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ARD Education and Awareness

A Patient's Guide to Adhesions & Related Pain 
Dr. David Wiseman PhD, MRPharms

Abdominal Adhesions
Written by Dr. Reich.

 
What are Adhesions (Internal Scar Tissue)?

 An ADHESION is a type of scar that forms an abnormal connection between two parts of the body.  Adhesions can cause severe clinical problems.  For example, adhesions involving the female reproductive organs (ovaries, Fallopian tubes) can and do cause infertility, dyspareunia (painful intercourse) and debilitating pelvic pain.  Adhesions involving the bowel can cause bowel obstruction or blockage.  Adhesions may form elsewhere such as around the heart, spine and in the hand where they lead to other problems. 

 Adhesions occur in response to injury of various kinds.  For example, non surgical insults such as endometriosis, infection, chemotherapy, radiation and cancer may damage tissue and initiate ADHESIONS.  By far the most common kind of ADHESION is the one that forms after surgery.  ADHESIONS typically occur at the site of a surgical procedure although they may also occur elsewhere.

The Magnitude of the Problem of Adhesions

 The rate of adhesion formation after surgery is surprising given the relative lack of knowledge about ADHESIONS among doctors and patients alike.  From autopsies on victims of traffic accidents, Weibel and Majno (1973) found that 67% of patients who had undergone surgery had adhesions.  This number increased to 81% and 93% for patients with major and multiple procedures respectively.  Similarly, Menzies and Ellis (1990) found that 93% of patients who had undergone at least one previous abdominal operation had adhesions, compared with only 10.4% of patients who had never had a previous abdominal operation.  Furthermore, 1% of all laparotomies developed obstruction due to adhesions within one year of surgery with 3% leading to obstruction at some time after surgery.  Of all cases of small bowel obstruction, 60-70% of cases involve adhesions (Ellis, 1997).

 Lastly, following surgical treatment of adhesions causing intestinal obstruction, obstruction due to adhesion reformation occurred in 11 to 21% of cases (Menzies, 1993).

Between 55 and 100% of patients undergoing pelvic reconstructive surgery will form adhesions.

Adhesions and Chronic Pelvic Pain (CPP)

 ADHESIONS are believed to cause pelvic pain by tethering down organs and tissues, causing traction (pulling) of nerves.  Nerve endings may become entrapped within a developing adhesion.  If the bowel becomes obstructed, distention will cause pain. 

 Some patients in whom chronic pelvic pain has lasted more than six months may develop "Chronic Pelvic Pain Syndrome.  In addition to the chronic pain, emotional and behavioral changes appear due to the duration of the pain and its associated stress.  According to the International Pelvic Pain Society: 

 "We have all been taught from infancy to avoid pain. However, when pain is persistent and there seems to be no remedy, it creates tremendous tension. Most of us think of pain as being a symptom of tissue injury. However, in chronic pelvic pain almost always the tissue injury has ceased but the pain continues. This leads to a very important distinction between chronic pelvic pain and episodes of other pain that we might experience during our life: usually pain is a symptom, but in chronic pelvic pain, pain becomes the disease."
 Chronic pelvic pain is estimated to affect nearly 15% of women between 18 and 50 (Mathias et al., 1996).  Other estimates arrive at between 200,000 and 2 million women in the United States (Paul, 1998).  The economic effects are also quite staggering.  In a survey of households, Mathias et al. (1996) estimated that direct medical costs for outpatient visits for chronic pelvic pain for the U.S. population of women aged 18-50 years are $881.5 million per year.  Among 548 employed respondents, 15% reported time lost from paid work and 45% reported reduced work productivity. 

 Not all ADHESIONS cause pain, and not all pain is caused by ADHESIONS.

