Adhesion Awareness: A National Survey of Surgeons.

Schreinemacher MH, ten Broek RP, et al: World J Surg; 2010;34 (December): 2805-2812


Objective: To report on a survey of Dutch surgeons, hypothesizing that lack of knowledge about adhesions and their consequences is related to surgeon practice and adhesion-related complications.

Design: Survey.

Participants: 1455 surgeons and trainees.

Methods: Initial survey questions were developed by a group of surgeons with a particular interest in adhesions. Questions were then edited by researchers with expertise in survey design and construction of multiple choice questions. Resultant survey was pilot-tested with 5 practicing surgeons and 3 surgical trainees. Final survey contained 55 multiple-choice questions, 4 open-ended questions, and 4 optional questions. Survey was sent to all members of the Dutch Association for Surgery, as well as to all registered surgical trainees. A reminder was sent electronically 1 week after the initial email if no response was obtained. Data from surveys with <80% p ="0.032).">Conclusions: The magnitude of the problem of postoperative adhesions is underestimated.
Reviewer's Comments: None of the agents that have been proposed as the magic bullet to prevent adhesions has lived up to expectations (or hopes), although certain products are effective in certain high-risk operations and populations. Even if adhesions are viewed as an inevitable result, it does make sense to include this in the preoperative discussion with patients, particularly those in high-risk groups. It appears that hopes and expectations will continue to rest on a future magic bullet.(Reviewer–Karen J. Brasel, MD, MPH).
© 2010, Oakstone Medical Publishing
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Will liver scar tissue hurt my chances for a natural birth?

Asked by Inga Johnson, Lake Mary, Florida

"I had a liver resection in late December 2008 because of a cavernous hemangioma (an abnormal buildup of blood vessels). I now have about a 10-inch scar from about center of my rib cage following along to the outer ribcage. Are there known complications of scar tissue like this? I am eight weeks pregnant and have started to wonder if the scar tissue may be an issue for natural birth and if there may be other issues that I should be aware of."

Conditions Expert
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society

Expert answer
Of course, I encourage you to discuss your concerns with your obstetrician. Perhaps I can give you some information to help in that discussion.

First let me explain that a hepatic hemangioma (also referred to as cavernous hemangioma) is a very common benign liver tumor. It is not known why these tumors occur. They are found in men and women of all ages. They usually have no symptoms and are frequently found when CT scans and ultrasounds are done for unrelated reasons.

Small asymptomatic hemangiomas are usually watched. Larger (greater than 5 centimeter in diameter) and symptomatic hemangiomas are treated.

The most common treatment is surgical removal. When a hemangioma is successfully removed, the overwhelming majority of patients do very well. Some patients will have multiple hemangiomas and only the largest one or the one causing symptoms is removed.

For women who have a known moderate to large hemangioma, there is concern that the high estrogenic levels found in women who are pregnant or taking oral contraceptives may encourage the growth of these hemangiomas. This is a concern and not a certainty.

As a result, controversy exists as to whether patients with known hemangiomas should be advised against pregnancy. For patients with hepatic hemangioma, full-term pregnancy without complication is the norm, but there have been a small number of women with hemangiomas that rupture and bleed during pregnancy. Some of these ruptured hemangiomas can be carefully watched and some need surgical resection.

In answer to your question, all surgeries in which the abdomen is entered carry a risk of postoperative adhesions, or the bowel sticking to itself. This is true for an appendectomy, a gallbladder surgery or a liver surgery. The risk is greatest for open surgeries and lower for laparoscopic surgery.

In general, a healthy pregnant woman with a history of a hemangioma resection should do well with the pregnancy. The risk of complications in delivery, be it by natural childbirth or by cesarean section delivery, are similar to that of a woman having had any successful abdominal surgery.

