January 7, 2002
Beverly J. Doucette
International Adhesion Society
Marinette, Wisconsin 54143
Dr. Frank A. Hamilton, M.D., M.P.H.
Chief, Digestive Diseases Program,
NIDDK Division of Digestive Disease
Dept. of health & Human Service
2 Democracy Plaza
Bethesda, MD, 20892
phone: (301) 594-8877
Subject: ICD9-CM Code for
“APPLICATION OF AN ADHESION BARRIER for PREVENTION of ADHESIONS”
Centers for Medicare and Medicaid Services
My name is Beverly Doucette (aka Bev).
I am an Independent Patient Advocate for people who suffer the indignities
of post surgical adhesions. I would like to thank the Centers for
Medicare and Medicaid Services for taking the initiative to recognize and
question the impact of Adhesion Related Disorder(ARD)
in the United States. As a person, who sufferers from the consequences
of post surgical adhesions - as well as having had 7 operations for adhesion-related
conditions - I am well aware of the need for an ICD9-CM code for the "APPLICATION
OF AN ADHESION BARRIER for PREVENTION of ADHESIONS."
I am also very aware of the increase in the incidence of post surgical
adhesions and the impact it is having in our society today! I am not going
to take the time to share my personal struggle with Adhesion Related
Disorder (ARD); because I think you are familiar with the symptoms
and struggles of ARD sufferers as they exist in our country today. My story
is no different than the ARD stories of others; so rather than share my
story with you, I prefer to share what I think will benefit those affected
I have assisted other ARD sufferers throughout the world in their
search for the highest quality medical intervention available to them;
and what I have learned, will offer you a better understanding of why securing
this ICD9-CM code is so vitally important! Considering my personal experience
with ARD and my background as a registered nurse, I understand and recognize
the need for the ICD9-CM code. If I understand the need for this code,
you can be assured that other citizens of the United States understand
it as well; and they are questioning why an ICD9-CM code has not
been established sooner - to afford them the opportunity to secure the
highest quality medical intervention available in this country. Yet, because
this ICD9-CM code did not exist, they have been denied the opportunity
to get as well as one might get while suffering from ARD. I am of the
opinion that this is an inexcusable act of negligence by the U. S. Government.
It is impossible for this to be an oversight; because the sheer magnitude
of information within the U. S. Government - regarding post surgical adhesions
- is staggering.
It has been my experience that the United States seriously lags behind
many other countries in recognizing the impact ARD has on our society;
and it has made no effort to decrease the ever- rising costs associated
with the numbers of repeated surgical procedures being performed
by surgeons for post surgical adhesions. The failure to recognize adhesiolysis
procedures as being one of the most commonly performed surgical procedures
performed in the USA today, leads to a lack of responsible medical intervention
for the victims - whose lives are impacted by adhesions; and it
deliberately imposes ever-rising medical costs on taxpayers!
I have communicated with people from the Ukraine, who are able to present
to a medical care provider and receive recognition of the disabilities
that ARD causes. This same recognition of ARD is evident
in other countries throughout Europe. The recognition of ARD
allows the use of adhesion barriers in surgical procedures for ALL citizens
of countries such as the Ukraine, Germany, the Netherlands, Sweden,
Belgium, Australia - as well as many other countries where medical care
is provided through the government.
Those same ARD sufferers have the opportunity to receive a much
better quality of medical intervention than their counterparts here in
the so-called "progressive" USA. The recognition of post surgical adhesions
as a disabling disorder - and taking the initiative, at the very least,
to assume responsibility for ARD in these other countries - offers
these countries the opportunity to reduce the incidence of repeated surgery
for adhesions. As a result, these countries are able to reduce personal
suffering from adhesion related disorder; and ultimately they are
able to offer a reduction in medical costs to their government.
[ BEV: Upon request, I can submit
substantiation of this information.]
As a taxpayer, I hold not only the Centers for
Medicare and Medicaid Services (CMS) - but also other departments (who
have anything to do with healthcare) within the U. S. Government - responsible
for their awareness of the reasons for the rapidly rising costs of healthcare
in this country. The responsibility is theirs to provide the highest
quality medical intervention available today for our citizens when it is
Post surgical adhesions create an increasing burden
on our tax dollars. We know that all too well. I am sure that the
rising cost of healthcare is one of the issues the CMS is taking into consideration
- as the CMS ponders the necessity for this IDC9-CM code. You
are to be commended in recognizing this - as well as taking the initiative
to secure that code in the USA for the sake of increasing the quality of
life for our citizens! Surgical intervention with the use of adhesion
barriers could very well be the answer to reducing costs incurred by so
many repeated surgeries.