 Not all surgeons, particularly general surgeons, agree that ADHESIONS cause pain.  Part of the problem seems to be that it is not easy to observe ADHESIONS non invasively, for example with MRI or CT scans. However, several studies do describe the relationship between pain and adhesions. According to an early study (Rosenthal et al., 1984) of patients reporting CPP, about 40% have adhesions only, and another 17% have endometriosis (with or without adhesions).  Kresch et al., (1984) also studied 100 women and found ADHESIONS in 38% of the cases and endometriosis in another 32%.
 Overall estimates (Howard, 1993) of the percentage of patients with CPP and ADHESIONS is about 25%, with endometriosis accounting for another 28%.  These figures must be understood in their context, and I recommend highly Howard's article.

 It is important to recognize that emotional stress contributes greatly to the patients perception of pain and her/his ability to deal with the pain.  Rosenthal et al. (1984) found that of the patients in whom a possible physical cause of pain (including ADHESIONS) could be identified, 75% had evidence of psychological influences on the pain.

Conclusion: You Are Not Alone
 Adhesions are almost an inevitable outcome of surgery, and the problems that they cause are widespread and sometimes severe.  It has been said by some that adhesions are the single most common and costly problem related to surgery, and yet most people have not even heard the term.  This lack of awareness means that many doctors are unable or unwilling to tackle the problems of adhesions, many insurance companies are unwilling to pay for treatment and many patients are left in misery. 
We are witnessing the beginning of a reversal of this situation as can be seen from a recent conference on pelvic pain. 

If you are suffering from the effects of adhesions, I hope that you have learned that  YOU ARE NOT ALONE   Emotional stress plays a major role in the pain that ADHESIONS can cause.  A good support network is essential and "a trouble shared is a trouble halved."  Many patients have reported that by sharing their experiences with others, be it by phone, local support group or the Internet, their feelings of loneliness, abandonment and frustration have abated, engendering a healing frame of mind.

 I have had a number of requests to start a patient support group for ADHESIONS sufferers (suggested motto: Let's Stick Together!!) whose goals would be: 

  • to share experiences and information
  • to provide support and advice to is members 
  • to raise the level of awareness among doctors, health care providers, government, prompting them to provide more comprehensive and integrated care for adhesions sufferers 
  • to support scientific research into adhesions and their prevention 
© 1998 SYNECHION, INC.
  Please note that this article is not intended to provide specific medical advice.  In all cases, an appropriately qualified medical doctor should be consulted about your condition and your proper treatment.

 Chronic pelvic pain and/or associated intestinal disturbance are a major cause of misery for thousands of patients.  Often in constant pain, the patient experiences loneliness, hopelessness, frustration and desperation with thoughts of suicide.  Family and work relationships are strained to the limit.  Although ADHESIONS are often (but not always) the cause of this pain, treatment for adhesions is not performed either because the surgeon does not believe that adhesions can cause the problem, or because lysis of adhesions is considered too difficult or futile.

 Adhesions are an almost inevitable outcome of surgery, and the problems that they cause are widespread and sometimes severe.  It has been said by some that adhesions are the single most common and costly problem related to surgery, and yet most people have not even heard the term.  This lack of awareness means that, excluding infertility, many doctors are unable or unwilling to tackle the problems of adhesions, many insurance companies are unwilling to pay for treatment and many patients are left in misery.

 This paper describes adhesions, their treatment and their relationship to pain and bowel obstruction.  In addition, stories from patients are featured to illustrate how adhesions (or suspected adhesions) affect their daily lives and how they cope with a sometimes insurmountable problem.

 A key lesson and source of comfort for patients with this problem is that they are not alone and the importance of mutual support among patients cannot be underestimated.

 There are no easy answers as yet.  In drawing attention to the human side of this problem, we hope to (begin to) educate patients and doctors about the range of treatments available, be they of a medical, surgical or psychological nature.  In addition, the establishment of a group to provide support and information to adhesions sufferers is proposed.

 


 
 
Abdominal Adhesions
Written by Dr. Reich.
Adhesions are abnormal, scar-like, fibrous tissue bands that develop after surgery between separate tissues, organs and structures in the body. They are sometimes known as intrauterine, pelvic or pericardial adhesions.
Adhesions may be the result of an episode of pelvic inflammatory disease or endometriosis, but most commonly are caused by previous pelvic and abdominal surgery. Adhesions cause pain through entrapment of the organs they surround, as well as disrupt bowel function, or cause infertility. The surgical management of extensive pelvic adhesions is one of the most difficult problems facing surgeons today.


