining total parenteral nutrition (intravenous feeding) with medications. 6-MP, an immunomodulator drug, often successfully heals fistulas that once required surgery.
You'll also want to know:
Are there other surgical options?
What risks will I face by having the operation?
How will the operation improve my condition?
How long will my recovery take?
Will I require medications following surgery?
Whom do you recommend as a surgeon? As anesthesiologist?
Choosing a Surgeon
Many sources can help you find a surgeon:
Friends, relatives, neighbors
Your primary-care physician
American Board of Medical Specialties (ABMS): (800) 776-CERT. (The ABMS can tell you whether a surgeon is board-certified.)
American College of Surgeons: (312) 664-4050, Ext. 391
The American Society of Colon and Rectal Surgeons: (708) 290-9184
Your local CCFA chapter
Your health insurance carrier
Your local hospital, or your state or county medical association -- all can provide lists of board-certified surgeons.
Once you've compiled a list of two or three possible surgeons, ask the following questions about each one:
Is he experienced with the particular operation you need? (This is particularly important if you are undergoing a fairly new procedure, such as an ileoanal anastomosis.)
Does she treat many IBD patients?
Is he affliated with the hospital you want to be in?
Is she affiliated with a medical school or is she a member of its clinical faculty?
You'll also want to know:
Where the surgeon trained, what his specialization is, and whether he belongs to any professional organizations or has published any professional articles. (To get this information, ask the surgeon directly or go to the library.)
Whether the hospital frequently performs your kind of surgery and whether the staff is well-versed in IBD.
Getting a Second Opinion:
It is always wise to get a second opinion. In fact, many insurance companies require it. Before seeking a second opinion, you may want to get copies of all your medical records. However, any physician can request these for you.
If you receive conflicting opinions, visit a third surgeon or review the situation with your primary-care physician. Though this process can be frustrating and time-consuming, it will give you peace of mind.
http://www.adhesionrelateddisorder.com/adhesion3.html
Saturday, September 24, 2011
¿Cuál es el desorden relacionado las adherencias (ARD)?
¿Cuál es el desorden relacionado las adherencias (ARD)?
La nota del Blogger… esto es una de muchas definiciones
El desorden relacionado adherencia es un complejo de los síntomas relacionados con las adherencias. La queja primaria del paciente es generalmente dolor abdominal crónico. Sus síntomas pueden estar sobre todo en una área del abdomen pero son generalizados a menudo, vagos, crampy y difíciles de definir. Los síntomas de ARD podían incluir:
Dolor crónico
Infertilidad
Obstrucción del intestino
Enfermedad del reflujo gastroesofágico, (GERD)
Disfunción de la vejiga urinaria
Dolor y dificultad que tienen un movimiento de intestino
Dolor en el movimiento por ejemplo: El caminar, el sentarse o colocación en ciertas posiciones.
Pérdida de alimentos debido a los hábitos alimentarios pobres o pérdida de apetito.
Pérdida de empleo debido a los días perdidos del trabajo
Pérdida de familia y de vida social
Desordenes emocionales por ejemplo: Depresión, pensamientos del suicidio, desesperación
Otros problemas intestinales pueden acompañar el dolor. El estreñimiento o la obstrucción se encuentra a veces. El estreñimiento de alternancia con diarrea de la obstrucción parcial puede también ser considerado. Los síntomas se pueden también relacionar con las órdenes ginecológicas en mujeres mientras que este desorden afecta con frecuencia a mujeres. Los cambios en el ciclo menstrual, la infertilidad, y el dolor con cópula sexual pueden ser encontrados. Otros síntomas, relacionados no no directamente con las adherencias, pueden también ser encontrados. Desde ARD da lugar generalmente a los problemas crónicos, ansiedad y la depresión puede resultar. Las relaciones filtradas pueden ocurrir especialmente cuando el desorden afecta a la función sexual. La dificultad con el concepto puede resultar. Este más futuro agrega a la ansiedad y a los problemas con el amor propio experimentado por las mujeres que sufren con este desorden. La consumición de la dificultad puede dar lugar a la nutrición pobre, el debilitamiento sufre la dolencia total y puede también llevar a una disminución de la función inmune que lleva a muchas otras enfermedades. Puesto que muchos de los síntomas relacionados con ARD son vagos y separan de par en par e incluyen a menudo factores emocionales, son a menudo difíciles de diagnosticar. Los síntomas de ARD serán atribuidos a menudo a otras anormalidades. El paciente llevará a menudo diagnosis múltiples incluyendo el síndrome crónico de la fatiga, endometriosis, síndrome de intestino irritable, fibromyalgia, depresión, ansiedad, junto con un anfitrión entero de otros síndromes posibles. Mientras que los desordenes múltiples pueden existir ciertamente en un paciente, la confusión sobre quien anormalidad está causando verdad los síntomas agrega a la frustración de ARD. Esto, desafortunadamente, agrega al malestar experimentado por los que sufran con adherencias. El dolor crónico Undiagnosed causa tanto el dolor físico y emocional para las víctimas del desorden relacionado adherencia - y llena sus vidas tanto de la indecisión. A tiempo los efectos de ARD comenzarán a afectar a las vidas de sus familias, de sus relaciones y de sus trabajos. ¡Este control excesivo por ARD tiene la energía de erosionar y de cambiar nuestras vidas - y no no necesariamente para el mejor! Es así que importante creer en se, confiar en las sensaciones que usted tiene sobre su dolor, y decirlo tenga gusto de él es. ¡Usted tiene la derecha de ser escuchado y de ser tratado con el respecto - nada menos!!