It remains a curiosity to me - and a bit of a
sore spot - that the incidence of adhesion formation as the direct result
of certain surgical procedures and the increasing number of those surgeries
has been recognized within the medical arena for many decades. Yet,
no IDC9-CM code exits to recognize adhesions as being the major medical
problem that they are; and there is no ICD9-CM code to diagnose them.
Bev: Take a look at the following
report - which dates back to 1932 - regarding a study done on post surgical
adhesions! Then review the medical reports issued years later...
POSTOPERATIVE ADHESIVE INTESTINAL OBSTRUCTION
Dr. Ketan R Vagholkar, practicing
Surgeon Fracture and Accident Hospital, Thane-400602
Vick, in 1932,
reported that adhesions accounted for 7% of all cases of intestinal
obstructions.(35) During the last few decades the leading cause
of intestinal obstruction was strangulated external hernia. The overall
incidence of adhesive intestinal obstruction is 30% as shown in
studies conducted by Nemir, Perry, Bevan and McEntree, (2), (23),(26)
Subsequent studies have revealed a steady rise in the incidence of intestinal
obstruction to the present day incidence of about 40%. (2)
Various studies have been carried out to assess
the severity of problems posed by adhesions. Webel and Majno carried
out a study in a post mortem series to find out the incidence of adhesions.
(21, 22) In cadavers with no preceding abdominal surgery, adhesions
were found in 28% and in those that had minor abdominal surgery
had adhesions.(21, 22) With other abdominal surgery the report incidence
was 50%. If major surgery had been performed, adhesions were
present in 76% and in cases of multiple surgery 93% had adhesions.
Ref: POSTOPERATIVE ADHESIVE
INTESTINAL OBSTRUCTION - Dr. Ketan R. Vagholkar, practicing Surgeon Fracture
and Accident Hospital, Thane-400602
[ Bev: Full report available.]
When we look at the above medical report about adhesions - and we look
at more recent reports on the incidence of adhesions (included below) -
be the etiology due to post surgical or traumatic adhesion formation, the
real issue here is that there have been NO changes in these reports that
would reflect action on the part of those who sit in government positions.
Government officials could have intervened and
created changes in the best interest of people who suffer adhesions. As
the result of no change, the cost to the U.S. Government has been staggering,
which equates to lack of concern by government officials in how OUR tax
dollars are spent!
In fact, the only change that has occurred
- within the time span of the reports that I have included in this
letter - was that the incidence of surgeries in the United States increased!
the increase of surgeries - that resulted in adhesion formation and
reformation of adhesions - increased enough so thatadhesiolysis
procedures rival appendectomies, hip replacements(and
though I only surmise this, adhesiolysis procedures
are probably performed MORE than tonsillectomies!)
All anyone needs to do - even the untrained medical
person - is to review the material in this letter; and they will be able
to conclude that it is only common sense
to secure this ICD9-CM code.
(There are a total of 10 reports
- included in the above report.)
Bev: Let's take a look at
a few more medical reports regarding the incidence of surgeries that lead
to adhesion formation. In the following report NOT
ONE WORD is mentioned about post surgical adhesions!!
AHCPR Funding Studies on Hysterectomy vs. Alternative Treatment for Uterine
Press Release Date: October 31, 1996
The Agency for Health Care Policy and Research
(AHCPR) today announced the start of three research projects to determine
the outcomes of surgery versus other treatments for dysfunctional uterine
bleeding (DUB), as well as patient treatment preferences for women with
endometriosis, chronic pelvic pain, fibroids, uterine prolepses or DUB.
Each year in the United States, 590,000
women have hysterectomies for various conditions. The majority
of hysterectomies are performed before menopause, often for abnormal uterine
bleeding. U.S. hysterectomy rates are much
higher than in other Western nations;
and rates vary by geographic region, ethnicity and socioeconomic status.
Although alternative treatments are available, there is little data that
compares these treatments to hysterectomy, or various types of hysterectomy
to each other. This lack of information makes it more difficult for women
to choose the best treatment option.
The following studies resulted from a "Request
For Application" issued by AHCPR March 1. The total amount of the
awards is $17.4 million over five years. The studies are:
Treatments Outcomes Project for Dysfunctional Uterine Bleeding. Principal
Investigator Kay Dickersin, University of Maryland at Baltimore. Grant
No. HS09506. 1996-2001.
is interesting when you take into consideration that in the Vick
report of 1934 (See # 1.), "a major surgical
procedure had one of the second highest incidence of causing adhesion formation,
only second to multiple surgeries! "There
is NOT ONE WORD about
post surgical adhesive disease in this report!!
The purpose of this study is to
determine the equivalence of two therapies for DUB—hysterectomy and endometrial
ablation—using two randomized controlled trials. The study will examine
the natural history of DUB, the effectiveness of treatment and cost.
· MEDTEP Study on Hysterectomy
and Dysfunctional Uterine Bleeding. Principal Investigator Sarah E. Fowler.