************************************

Data suggests 67 to 93 percent of abdominal surgery patients will develop the condition following surgery, while 55 to 100 percent of gynecologic surgery patients will develop them. 

De novo are new adhesions that may form at a site of direct surgical trauma such as an incision. They may also develop at locations away from the site of surgery, for example, around the adnexa at the time of a cesarean section. Adhesions may also reform following adhesiolysis or adhesiectomy. 

Three greater types of adhesions exist, but the underlying pathophysiology is similar for each: 
Filmy 
Vascular 
Cohesive 

  A better scientific understanding of peritoneum and its response to injury is important in understanding how we might prevent adhesion formation. The peritoneum is a strong, colorless membrane that lines the abdomino-pelvic walls and forms a double-layered sac continuous with the mucous membrane of the uterine tubes in the female. The space between the parietal and visceral peritoneum is called the peritoneal cavity. The peritoneum is composed of multiple layers, that respond to injury through inflammation. This result is inevitable during surgery. The process occurs over 1 to 7 days. Over the next several months, changes continue characterized by the adhesions becoming more dense.
There is evidence that the use of physical barriers between tissues may reduce the incidence of adhesions. Barriers have included gauze, minimally moistened dry sponges, Intercede by Johnson and Johnson Medical, Inc., a Gore-Tex surgical membrane composed of expanded polytetrafluoroethylene, and Seprafilm.1 Steroids and other liquid and pharmacological agents to prevent post-operative adhesions may be beneficial, but more research needs to be conducted.2 Antihistamines, corticosteroids, and nonsteroidal anti-inflammatory drugs have been used. Efforts are currently underway to use a promising new hyaluronic acid-based gel, which is being evaluated in a multicenter randomized trial to determine its safety and effectiveness. One established standard-of-care that has been widely adopted includes the administration of a steroid along with an antihistamine. Frequent irrigation of tissues is also recommended to keep tissues moist and limit tissue desiccation.
Minimally invasive surgery, along with microsurgical techniques, lead towards less tissue destruction during surgery. It may be possible, therefore, for less of a chance of adhesions developing. However, studies have shown that adhesion rates in patients undergoing laparotomy may be between 70 and 90 percent. So in order to minimize the chances of adhesion formation, trauma should be minimized, tissues hydrated, less-restrictive sutures used, and good bleeding control applied. Other investigators have observed a 70 percent incidence in patients with previous gynecologic surgery, 50 percent incidence with previous appendectomy and even a more than a 20 percent incidence in patients with no surgical history. Other studies continue with special attention being paid to the incidence of de novo adhesion formation in laparotomy and laparoscopy
Sidebar:  The Chemical Process That Leads To Adhesions 
During the body's reaction that leads to an adhesion, chemicals called inflammatory mediators and histamines are released from the blood (more specifically the blood's mast cells and leukocytes).
Capillaries dilate. This allows leukocytes, red blood cells and platelets to concentrate at the injury site in a bundle called a fibrinous exudate. A variety of other factors are at play in the system such as asprostaglandins, bradykinin, chemotactic agents, lymphokines, seretonin and transforming growth factor.
At this point in time fibrinolysis may clear the fibrinousexudate. In order for this to occur, plasminogen must be converted to plasmin by tissue plasminogen activator (t-PA). There is constant play between the t-PA and plasminogen-activator inhibitors. 
Unfortunately surgical trauma normally decreases t-PA activity while simultaneously increasing plasminogen activator inhibitors. If this occurs, the fibrinous exudate is transformed into an organized adhesion where fibers of collagen are deposited. Blood vessels begin to form, which leads to an adhesion.
#3 What Are the Symptoms of Adhesions?
Symptoms vary depending on the tissues involved. For example, in the gastrointestinal tract, bowel obstructions may occur. In the uterus, adhesions can cause ... In the pelvis, adhesions can cause infertility and other reproductive problems.
Clinically, adhesions present as fever, chronic or acute abdominal, pelvic or chest pain, partial or complete mechanical bowel obstruction, and infertility. Mechanical small bowel obstruction after previous surgery can be the most severe effect of adhesions. 
#4 Background:  Historical Understanding, Causes & Frequency Data
During 1988 there were 281,982 hospitalizations during which adhesiolysis (the cutting, ablation or division of adhesions) was performed in the United States, accounting for 948,727 days of inpatient care.  Of the admissions, 54,100 were precipitated by adhesions.  At the time, these hospitalizations were responsible for an estimated $1,179,900 in healthcare expenditures.  This estimate does not include outpatient surgical procedures. 
 