Adhesions are the result of tissue trauma and subsequent healing. They can cause abdominal pain, infertility, bowel obstruction, and they can increase the difficulty of subsequent surgical procedures. Bowel obstruction is the most common concern. In one large study, 3 of every 100 patients having an open abdominal surgery were diagnosed with symptomatic adhesions. Most are diagnosed within the first year after surgery.

To understand adhesions and obstruction, picture the gastrointestinal tract. It is a long tubular structure running from the mouth to the anus. The large and small intestine is a part of that tract and runs more than 25 feet long in the average adult. Imagine the large and small intestine like a garden hose coiled up in the abdominal cavity. It is possible for some of the bowel to have folds stuck to itself that can at times, due to shifting and movement, impede the flow of bowel content.

Acute bowel obstruction due to adhesions usually manifests itself with abdominal pain, nausea and vomiting. It is usually treated with hydration and bowel rest and can resolve with no further ill effects. Severe obstruction and especially recurring obstruction may be treated with surgical removal of the blockage.

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Acute kidney injury due to osmotic nephrosis following intraoperative placement of an intraperitoneal antiadhesive barrier.

Am J Kidney Dis. 2011 Feb;57(2):304-7.

Acute kidney injury due to osmotic nephrosis following intraoperative placement of an intraperitoneal antiadhesive barrier.
Economidou D, Stavrinou E, Giamalis P, Dimitriadis C, Economou S, Memmos D.

Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.

Abstract
In recent years, a common strategy for the prevention of postsurgical intra-abdominal adhesions has been intrasurgical placement of adhesion barriers into the peritoneal cavity. Osmotic agents, such as various polysaccharides, frequently are used as antiadhesive materials. The effects of these materials on kidney function have not yet been studied. We report a case of an individual with pre-existing chronic kidney disease who developed acute kidney injury after surgical placement of an antiadhesive barrier of macromolecular polysaccharides. A kidney biopsy, performed because of persistent kidney failure, showed tubular cell lesions compatible with osmotic nephrosis lesions. This case suggests that use of polysaccharide-containing antiadhesive barriers can induce severe kidney damage. Such barriers should be used with caution in patients with abnormal kidney function to prevent irreversible damage.

Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
PMID: 21251542 [PubMed - in process]


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Adhesions, Adhesions-Related Disorder or CAPPS – a way to think about the problem from the patient’s perspective.

Adhesions, Adhesions-Related Disorder or CAPPS – a way to think about the problem from the patient’s perspective.

Dallas TX. June 11 2010. The International Adhesions Society (IAS) is proud to post on its adhesions.org web site the results of groundbreaking and innovative research which will forever change the way the problem of adhesions is viewed.

The paper was published after Dr. Wiseman was invited to submit a manuscript for inclusion in a special volume of “Seminars in Reproductive Medicine” on the subject of adhesions. The paper is entitled: “Disorders of Adhesions or Adhesion-Related Disorder: Monolithic Entities or Part of Something Bigger—CAPPS? “ (click here for .pdf)

Since forming the International Adhesions Society (IAS) in 1996, it became increasingly obvious that the problems of patients suffering from adhesions were not just about adhesions. Accordingly, we were the first to coin the term “Adhesion Related Disorder” (ARD) to include the entire complex of pain, infertility, obstruction, nutrition, psychological and social issues that ARD sufferers and their families experience.

Based on formal patient surveys as well as thousands of emails and phone calls from patients, it became apparent to us that even the term ARD may be inadequate to address the problem. In reality, the ARD patient is part of a much larger group of patients who, in varying degrees, combinations and sequences experience a range of symptoms and conditions including endometriosis, interstitial cystitis (IC), irritable bowel syndrome (IBS), bowel obstruction and chronic abdominal and/or pelvic pain.

Although ‘‘adhesions’’ may start out as a single, stand-alone entity, an adhesions patient may develop a number of related conditions (ARD) which renders those patients practically indistinguishable from patients with multiple symptoms originating from other abdominal or pelvic conditions. (continued)
release.