Case-Western/Henry Ford Health Sciences Center, Detroit, Mich. Grant No.
Using collaborative, multisite,
randomized controlled trials, this study will compare the effectiveness,
relative costs and patient outcomes of hysterectomy, endometrial ablation
and hormone therapy for women with dysfunctional uterine bleeding.
· Medicine Or Surgery?
Principal Investigator Stephen B. Hulley, University of California at San
Francisco. Grant No. HS09478. 1996-2001.
The study will run two randomized
controlled trials: one to compare the effects (including quality of life)
and costs of medical therapy versus hysterectomy; the other to compare
the effects of supracervical versus total hysterectomy on function and
well-being in women who undergo abdominal hysterectomy. The study also
will determine rates and patient preferences for management options for
women with diagnoses of fibroids, dysfunctinal uterine bleeding, chronic
pelvic pain, endometriosis or uterine prolapse.
For additional information contact,
AHCPR PUBLIC AFFAIRS: Karen Carp, (301) 549-0313: Karen Migdail, (301)
594-6120; or Salina Prasas, (301) 549-6385.
Fact sheet: Hysterectomy in the United States, 1980 - 1993
Frequency of Hysterectomy:
Approximately 600,000 hysterectomies are performed
each year in the United States
at an estimated annual cost of more than $5
billion. More than one-fourth of U.S. women will have this
procedure by thetime they are 60 years of age. Hysterectomy is the second
most frequent major surgical procedure among reproductive-aged women.
From 1980 through 1993, an estimated
8.6 million U.S. women had a hysterectomy.
Wanda K. Jones, Dr PH
Deputy Assistant Secretary for Health (Women’s
Director, Office on Women’s Health, U.S.
Public Health Service
Closure in Obstetric and Gynecological Surgery 1996
Individual recommendations have been graded according to the level of
evidence on which they are based using the scheme endorsed by the NHS Executive:
The traditional arguments for peritoneal closure have included, firstly,
restoring the anatomy and approximation of tissues for healing, secondly,
the re-establishment of a peritoneal barrier to reduce the risks of infection
and, thirdly, a reduction in the risk of wound herniation or dehiscence.
addition, peritoneal closure was thought to minimize adhesion formation.
On the other hand, there are arguments against peritoneal closure and
these have been summarized by Duffy and diZerega.1,2Firstly,
non-closure has not been observed to be detrimental, secondly, without
re-approximation the peritoneum heals rapidly and, thirdly, suture
presence and additional tissue handling may contribute to adhesion formation.
There appears to be a good physiological explanation for this. Buckman
et al3 showed that deperitonealised surfaces,
which have not been otherwise traumatised, heal without permanent adhesions
because they retain their ability to lyse fibrinous adhesions before organisation
can occur. Peritoneum which has been made ischaemic by grafting or tight
suturing not only loses its ability to lyse fibrin, but may actively inhibit
fibrinolysis by normal tissues.
A review of the literature was undertaken to establish the evidence
for and against peritoneal closure in obstetric and gynaecological surgery.
This included a 10 year MedLine literature search, and a reference search
from review articles.4-6
3.1 Pathophysiological studies
There is observational evidence that when left undisturbed, peritoneal
defects demonstrate mesothelial integrity within 48 hours and indistinguishable
healing with no scar formation in five days.3,7-11
3.2 Caesarean section RCTs
The question of closure of peritoneum at caesarean section was addressed
in four randomised controlled trials.12-15
In the last two studies, a reduced need for postoperative analgesia and
a quicker return of bowel function was found when both visceral and parietal
peritoneum14 or only the parietal peritoneum15
were left open. The most recent randomised controlled trial13
found shorter operating and anaesthesia times in patients receiving non-closure
of the visceral peritoneum. In addition, the incidence of febrile morbidity
and cystitis and the need for antibiotics and narcotics were all significantly
greater when the peritoneum was closed.13 The
hospital stay was significantly shorter after non-closure. Irion et al12
compared closure of both visceral and parietal peritoneum with non-closure.
Postoperative ileus resolved later in the closure group and the mean operative
time was shorter in the non-closure group.
These four trials have all been included in the Cochrane Systematic
Review.16 The review concludes that 'currently
available evidence raises questions concerning the routine use of peritoneal
closure as conventional practice in routine caesarean section' (Grade A
3.3 Gynaecological surgery RCTs
Similar findings have been noted in randomised controlled trials carried
out in gynaecology. Kadanali et al17 and Than
et al,18 in ovarian cancer surgery and cervical
cancer surgery respectively, found improved outcomes (reduced adhesions
and reduced fever) where the visceral peritoneum was left to heal on its
own. In general gynaecology, Lipscomb and co-workers19
found, in a randomised controlled trial of peritoneal closure at vaginal
hysterectomy, that there were no differences in postoperative complications.