Intra-abdominal adhesions are usually the result of surgical or gynecologic operations, pelvic inflammatory disease (gonococcal or chlamydial), appendicitis or endometriosis.  Adhesions occur after abdominal surgery in more than 60 percent of cases, though less than 30 percent are symptomatic. 

Adhesions may be responsible for chronic persistent abdominal pain without associated pelvic pathology.  Clinically, adhesions present as chronic or acute abdominal or pelvic pain, partial or complete mechanical bowel obstruction, and infertility.  Though adhesions probably cause pain by entrapment of expansile viscera, the relationship of adhesions to abdominal pain is still controversial.  In contrast, mechanical small bowel obstruction after previous surgery demonstrates unequivocally the most severe effect of adhesions. 

Patients with chronic or recurrent abdominal pain and a history of numerous abdominal surgical procedures are often denied treatment if they are not obstructed or symptomatic of intermittent bowel obstruction.  This may be because, from the surgeon's viewpoint, adhesiolysis is associated with low reimbursement for long operations with high medicolegal risk.  Also, adhesions may recur, and the risk of enterotomy (a hole in the bowel) during surgery is very high. 

While surgical therapy is withheld, multiple abdominal diagnostic procedures including abdominal CT scan are frequently ordered.  The patients are then sent to chronic pain clinics for evaluation.  Though few studies exist, a recent report suggests that women with severe, dense vascularized bowel adhesions have a significant reduction in pain after adhesiolysis.

A View From the Inside Out... Dr. Harry Reich is the most skilled laparascopic surgeons develop ambidextrous surgical skills in order to maneuver the various cutting, sewing, laser and visualization (endoscopic mini-video cameras) tools required in minimally invasive laparoscopic surgery. Here, Dr. Reich views a patient's pathology on a TV screen while manipulating two surgical tools from outside the patient's body. The tools fit through ports in the patient's skin. Photo by Mario Costa. Copyright © Harry Reich.

#5 Minimally Invasive Treatments
No longer can the public ignore the benefits of minimally invasive surgery for adhesions. While these techniques and procedures are not without risk, patients should not be denied the procedures' inherent advantages. Astute clinicians must work together to discern the most appropriate uses and cases for this therapy. 
Patients with symptomatic adhesions usually want minimally invasive therapy. If given the choice between a laparoscopic surgical procedure and laparotomy, they will rarely choose the latter. Unfortunately this choice is seldom offered, even though most adhesiolysis laparotomy procedures presently performed can be done through the laparoscope. 

While the advantages of laparoscopic enterolysis compared with classical laparotomy has not been proven in studies, it is obviously possible with laparoscopy to diminish peritoneal mesothelial cell ischemic damage from trauma, drying, talc, packs and delayed bleeding. 
Laparoscopic surgery is distinctly advantageous as the preferred method of access for infertility surgery due to the decreased risk of de novo adhesion formation.  Similar surgical outcomes when compared to laparotomy have been demonstrated in the management of endometriosis and extensive adhesions. The surgical advantages of laparoscopy include panoramic pelvic visualization and magnification, techniques similar to microsurgery, documentation of absolute hemostasis via underwater examination.
Finally, the patient enjoys simultaneous diagnosis and treatment and all the advantages of minimally invasive surgery in terms of cosmetics and rapid recuperation. Ileus is rare after laparoscopic surgery. In 2000, the onus should be on the surgeon to prove that laparotomy results in better outcome than laparoscopy, not vice-versa. 