Click here for a pdf copy of the entire press
Click here for a .pdf copy of the CAPPS article


Please visit the Internation Adhesion Society to interact and become educated!
www.adhesions.org

What Patients Deserve to Know: Even Vegas has to Publish Its Odds

By Donna Smith

Since millions of American patients face medical debt they didn’t know they’d have – and many if not most of them purchased insurance to protect against that debt – it seems logical to me that patients should be fully informed up front of the financial risks they are taking on when they seek medical care. Doctors and others providers should publish and post in their offices their methods of debt collection and the numbers of patients they sue in an average practice year. They can put the disclosures of medical debt collection practices right next to the little signs that tell patients they must pay their co-pays prior to receiving medical care.

I shared the idea with my University of Chicago educated son, and he liked it. He said, “Even Vegas has to disclose the odds of winning.” True enough. Even those who love the market economy like to know as much as possible about their financial entanglements before they enter them.

Disclosure. Disclosure. Disclosure. (Much like the old real estate advice – location, location, location.) Financial. Debt collection practices. Health condition outcomes.

So, along with the releases and privacy statements and risk assignment forms I must sign before I am accepted as a patient, providers should also publish their outcomes evidence as well. How am I to know if a given provider is just good buddies with the referring physicians or if they truly have a success record with the condition for which I require care?

I’d feel better about reform that promised those things than I do about a reform measure that simply forces me to purchase the defective financial product sold as private health insurance. Private health insurance is marketed to me to protect my health and wealth, and yet it may or may not do either. It’s a crap shoot.

Did you know some medical providers in Pennsylvania go to what’s known as “collectors’ universities” to learn how to collect their medical debt from the families of deceased patients? They study two legal documents offered by the collection experts: the “Doctrine of Necessities” and “Collecting from the Deceased.” Ouch. Imagine that after your loved one’s for-profit private insurance company fails to pay all the bills when a child or spouse or parent dies. And Pennsylvania providers are no different than many others around the nation. Collecting medical debt is big, big business.

So regardless of what this Congress does or what this President celebrates in the Rose Garden framed by the billowing cherry blossoms, I’ll still be slugging it out in the front offices of providers, at the admissions desks in hospitals and at the pharmacy counters to try to secure the care I need and pay for. Nothing has been done to improve my chances of getting what I bargained for as a patient. I am to accept on good faith what the providers secure as a legal guarantee from me.

I want a single standard of high quality care through progressive financing. I want to be able to choose the care that is high quality. I simply cannot do that unless and until my rights as a patient are protected. And we are a long way away from that day. Under an improved Medicare for all system, I would be saved from the terrible loop that is the medical collection system in this nation. I’d still want to know health outcomes data, but that would be far easier to obtain and track. Wow, imagine that.

Should gamblers playing slot machines really be given the legal right to know pay-out odds in a nation that thinks patients have no right to knowledge of results expected from their medical care providers? Surely, reputable providers could not object to that sort of patient or citizen empowerment. But wait. A lawyer friend of mine from Colorado tells me that hospitals and many doctors could hardly be less cooperative in talking about this topic. Big surprise.

The day will come when patients will be the center of this debate. It has not come yet. This Congress and this administration have never put our interests first, so this effort was flawed from the start. Because the improvements I need to see as a patient are nowhere to be found in this mess, I understand why people lose interest in the fight. The disconnect between what we need and what we are getting from this round of health reform effort as patients and as citizens is a chasm too deep.
Link to article