Nagele et al20 in a randomised controlled trial
of closure or non-closure of the visceral peritoneum in abdominal hysterectomy,
found that the non-closure group had a smaller number of postoperative
It can be concluded that the data do not support the use of reperitonealisation
on a routine basis
(Grade A recommendation).
3.4 Other evidence (from observational studies and general surgical
Tulandi and co-workers11 did second-look
operations in a series of patients who had parietal peritoneal closure
compared to those without closure, and compared the findings to a control
group of infertile women with no history of abdominal surgery. The incidence
of adhesions in the two groups was not statistically significant
with the incidence being 22.2% in the peritoneal closure group and 15.8%
in the group not having peritoneal closure. In the control group of women
who had never had abdominal surgery, no patients were found to have adhesions
to the anterior abdominal wall.
There have been a number of studies carried out in general surgery
and the principle of non-closure of peritoneum has, for some time, been
recognised by general surgeons. For example, Gilbert and co-workers21
showed that it was unnecessary to close the peritoneum with a paramedian
incision. Hugh and co-workers22 found that
single-layer closure of a midline abdominal incision (superficial part
of the rectus sheath) was quicker and less costly and theoretically safer
than layered closure, and they recommended that separate suture of the
peritoneum be abandoned.
In another surgical study23 the records
of women who had been admitted with intestinal obstruction were examined.
In this unselected patient series, a history of gynaecological surgery
was a significant factor contributing to the occurrence of intestinal obstruction.
They felt, in addition, that surgical peritoneal closure may result in
an increased incidence of intestinal obstruction.
It would appear that the closure of peritoneal surfaces, even
with minimally reactive suture materials, results in increased tissue reaction
and may result in increased adhesion formation. Non-closure appears
to have few associated risks and may be recommended in many obstetric and
gynaecological operations. Surgeons abandoning closure should be no
less meticulous in other aspects of their craft.
1. Duffy D M, diZerega G S. Is peritoneal closure necessary?
Obstet Gynecol Surv 1994; 49:817-22.
2. diZerega G S, Duffy D M. Is peritoneal closure necessary?
The Royal College of Obstetricians and Gynaecologists, 1996, PACE Review
3. Buckman R F Jr, Buckman P D, Hufnagel H V, Gervin
A S. A physiologic basis for the adhesion-free healing of deperitonealized
surfaces. J Surg Res 1976; 21:67-76.
4. Nygaard I E, Squatrito R C. Abdominal incisions from
creation to closure. Obstet Gynecol Surv 1996; 51:429-36.
5. Rayburn W F, Schwartz W J 3rd. Refinements in performing
a cesarean delivery. Obstet Gynecol Surv 1996; 51:445-51.
6. Hankins G D V, Clark S L, Cunningham G, Gilstrap L
C (eds). Caesarean section. In: Operative Obstetrics, 1995. Appleton and
Langer, Connecticut, 301-32.
7. Elkins T E, Stovall T G, Warren J, Ling F W, Meyer
N L. A histological evaluation of peritoneal injury and repair: implications
for adhesion formation. Obstet Gynecol 1987; 70:225-8.
8. Ellis H. The aetiology of post operative abdominal
adhesions, an experimental study. Br J Surg 1962; 50:10
9. Ellis H, Heddle R. Does the peritoneum need to be
closed at laparotomy? Br J Surg 1977; 64:733-6
10. McFadden P M, Peacock E E Jr. Preperitoneal abdominal
wound repair: incidence of dehiscence. Am J Surg 1983; 145:213-4.
11. Tulandi T, Hum H S, Gelfand M M. Closure of laparotomy
incisions with or without peritoneal suturing and second-look laparoscopy.
Am J Obstet Gynecol 1988; 158:536-7.
12. Irion O, Luzuy F, Beguin F. Nonclosure of the visceral
and parietal peritoneum at caesarean section: a randomised controlled trial.
Br J Obstet Gynaecol 1996; 103:690-4.
13. Nagele F, Karas H, Spitzer D, Staudach A, Karasegh
S, Beck A, Husslein P. Closure or nonclosure of the visceral peritoneum
at caesarean delivery. Am J Obstet Gynecol 1996; 174:1366-70.
14. Hull D B, Varner M W. A randomized study of closure
of the peritoneum at cesarean delivery. Obstet Gynecol 1991; 77:818-21.
15. Pietrantoni M, Parsons M T, O'Brien W F, Collins
E, Knuppel R A, Spellacy W N. Peritoneal closure or non-closure at cesarean.
Obstet Gynecol 1991; 77:293-6.