Laparascopic Peritoneal Cavity Adhesiolysis
Although both laparoscopic and laparotomy adhesiolysis can be very time-consuming (2 to 4 hours), and for the surgeon technically difficult, many women are discharged on the same day of the procedure, avoid major abdominal incisions, experience minimal complications and return to full activity within one week of the procedure. The extent, thickness and vascularity of adhesions varies widely. Intricate adhesive patterns exist with fusion to parietal peritoneum and/or various meshes. 
Peritoneal adhesiolysis is classified into enterolysis, which includes omentolysis and female reproductive reconstruction (salpingo-ovariolysis and cul-de-sac dissection with excision of deep fibrotic endometriosis).
Bowel adhesions are divided into:
* Upper Abdominal 
* Lower Abdominal 
* Pelvic 
* Combinations of the Above 

Adhesions surrounding the umbilicus are upper abdominal as they require an upper abdominal laparoscopic view for division. 
Extensive small bowel adhesions are not a frequent finding at laparoscopy for pelvic pain or infertility. In these cases, either the tube is stuck to the ovary or the ovary is adhered to the pelvic sidewall. The rectosigmoid (the rectum and sigmoid colon) may cover both. Rarely, the omentum (a fold of peritoneum extending from the stomach to adjacent organs in the abdominal cavity) and small bowel are involved. 
On a side note, we are working on a classification system for extensive peritoneal cavity adhesion procedures that relates to their degree of severity and expertise necessary for adhesiolysis. For now, the single best indicator of the degree of severity and expertise necessary for adhesiolysis is the number of previous laparotomies. The frequency of small bowel obstruction symptoms also indicates the need for surgery. 

Typical Surgical Plan for Extensive Enterolysis
A well defined strategy is important for small bowel enterolysis. In general, cases are divided into three parts: 

1.) Division of all adhesions to the anterior abdominal wall parietal peritoneum. Small bowel loops encountered during this process are separated using their anterior attachment for countertraction instead of waiting until the last portion of the procedure (running of the bowel). 

2.)Division of all small bowel and omental adhesions in the pelvis. The rectosigmoid, cecum and appendix often require some separation during this part of the procedure. 

3.)Running of the bowel. Using atraumatic grasping forceps and (usually) a suction irrigator for suction traction, the bowel is run. Starting at the cecum and terminal ileum, loops and significant kinks are freed into the high-upper abdomen to the ligament of Treitz. 

4.)Optional. Tubo-ovarian pathology is then treated if indicated. 
Time frequently dictates that all adhesions cannot be lysed. From the history, the surgeon should conceptualize the adhesions most likely to be causing the pain, i.e., upper or lower abdomen, left or right, and clear these areas of adhesions. 
With minimally invasive surgical approaches, same-day discharge is common, even after long procedures. Physical motility of the bowel is encouraged by early ambulation and a clear liquid diet for 2 to 4 days. Patients are instructed to return gradually to their normal activity during the week after surgery. 
Partial small-bowel obstruction during the week after surgery is usually due to ileus and is treated by intravenous hydration and a nasogastric tube if vomiting is present. Surgical exploration should be avoided in these cases. 
If peritonitis occurs in the days after the operation, it must be assumed that an injury to the bowel has gone unnoticed and a laparotomy is indicated. If an abscess forms postoperatively it can be drained percutaneously under sonographic guidance, or possibly by means of a laparoscopy. Recurrent adhesions may occur even with atraumatic techniques. 

