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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 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 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%.
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.
You Are Not Alone
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:
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.
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.
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.
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.
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
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Typical Surgical Plan for Extensive Enterolysis
|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:
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
Beverly J. Doucette
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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.
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.
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