16. Wilkinson C S, Enkin M W. Peritoneal non-closure
at Caesarean section. In: Neilson J P, Crowther C A, Hodnett E D, Hofmeyr
G J (eds). Pregnancy and Childbirth Module of The Cochrane Database of
Systematic Reviews, [updated 2 December 1997]. Available in The Cochrane
Library [database on disk and CDROM]. The Cochrane Collaboration; Issue
1. Oxford: Update Software; 1998. Updated quarterly.
17. Kadanali S, Erten O, Kucukozkan T. Pelvic and periaortic
peritoneal closure or non-closure at lymphadenectomy in ovarium cancer:
effects on morbidity and adhesion formation. Eur J Surg Oncol 1996; 22:282-5.
18. Than G N, Arany A A, Schunk E, Vizer M, Krommer K
F. Closure or non-closure of visceral peritoneums after abdominal hysterectomies
and Wertheim-Meigs radical abdominal hysterectomies. Acta Chir Hung 1994;
19. Lipscomb G H, Ling F W, Stovall T G, Summitt R L
Jr. Peritoneal closure at vaginal hysterectomy: a reassessment. Obstet
Gynecol 1996; 87:40-3.
20. Nagele F, Kurz C, Staudach A, Steiner H, Grunberger
W, Beck A, Husslein P. Closure or nonclosure of the visceral peritoneum
in abdominal hysterectomy. J Gynecol Surg 1995; 11:133-9.
21. Gilbert J M, Ellis H, Foweraker S. Peritoneal closure
after lateral paramedian incision. Br J Surg 1987; 74:113-5.
22. Hugh T B, Nankivell C, Meagher A P, Li B. Is closure
of the peritoneal layer necessary in the repair of midline surgical abdominal
wounds? World J Surg 1990; 14:231-3.
23. Stricker B, Blanco J, Fox H E. The gynecologic contribution
to intestinal obstruction in females. J Am Coll Surg 1994; 178:617-20.
24. Mann T. Clinical guidelines: using clinical guidelines
to improve patient care within the NHS, 1996. NHS Executive (Catalogue
5.) Scars and Adhesions
Adhesions have been implicated as causing infertility, intestinal
obstruction, and chronic pelvic pain. Data suggests that 67% to 93%
of patients will develop adhesions following abdominal surgery and
55% to 100% of patients will develop adhesions following gynecologic
1998 © Clear Passage Therapies,
December 2000 American Journal of Obstetrics & Gynecology 183, pp.
Hospital readmission due to complications after
hospital discharge was the factor most strongly and consistently associated
with women's reports of negative outcomes from hysterectomy.
For example, women who were readmitted to the hospital during the first
year after hysterectomy were 23 times more likely to report that the results
of the surgery were worse than they had expected, after adjustment for
all other factors. About 5.4 percent of women were readmitted at
least once to the hospital during the 2 years of follow up, and 4 percent
were readmitted during the first year. The
most common reasons for readmission were incision problems, surgery for
adhesions, intestinal blockage, and urinary tract problems.
For more information, see "Patient satisfaction with results
of hysterectomy," by Kristen H. Kjerulff, Ph.D., Julia C. Rhodes, Ph.D.,
Patricia W. Langenberg, Ph.D., and Lynn A. Harvey, in the December 2000
Journal of Obstetrics & Gynecology 183, pp. 1440-1447.
Southern Medical Journal (2001)
Chronic Intermittent Intestinal Obstruction From a Seat Belt Injury
Janet R. Harrison, MD, Michael O. Blackstone, MD, Thomas Vargish, MD,
Arunas Gasparaitis, MD, Division of Gastroenterology, University of Chicago
Hospitals, Chicago, Ill
Most patients with intestinal obstruction have
had previous surgery. Rarely, the development of adhesions and resulting
small bowel obstruction is attributed to previous intra-abdominal trauma.
present the case of a young man, without a history of surgery, who had
been a restrained driver in a motor vehicle crash. Seven years later, the
patient had an intermittent partial small bowel obstruction that recurred
over the next 5 years. We review the pathophysiology and epidemiology of
similar occurrences, as well as diagnostic options.
[South Med J 94(5):499-501, 2001. © 2001 Southern Medical Association]
Internationa Adhesions Society: 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.
all cases of small bowel obstruction, 60-70% of cases involve adhesions
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.
The impact of adhesions as a complication of surgery is huge.
In the United States (1993) 347,000 operations for lysis of peritoneal
adhesions were performed (Graves, 1995), of which about 100,000 involved
intestinal adhesions. Estimated another way, 446,000 procedures were
performed in the U.S. to lyse abdominopelvic adhesions in 1993 (HCIA, 1994).
In 1988, there were about 280,000 hospitalizations for adhesions, the
economic cost of which was estimated conservatively as $1.2 billion per
year (Fox Ray et al., 1993)
9.) Incidence of Pelvic Adhesions
The incidence of pelvic adhesions varies following reconstructive surgery.