 

 


Despite refinement in operative technique and the recent introduction of adhesion-prevention products, the problem of postoperative adhesions remains a major cause of infertility and pain. All surgeons must deal with the potential for formation of adhesions after surgery, as well as the sequelae of adhesions from previous surgery which may markedly increase the difficulty of any particular surgerical case. 
Post-surgical adhesions often occur following pelvic and abdominal surgery. Data has suggested that 67% to 93% of patients will develop adhesions following non-gynecologic abdominal surgery and 55% to 100% of patients will develop adhesions following gynecologic surgery. These issues become critically important from a standpoint of reproductive potential.Additionally, adhesions may be associated with issues such as pelvic pain, abnormalities of bowel function, and small bowel obstruction. 

Definitions
Several definitions of adhesions exist. De novo or new adhesions may form at a site where none existed before but a surgical procedure was performed. Examples include a myomectomy incision or an ovarian incision at the time of ovarian cystectomy. De novo adhesions may also develop away from the site of surgery,such as adhesions developing around the tubes and ovaries at the time of a cesarean section. Adhesions may also reform following adhesiolysis or adhesiectomy. 
Three general types of adhesions exist - filmy, vascular, and cohesive. The underlying pathophysiology of all three, however,is similar. The American Fertility Society has attempted to classify adhesive disease according to the location and type of adhesions. 

The Peritoneum
An understanding of the anatomy of the peritoneum and the response of the peritoneum to injury is important in understanding how we might prevent adhesion formation. The peritoneum is composed of multiple layers. The mesothelium is the innermost layer, a layer of connective tissue which contains the blood vessels, and a basement membrane. When the peritoneum is injured (which is inevitable during surgery), there is an inflammatory response. 
During the initial phase of this inflammatory response, inflammatory mediators and histamine are released from mast cells and leukocytes. Capillaries located within the connective tissue dilate and an increased permeability of the capillary wall is noted. This allows leukocytes, red blood cells and platelets to become concentrated at the site of in injury. A fibrinous exudate is thus formed at the site of injury. Multiple factors such as prostaglandins, lymphokines, bradykinin, serotonin, transforming growth factor and other chemotactic agents are present within the exudated material.
At this point the fibrinous exudate may be cleared through fibrinolysis. In order for this to occur, plasminogen must be converted to plasmin by tissue plasminogen activator (t-PA).There is a constant balance in the system between tissue plasminogen activator and plasminogen activator inhibitors. Unfortunately, surgical trauma may have an inherent ability to decrease tissue plasminogen activity while increasing plasminogen activator inhibitors. Under normal circumstances plasmin breaks down exudated fibrin. If this does not occur, the fibrinous exudate is converted into an organized adhesion and fibers of collagen are deposited. Following this, blood vessels begin to form allowing organization of the adhesion. 
This process occurs over a one to seven day period of time. In general, at seven days the quantitative development of adhesions is complete. Qualitative changes continue over the next several months with adhesions becoming more dense and vascularized. 


 


 
Author: Eugene Hardin, MD, Chair, Department of Emergency Medicine, Martin Luther King Jr/Charles R Drew Medical Center; Medical Director, Hubert H Humphrey Comprehensive Health Center 
Coauthor(s): Christopher R Westfall, DO, Staff Physician, Department of Emergency Medicine, Kern Medical Center
Editor(s): Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Carmelito (Sonny) Arkangel, Jr, MD, Assistant Professor, Department of Surgery, Division of Emergency Medicine, University of Texas Health Science Center at San Antonio; Jonathan Adler, MD, Instructor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School; and Anthony Anker, MD, Consulting Staff, Department of Emergency Department, Rogue Valley Medical Center