Pregabalin relieves discomfort from abdominal adhesions, study finds

Posted On: October 26, 2009 - 3:30pm
DETROIT – Pregabalin, FDA-approved for neuropathic pain (pain caused by shingles and peripheral neuropathy), effectively reduced abdominal pain and improved sleep in women with adhesions, according to a Henry Ford study.
Adhesion pain, a common complication after abdominal or pelvic surgery, currently lacks effective therapy. Adhesions can also form after infections in the bowel such as diverticulitis.
"Many patients in the study went from debilitating pain to complete resolution of pain on pregabalin," says Ann Silverman, M.D., senior staff gastroenterologist at Henry Ford Hospital and lead author of the study.
Study results will be presented Oct. 26 at the American College of Gastroenterology's Annual Scientific Meeting in San Diego.
"Aside from the use of analgesics, additional surgery is the only treatment option for abdominal pain from adhesions but repeat surgery can lead to more adhesions," says Dr. Silverman.
The estimates of abdominal adhesion formation following surgery have been found to be as high as 100 percent in certain studies. Surgery is only recommended for bowel obstruction.
The randomized Henry Ford study looked at 18 women who received the drug or a look-alike placebo. All patients had previous abdominal surgery and were similar in age. The first eight weeks was a randomized placebo controlled trial of pregabalin followed by a four-week open label study in which all patients received the active study drug.
The primary objective was to demonstrate a significant reduction in pain scores.
The pain score result from the blinded phase indicated that the amount of decrease was significantly greater in the drug group (p-value = 0.024) compared with those on placebo, while the pain score resulted from the open label setting indicated that the amount of decrease was significantly greater in the placebo group (p-value = 0.043). This would be expected since those on active drug continued to take active drug and patients who had received the look-alike placebo received the active drug only during this phase of the study.



Source: Henry Ford Health System
Link to article

Malpractice lawsuit claims surgeon erred using blind laparoscopic technique.

To See or Not to See During Laparoscopy

Is a blind laparoscopic technique to blame for a routine cholecystectomy that went awry? That's the crux of a lawsuit filed in December 2009 in U.S. District Court in Maryland by a woman who needed emergency surgery after her surgeon nicked her intestines during gallbladder surgery.

In the suit, Gloria Milbourne, of Atlantic, Va., claims that during her pre-operative visit she told surgeon Janet Wasson, MD, of Salisbury, Md., about her previous hysterectomy. However, the medical records for the cholecystectomy performed in March 2007 don't mention the hysterectomy.

Ms. Milbourne and her attorney claim that if the surgeon had been able to see inside the abdomen, she might not have nicked the small intestine that had adhered to a scar just below the navel and the trocar port. During the surgery, Dr. Wasson used a Veress insuflation needle and a 10 mm trocar port and no visualization device for the procedure. Ms. Milbourne's complaint says that since she had adhesions in her abdomen as a result of the hysterectomy, Dr. Wasson should have performed the procedure "at another site in the abdomen or by a different technique, such as the Hassan method where dissection occurs through each layer and the abdomen is entered under direct vision."

The day after outpatient surgery, Ms. Milbourne was in great pain, vomited and had to be taken to the emergency department at Peninsula Regional Medical Center in Salisbury. At the hospital, Dr. Wasson's partner said that Ms. Milbourne's intestines had been nicked during the cholecystectomy and that "'poison was leaking' into her system," according to the complaint, which also names as negligent the Chesapeake Surgery Center in Salisbury.

The night that she went to the emergency department, Ms. Milbourne had to undergo emergency surgery to remove 2 to 3 inches of her intestines through a 9-inch incision that went from her breastbone to her pelvis, says the complaint.

Ms. Milbourne had to stay in the hospital for 14 days with a surgical wound that could not be closed because of the infection in her abdomen. At home, Ms. Milbourne suffered a long recovery and now is often short of breath and can't lift things, according to court documents. Ms. Milbourne's attorney did not reply to a request for comment.

In court documents, Dr. Wasson denies that she was negligent in caring for Ms. Milbourne and denies that she delivered substandard care. Dr. Wasson's attorney said he would not comment on the case because it's still pending. The case is still in discovery, and no trial date has been set.

Kent Steinriede
http://www.outpatientsurgery.net/news/2010/03/10