Diamond et al noted an 86% incidence of pelvic adhesions at second-look
laparoscopy after reconstructive surgery. DeCherney and Mezer abserved
a 75% incidence of adhesions after the initial procedures at 4-16 weeks.
Surrey and Friedman noted a 71% incidence of adhesion formation.
When a subset of these patients were studied long-term, 83% of them had
adhesions. Pittaway et al found that all 23 of their patients had
adhesions. Trimbos-Kemper et al observed adhesions in 55% of their
patients. Finally, Daniell and Pittaway noted adhesion formation
in 96% of women at second look laparoscopy following reconstructive surgery.
It is important to note that the adhesions seen
in these studies represent not only adhesion reformation, but De Novo adhesion
formation as well.
[Bev: De Nova adhesions are reformed adhesions.]
Diamond MP. Surgical aspects of infertility. In: Sciarra JW, ed. Gynecology
and Obstetrics. Philadelphia, Pa: Harper & Row; 1988;5:chap 61.
Making and covering of surgical footprints (surgical adhesions). (Commentary)
Author/s: Lena Holmdahl
Issue: May 1, 1999
There is little doubt that abdominal adhesions form in response to
peritoneal trauma. Although adhesions may result from events occurring
during fetal development, the vast majority can be
directly linked to surgery. However, adhesions have not been widely held
to be a surgical complication, even though the impact of just one complication
due to adhesions -- that of small-bowel obstruction after colorectal surgery
-- equals, or surpasses, that of wound infection.1,2
(In part, full report on request)
ICD9-CM code IS primarily for the use of adhesion barriers in a surgery
and I agree that is vital, if we are going to impact ARD in a progressive
way and offer opportunities that will help to benefit some adhesion sufferer
and put them on the road to a higher quality of life!
I see more possibilities for this ICD9-CM, as
well. Once this ICD9-CM code is approved, the doors will be open once
again for the U.S. Government to take a look at the impact that Adhesion
Related Disorder has on our society!! The
acceptance of this code will give those government officials (whom I mentioned
earlier) - who have the responsibility to make changes in our national
health care system - the opportunity to right a wrong!! Hopefully,
these officials will be compassionate, honest people with new and progressive
attitudes about the welfare of their consitituents!!
There is no doubt in my mind that this ICD9-CM code will be secured;
because it would be plain negligence for any national government agency
to ignore or deny that there is overwhelming evidence
that post surgical and traumatic adhesions are one of the most costly medical
expenses in the United States today!!!
Our government is experiencing a new generation
of voters and tax payers, who are better educated and better informed than
ever before; because ready access to information does not allow anything
to be hidden from anyone who looks for it today!
The word is already out regarding Adhesion
Related Disorder; and the facts surrounding ARD will not disappear!!
agencies and positions will be held accountable for the health care needs
of our nation's taxpayers.
Attention to those needs must start now with
the implementation of this new ICD9-CM code for the application of adhesion
barriers for adhesion protection!! If it is not, someone will have
to answer to why it wasn't implemented!!
If the governing bodies of our nation's health
care system had heeded reports - like those I have share with you (reports
numbered 1-10) - those who currently suffer from Adhesion
Related Disorder might have been spared
the pain and anguish so many experience today!! Reports show
that our tax dollars have been spent on government-funded health care programs;
these reports prove - without a doubt - that post surgical adhesions
have impacted the people of our nation with unnecessary suffering at a
staggering rate and cost!!
Questions are beginning to surface as to why
has there never been a national campaign for awareness and education about
the existence and etiology of post surgical adhesions? Our
government knew of
the magnitude of this medical problem!!
How come the numbers increased instead of decreased? There are hundreds
of thousands of people in this country, who struggle with the intractable
pain of adhesions on a daily basis - every minute of each day!! Had the
government responded to these reports in a responsible and respectful way,
these people could've had a better chance for a more comfortable, pain-free
If only I had known that adhesions are one
of the risks of surgery, I know that I could be enjoying a higher quality
of life today; and there is no doubt about that at all!
If our government health agencies had acted in
our best interests when the connection between surgery and adhesions first
became known, many people of this great nation could have been spared alot
of pain and suffering; and the resulting tremendous cost to our government
could have been averted!!
We trusted our government to inform us about health
issues; but our government failed us when we were not given the opportunity
to be informed so that we would be able to make informed decisions about
our personal health issues.
I am asking the Centers for Medicare and Medicaid
Services to pursue with diligence in getting the ICD9-CM surgical code
approved for the application of adhesion barriers for adhesion protection.
I am offering my assistance in any way possible.
This code is justified; and God knows it is
time to get it secured for the United States of America!