An adhesion is:
· A band of scar tissue that binds 2 parts of your tissue together. They should remain separate. Adhesions may appear as thin sheets of tissue similar to plastic wrap, or as thick fibrous bands. 
· The tissue develops when the body's repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation. Although adhesions can occur anywhere, the most common locations are within the stomach, the pelvis, and the heart. 
· Abdominal adhesions: These are a common complication of surgery, occurring in up to 93% of people who undergo abdominal or pelvic surgery. Adhesions also occur in 10.4% of people who have never had surgery. 
·  Most adhesions are painless and do not cause complications. However, adhesions cause 60%-70% of small bowel 
· Obstructions in adults and are believed to contribute to the development of chronic pelvic pain. 
·  Adhesions typically begin to form within the first few days after surgery, but they may not produce symptoms for months or even years. As scar tissue begins to restrict motion of the small intestines, passing food through the digestive system becomes progressively more difficult. The bowel may become blocked. 
·  In extreme cases, adhesions may form fibrous bands around a segment of an intestine. This constricts blood flow and leads to tissue death. 
· Pelvic adhesions: These may involve any organ within the pelvis, such as the uterus, ovaries, fallopian tubes, or bladder, and usually occur after surgery. Pelvic inflammatory disease (PID) results from an infection (usually a sexually transmitted disease) that frequently leads to adhesions within the fallopian tubes. A woman's eggs pass through her fallopian tubes into her uterus for reproduction. Fallopian adhesions can lead to infertility and increased incidence of ectopic pregnancy in which a fetus develops outside the uterus.
· Heart adhesions: Scar tissue may form within the membranes that surround the heart (pericardial sac), thus restricting heart function. Infections, such as rheumatic fever, may lead to adhesions forming on heart valves and leading to decreased heart efficiency.

 When the body attempts to repair itself, adhesions develop. This normal response can occur after surgery, infection, trauma, or radiation. Repair cells within the body cannot tell the difference between one organ and another. If an organ undergoes repair and comes into contact with another part of itself, or another organ, scar tissue may form to connect the 2 surfaces.
Signs and symptoms NS AND SYMPTOMS
Doctors associate signs and symptoms of adhesions with the problems an adhesion causes rather than from an adhesion directly. As a result, people experience many complaints based on where an adhesion forms and what it may disrupt. Typically, adhesions show no symptoms and go undiagnosed.
Most commonly, adhesions cause pain by pulling nerves, either within an organ tied down by an adhesion or within the adhesion itself. 
· Adhesions above the liver may cause pain with deep breathing. 
· Intestinal adhesions may cause pain due to obstruction during exercise or when stretching. 
· Adhesions involving the vagina or uterus may cause pain during intercourse. 
· Pericardial adhesions may cause chest pain. 
· It is important to note that not all pain is caused by adhesions and not all adhesions cause pain. 
· Small bowel obstruction (intestinal blockage) due to adhesions is a surgical emergency. 
.These adhesions trigger waves of cramp like pain in your stomach. This pain, which can last seconds to minutes, often worsens if you eat food, which increases activity of the intestines. 
Once the pain starts, you may vomit. This often relieves the pain. 
·  Your stomach may become tender and progressively bloated. 
·  You may hear high-pitched tinkling bowel sounds over your stomach, accompanied by increased gas and loose stools. 
·  Fever is usually minimal.
· Such intestinal blockage can correct itself. However, you must see your doctor. If the blockage progresses, these conditions may develop: 
·  Your bowel stretches further. 
·  Pain becomes constant and severe. 
·  Bowel sounds disappear. 
·  Gas and bowel movements stop. 
·  Your belly will grow. 
·  Fever may increase. 
·  Further progression can tear your intestinal wall and contaminate your abdominal cavity with bowel contents. 
See a doctor any time you experience abdominal pain, pelvic pain, chest pain, or unexplained fever. If you have undergone surgery or have a history of medical illness, discuss any changes in your recovery or condition with your doctor.
Go to the nearest Emergency Department if chest pain, abdominal pain, pelvic pain, or unexplained fever occurs.
Doctors typically diagnose adhesions
 During a surgical procedure such as laparoscopy (putting a camera through a small hole into the stomach to visualize the organs). If they find adhesions, doctors usually can release them during the same surgery. 
Studies such as blood tests, x-rays, and CT scans might be useful to determine the extent of an adhesion-related problem. However, a diagnosis of adhesions is made only during surgery. A physician, for example, can diagnose small bowel obstruction but cannot determine if adhesions are the cause without surgery.
Treatment varies depending on the location, extent of adhesion formation, and problems the adhesion is causing.   Adhesions requiring surgery commonly come back because surgery itself causes adhesions. Unless a surgical emergency becomes evident, a doctor may treat symptoms rather than perform surgery.
A common surgical techniques used to diagnose abdominal adhesions ia a laparoscopy  but many of these surgeries result in a laparotomy. 
· With laparoscopy, a doctor places a camera into your body through a small hole in the skin to confirm that adhesions exist. The adhesions then are cut and released (adhesiolysis).
· In laparotomy, a doctor makes a larger incision to directly see adhesions and treat them. The technique varies depending on specific circumstances.
Several surgical products have been developed to prevent adhesions from forming during surgery. However, the effectiveness of these products is debatable.
 