Fijado por IHRT en 9/24/2011 08:35: 00
Etiquetas: Adherencias, adhesiolysis, adherencia relacionó el desorden, adhesioninfo, adherencias, ARD, capps, esperanza del dolor de la adherencia, dolor, adherencia postoperatoria, tejido de la cicatriz, adherencias quirúrgicas, synechiae
comentarios 0:
La nota del Blogger… esto es una de muchas definiciones
El desorden relacionado adherencia es un complejo de los síntomas relacionados con las adherencias. La queja primaria del paciente es generalmente dolor abdominal crónico. Sus síntomas pueden estar sobre todo en una área del abdomen pero son generalizados a menudo, vagos, crampy y difíciles de definir. Los síntomas de ARD podían incluir:
Dolor crónico
Infertilidad
Obstrucción del intestino
Enfermedad del reflujo gastroesofágico, (GERD)
Disfunción de la vejiga urinaria
Dolor y dificultad que tienen un movimiento de intestino
Dolor en el movimiento por ejemplo: El caminar, el sentarse o colocación en ciertas posiciones.
Pérdida de alimentos debido a los hábitos alimentarios pobres o pérdida de apetito.
Pérdida de empleo debido a los días perdidos del trabajo
Pérdida de familia y de vida social
Desordenes emocionales por ejemplo: Depresión, pensamientos del suicidio, desesperación
Otros problemas intestinales pueden acompañar el dolor. El estreñimiento o la obstrucción se encuentra a veces. El estreñimiento de alternancia con diarrea de la obstrucción parcial puede también ser considerado. Los síntomas se pueden también relacionar con las órdenes ginecológicas en mujeres mientras que este desorden afecta con frecuencia a mujeres. Los cambios en el ciclo menstrual, la infertilidad, y el dolor con cópula sexual pueden ser encontrados. Otros síntomas, relacionados no no directamente con las adherencias, pueden también ser encontrados. Desde ARD da lugar generalmente a los problemas crónicos, ansiedad y la depresión puede resultar. Las relaciones filtradas pueden ocurrir especialmente cuando el desorden afecta a la función sexual. La dificultad con el concepto puede resultar. Este más futuro agrega a la ansiedad y a los problemas con el amor propio experimentado por las mujeres que sufren con este desorden. La consumición de la dificultad puede dar lugar a la nutrición pobre, el debilitamiento sufre la dolencia total y puede también llevar a una disminución de la función inmune que lleva a muchas otras enfermedades. Puesto que muchos de los síntomas relacionados con ARD son vagos y separan de par en par e incluyen a menudo factores emocionales, son a menudo difíciles de diagnosticar. Los síntomas de ARD serán atribuidos a menudo a otras anormalidades. El paciente llevará a menudo diagnosis múltiples incluyendo el síndrome crónico de la fatiga, endometriosis, síndrome de intestino irritable, fibromyalgia, depresión, ansiedad, junto con un anfitrión entero de otros síndromes posibles. Mientras que los desordenes múltiples pueden existir ciertamente en un paciente, la confusión sobre quien anormalidad está causando verdad los síntomas agrega a la frustración de ARD. Esto, desafortunadamente, agrega al malestar experimentado por los que sufran con adherencias. El dolor crónico Undiagnosed causa tanto el dolor físico y emocional para las víctimas del desorden relacionado adherencia - y llena sus vidas tanto de la indecisión. A tiempo los efectos de ARD comenzarán a afectar a las vidas de sus familias, de sus relaciones y de sus trabajos. ¡Este control excesivo por ARD tiene la energía de erosionar y de cambiar nuestras vidas - y no no necesariamente para el mejor! Es así que importante creer en se, confiar en las sensaciones que usted tiene sobre su dolor, y decirlo tenga gusto de él es. ¡Usted tiene la derecha de ser escuchado y de ser tratado con el respecto - nada menos!!
Fijado por IHRT en 9/24/2011 08:35: 00
Etiquetas: Adherencias, adhesiolysis, adherencia relacionó el desorden, adhesioninfo, adherencias, ARD, capps, esperanza del dolor de la adherencia, dolor, adherencia postoperatoria, tejido de la cicatriz, adherencias quirúrgicas, synechiae
comentarios 0:
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