In peace and friendship,
Beverly J. Doucette
Dr. David Satcher, MD, Surgeon
Tommy Thompson, Secretary of the
U.S. Department of Health and Human Services
Mr. John Gard, Assemblyman, Wisconsin
89th Assembly District
Dr. David Wiseman, PhD, SYNECHION,
Dr. Frank Hamilton, M.D. M.P.H.
Chief, NIDDK Division of Digestive Disease And Nutrition - Dept. of Health
& Human Service
Lynn Armstrong, National Centers
for Disease Control and Prevention (CDC) Atlanta, GA
from Dr. Frank A. Hamilton acknowledging my communication to Secretary
Tommy Thompson May 4, 2002
response to Dr. Frank A. Hamilton May 18, 2001
May 18, 2001
Beverly J. Doucette
Adhesion Related Disease
Marientte, Wisconsin 514431
Dr. Frank A. Hamilton, M.D., M.P.H.
Chief, Digestive Diseases Program,
NIDDK Division of Digestive Disease
Dept. of health & Human Service
2 Democracy Plaza
Bethesda, MD, 20892
phone: (301) 594-8877
Subject: Re: Adhesion Related Disease
Dear Dr. Hamilton;
I am Beverly J. Doucette, Patient Advocate for
persons suffering Adhesion Related Disease. I am a volunteer with the International
Adhesion Society and the director of the IAS outreach program as well as
being instrumental in many other areas of the IAS.
Dr. Hamilton, you were directed to respond to
my communication to Secretary Tommy
Thompson regarding ARD and I thank you
for taking the time to do that.
If you recall, you enclosed a number of pages
containing information on ARD research as well. You also closed your letter
by saying that you hoped this information would be helpful to me.
I was pleased to receive your directive’s to help
me explore the avenues to possible secure assistance in educating the public
about adhesion related disease. Your referral to John D. Chapin,
Administrator of the Wisconsin Dept. of Health and Family Services in Madison
is greatly appreciated. I did follow up on your advice to check into the
Centers for Disease and Prevention (CDC) of Atlanta, GA. Unfortunately
there was no mention of adhesions anywhere within the contents of this
web site. I did make inquires as to that and will continue to pursue the
reasons why ARD is not a part of this centers interests.
The unfortunately thing, Dr. Hamilton, was that
non of your information regarding “Research of Adhesion Tissue & Studies
” was news to me and all of it simply substantiated what I was aware of
in the first place...there is NO current effective research being conducted
anywhere in the world, that we are aware of, that will impact the lives
of those suffering ARD today, nor will it affect those currently suffering
the most painful and disabling complications of ARD in the near future!
I was somewhat amused at the growing
number of adhesion tissue researchers I have now amassed, your additions
included!!! It appears that one out of every ten scientist in the world
is looking to win the “Pulitzer” prize by figuring out adhesion formation!
With the progress that has been made in this area of research within the
past 15 years, not with standing the measly amounts of grant money given
to this, I fear we shall not see anything resolved on adhesion tissue in
our lifetime, short of a miracle that is!
In fact, Dr. Hamilton, I think that the information
I attached in this email to you will offer you much more education regarding
Adhesion Related Disease then your information did for me!
My information is current at that! You did state that Dr. James Pachence
at Vertitas Medical Technologies, Inc. had recently completed the study
you sent me, but no dates were given on that study as to just how recent
I also went to the web site of the Center for
Disease Control and Prevention (CDC) and based on what I did NOT find in
that site simply substantiated what I had known. "Adhesion Related Disease"
is one of the worlds best kept medical secrets! That will not continue
to be the case as the IAS, under my direction, is currently completing
"ARD Press Kit " and we have a number of reporters
throughout the USA waiting to receive them.
I am not sure what you thought you were going
to accomplish in sending me
the research information that you did, or if
you simply thought I was not
acclimated to ARD to the degree that I am.
I am inclined to think the later is true.
Dr. Hamilton, I know Dr. Lena Holmdahl of Sweden
personally, and I am
very familiar with her research on adhesions,
her philosophy's on ARD and her
choice of adhesiolysis procedures! If you are
interested in those issues, feel
free to ask me about them. I am also
very familiar with the three Dr.'s Nezhat, and I am very acclimated to
their ARD research and claims. I have attached the most current information
I have received regarding the Dr.s Nezhat encompassing those very same
issues! For the record, Dr. Hamilton, I have been following a number of
the issues surrounding these Dr.s for two years now.
You might be interested to know that in April
of 2000 and again this week, I was approached by the Lifecore / Ethicon
Pharmaceutical Division of Johnson & Johnson to speak on their behalf
in front of the FDA regarding the adhesion barrier, " Intergel!"
I am not going to accept that offer though.
I am also very acclimated to the
clinical trials of this product, both herein the United States as well
as in Europe. I was able to study the use of and effectiveness of Intergel
on my two trips to Europe last year by the way.