Beverly J. Doucette 
International Patient Advocate
International Adhesion Society
 In my personal experience and in dealing with hundreds of victims of adhesions, an adhesiolysis performed by an unskilled surgeon will lead to more adhesions and disabling symptoms. Do not allow a surgery to be performed on you until you had a second opinion and educated yourself to Adhesion Related Disorder. This can be accomplished by going to www.adhesions.org

Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert
 


 
 


Liklihood
Laparotomy  Laparoscopy
Procedure (%) (%)
Adhesiolysis 76 66
Ovarian surgery 90 80
Ectopic pregnancy -- 50
Fimbrioplasty -- 67
Myomectomy 68 --
Endometriosis removal 82 --

_______________________________________________________________________________________

Most gynecologic procedures performed in the peritoneal cavity lead to the formation of adhesions. The incidence rates shown on this slide were confirmed through clinical studies involving both laparotomy and laparoscopic techniques. The ovary appears to be the most common site for adhesion formation regardless of which surgical technique is used. In the Mais study on adhesion formation following laparoscopic myomectomy, the ovary was the most common attachment site. However, it is important to note that while laparoscopic surgery does reduce ancillary de novo adhesions (possibly because of the reduced handling of tissues), the incidence of reformed adhesions with laparoscopy is the same as with laparotomy. It is important to note that the formation of de novo adhesions that form at the surgical site (e.g., myomectomy) are the same for laparotomy and laparoscopy.

References:
1. INTERCEED* (TC7) Absorbable Adhesion Barrier Study Group. Prevention of postsurgical adhesions by INTERCEED Barrier, an absorbable adhesion barrier: a prospective, randomized multicenter clinical study. Fertil Steril. 1989;51:933-938.

2. Sekiba K and the Obstetrics and Gynecology Adhesion Prevention Committee. Use of INTERCEED (TC7) Absorbable Adhesion Barrier to reduce postoperative adhesion reformation in infertility and endometriosis surgery. Obstet Gynecol. 1992;79:518-522. 

3. Diamond MP et al for the Operative Laparoscopy Study Group. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Fertil Steril. 1991;55:700-704. 

4. Lundorff P, Thorburn J, Lindblum B. Second-look laparoscopy after ectopic pregnancy. Fertil Steril. 1990;53:604-609. 

5. Lundorff P, Hahlin M, Kallfelt B, et al. Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. Fertil Steril. 1991;55:911-915. 

6. Diamond MP. Surgical aspects of infertility. In: Sciarra JJ, Simpson JL, Speroff L, eds. Gynecology and Obstetrics. Philadephia, Pa: JB Lippincott Co; 1991;5:1-23. 

7. Tulandi T, Murray C, Guralnick M. Adhesion formation and reproductive outcome after myomectomy and second-look laparoscopy. Obstet Gynecol. 1993;82:213-215. 

8. Gehlbach DL, Sousa RC, Carpenter SE, et al. Abdominal myomectomy in the treatment of infertility. Int J Gynecol Obstet. 1993;40:45-50. 

9. Mais V, Ajossa S, et al. Prevention of de-novo adhesion formation after laparoscopic myomectomy: a randomized trial to evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier. Human Reproduction. 1995;10:3133-3135. 
 
 

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