Dr. Hamilton, my intentions for submitting the
information of Adhesion Related Disease to Secretary Thompson was to impress
upon him a number of issues surrounding ARD. The IAS intends to focus attention
on a number of issues concerning ARD through the news media by use of our
press kits. I did not want Tommy Thompson to be blindsided by the press
and the public in general once this information gets published.
Among the issues we intend to address are:
* Promote awareness of Adhesion Related
* Provide information on ARD, it's treatments
* Provide information on the impact of
ARD on society
* The lack of research regarding ARD
* The lack of medical intervention for
those who suffer ARD
* Including the lack of medical insurance
* And securing disability benefits for
ARD sufferers among other things.
The IAS has also been invited to personally present
our issues on ARD to the Surgeon General, Dr. David Satcher M.D. as well
as the Honorable Judy Biggert, Member of Congress, and co - chair person
for the "Women's Caucus. "
Dr. Hamilton, I am considered by some to be the
most informed consumer of
Adhesion Related Disease in the world today,
therefore, I am not easily
satisfied with most of the communications I receive
from persons within the
medical community regarding ARD! Over all
the information you sent to me
was of no benefit to me other then to support
my own findings on ARD in that there is very little being done to educate
the public and health providers in the United States!
I do have one question for you that I am hoping
you will elect to answer for me:
Based on the high incidence of ARD in our society,
the extremely high percent of people impacted by ARD in so many disabling
ways and the massive financial burden ARD places on America today, why
is it that your office, the CDC and many other public institutions, that
are being paid for by U.S. tax payers money, have not focused ANY public
awareness on ARD or attempted to reach out in a positive and progressive
way to help those who suffer it?
Dr. Hamilton, this same information is pointed
out in a number of the research papers you sent to me, and you knowing
that there is no plausible medical intervention for ARD sufferers
at this time, there is still no action taken to educate the public on it?
Seems strange to me! I ask you to please
Dr. Hamilton, you will note the information that
I have regarding the studies you sent for my review:
“Lawsuit against Doctors” which involves
two of the Nezhat surgeons.
I submit this report in response to the research
paper you sent to me stating:
“Laporoscopic adhesiolysis and relief
of chronic pelvic pain”
Nezhat FR, Crystal RA, Nezhat CH, Neahat
I believe you can see why a report such as the
one you sent to me cannot be regarded by me to be worth anything! I also
have followed a number of the Nezhat surgeon’s adhesion patients, and to
date, I would have to say those surgeons are quite fortunate they are only
involved in one lawsuit!
I have enclosed some of MY research information
for Your review, (in part only!)
“Hocking, D.C., J. Sottile, et al. (2000)
“Stimulation of Intergrin-mediated Cell…
is 48 pages in total.
“Cell Adhesion and Cell Adhesion Molecules”
is 38 pages in total.
“The Lancelot” is one page total.
“Antibody solution may prevent adhesions after
surgery” is 16 pages total.
I thank-you for taking the time to consider this
email and if there is
anything more I can offer you on the subject
of Adhesion Related Disease, please do not hesitate to call on me.
In peace and friendship,
Beverly J. Doucette
Harry Truman said, "I didn't really give ‘em hell.
I just told the truth and it felt like hell."
Cc: Secretary T. Thompson U.S.A.
Dept. of HSS
T. Debas Dean of UCSF
M. Pachence Veritas Technologies
Chapin Director of the WI Dept. of HSS
Satcher M.D. U.S.A. General Surgeon
All the following are attachments to the May 18, 2001 letter to Dr
Beverly J. Doucette
Adhesion Related Disease
Marientte, Wisconsin 514431
The enclosed research information is in part only!
“Hocking, D.C., J. Sottile, et al. (2000) “Stimulation of
Intergrin-mediated Cell… is 48 pages in total.
“Cell Adhesion and Cell Adhesion Molecules” is 38 pages in total.
“The Lancelot” is one page total.
“Antibody solution may prevent adhesions after surgery” is 16
Dr. Hamilton, you will note the information regarding the:
“Lawsuit against Doctors” which involves two of the Nezhat surgeons.
I submit this report in response to the research paper you sent to
“Laporoscopic adhesiolysis and relief of chronic pelvic pain”
Nezhat FR, Crystal RA, Nezhat CH, Neahat CR
I believe you can see why a report such as the one you sent to me cannot
be regarded by me to be worth anything! I also have followed a number of
the Nezhat surgeons adhesion patients, and to date, I would have to say
those surgeons are quite fortunate they are only involved in one lawsuit!
In peace and friendship,
Beverly J. Doucette
Harry Truman said, "I didn't really give ‘em hell. I just told
the truth and it felt like hell."
Cc: Secretary T. Thompson U.S.A. Dept. of HSS
Dr. David Satcher M.D.
U.S.A. General Surgeon