Medico-legal consequences of post-operative intra-abdominal adhesions. Int J Surg. 2009;7:187-191. [PMID: 19389492 DOI: 10.1016/j.ijsu.2009.04.004]

MR imaging for preoperative characterization of pelvic adhesions: role in diagnosis and surgical planning

Pelvic adhesions are nonanatomic connections between organs and normal peritoneal surfaces that develop secondary to a maladaptive inflammatory response to tissue insults. Comprised of fibrous tissue, adhesions can result in the distortion of operative dissection planes, which can complicate the establishment of abdominal access in patients undergoing surgery, prolong the length of surgery, and increase the risk of injury to bowel and other structures if involved by extensive adhesive disease. This can adversely impact patient outcomes by increasing the risk of surgical complications including bleeding, infection, and prolonging postoperative length of stay. Literature on the characterization of adhesions with imaging is limited and a systematic framework for evaluating adhesive disease on cross-sectional imaging of the pelvis does not currently exist. In this review, we discuss the MR imaging features of pelvic adhesions, highlighting unique teaching cases in which surgical exploration was significantly complicated by the presence of adhesive disease. We will also review the correlation between MR imaging and intraoperative findings in these cases. A proposed standardized framework for the detection and characterization of adhesions on pelvic MRI will be reviewed with multiple imaging examples. Identification and characterization of pelvic adhesive disease on preoperative imaging provides radiologists with an opportunity to inform the referring clinician of their presence, potentially improving outcomes and the quality of patient care.

Etiology and management outcomes of adult mechanical bowel obstruction in Nigeria: A systematic review and meta-analysis

BACKGROUND

Adult mechanical bowel obstruction (AMBO) has been previously reported to be majorly caused by hernias in developing countries. In Nigeria, however, there has been a recent change in pattern with adhesions now being the leading cause. The aim of this systematic review is to examine the changing pattern of the causes, and outcomes of patients managed for AMBO in Nigeria.

METHODS

Relevant keywords relating to AMBO were used to conduct a search on PubMed, Web of Science, Google Scholar, and AJOL. The search returned 507 articles, which were subjected to title, abstract, and full text screenings, according to the inclusion and exclusion criteria. This generated 10 articles which were included in the final qualitative synthesis.

RESULTS

The total sample size across the 10 studies was 1033. Adhesions, hernias, and intra-abdominal tumors, responsible for 46.25%, 26.31%, and 12.23% of cases respectively, were the major causes of AMBO in Nigeria. 65.6% of cases were managed operatively and 34.4% were managed conservatively. The meta-analysis revealed high morbidity and mortality rates of 31% (95% CI: 17; 44, 5) and 11% (95% CI: 6; 15, 5), respectively, among adult patients managed for mechanical bowel obstruction in Nigeria.

CONCLUSIONS

Adhesion, which results predominantly from appendicectomy is the most common cause of AMBO in Nigeria. This is unlike former reports where hernia was the most common cause. Morbidity results majorly from wound infection, recurrent adhesions, and postoperative enterocutaneous fistula. The mortality rate is similar to reports from various West African studies, and it is significantly influenced by surgical intervention time.

Cesarean bladder injury - obstetrician's nightmare

Urinary bladder is an adjacent viscus susceptible for intraoperative injury during cesarean section (CS). Prolonged labor, scarred uterus, intraabdominal adhesion, emergency CS, advanced labor, cesarean hysterectomy etc., are the predisposing factors for bladder injury during CS. While operating on such conditions, one should be meticulous to explore the possibility of bladder injury. Family physician practicing community obstetrics should be aware of this and know how to tackle this. Usually the dome of the bladder is injured and the trigonal area remains away from the injury field by 6-10 cm. Bladder rent is repaired in two layers either by continuous simple or interrupted suture with 3-0 & 2-0 polyglycolic acid suture. Suprapubic cystostomy and transurethral catheter are kept for 10-14 days. While postoperative adhesion, CS during full dilatation of cervix, abnormal anatomy etc., may not proceed for negligence, bladder injury in normal patients and unrecognized intraoperative bladder injury may attract penalty from the consumer court.

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Background

Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups.

Methods

The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion.

Recommendations

Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention.

Discussion

This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.

The Improvement of Laparoscopic Surgical Skills Obtained by Gynecologists after Ten Years of Clinical Training Can Reduce Peritoneal Adhesion Formation during Laparoscopic Myomectomy: A Retrospective Cohort Study

OBJECTIVE

To evaluate if improvement of laparoscopic skills can reduce postoperative peritoneal adhesion formation in a clinical setting.

STUDY DESIGN

We retrospectively evaluated 25 women who underwent laparoscopic myomectomy from January 1993 to June 1994 and 22 women who underwent laparoscopic myomectomy from March 2002 to November 2004. Women had one to four subserous/intramural myomas and received surgery without antiadhesive agents or barriers. Women underwent second-look laparoscopy for assessment of peritoneal adhesion formation 12 to 14 weeks after myomectomy. Adhesions were graded according to the Operative Laparoscopy Study Group scoring system. The main variable to be compared between the two cohorts was the proportion that showed no adhesions at second-look laparoscopy.

RESULTS

Demographic and surgical characteristics were similar between the two cohorts. No complications were observed during surgery. No adverse events were recorded during postoperative course. At second-look laparoscopy, a higher proportion of adhesion-free patients was observed in women who underwent laparoscopic myomectomy from March 2002 to November 2004 (9 out of 22) compared with women who underwent the same surgery from January 1993 to June 1994 (3 out of 25).

CONCLUSION

The improvement of surgeons' skills obtained after ten years of surgery can reduce postoperative adhesion formation.

Paeoniflorin prevents postoperative peritoneal adhesion formation in an experimental rat model

Although materials and modern surgical techniques have been developed to suppress postoperative adhesions, adhesion formation can still occur, and thus, a novel effective anti-adhesion drug is greatly needed. In the present study, we explored the efficacy of paeoniflorin treatment against postoperative peritoneal adhesions and examined the anti-oxidative stress and anti-inflammatory properties of PE. Forty-eight male Sprague-Dawley rats were randomly divided into 6 groups for the study: the sham, control, hyaluronan and three concentrations (10, 20 and 40 mg/kg/d) paeoniflorin groups. Abdominal adhesions were created by abrasion of the caecum and its opposite abdominal wall. In the paeoniflorin groups, the rats were administered daily oral doses of paeoniflorin for 7 days. The abdominal cavities of the rats were reopened with a U-shaped incision to macroscopically grade the adhesions. Histologic analysis was performed, and oxidative stress, inflammatory cytokine, collagen fiber degradation and cytokeratin levels were measured. Macroscopic and histopathological measurements revealed that paeoniflorin reduced peritoneal adhesion and inflammation. Notably, treatment with paeoniflorin reduced the protein levels of TGF-β1, IL-6 and COX-2. The collagen fiber fractions were distinctly lower in the PE groups than in the control group. Western blotting analyses showed that paeoniflorin increased MMP-9 and superoxide dismutase-2 protein expression and sharply reduced α-SMA and COX-2 protein expression. Peritoneal mesothelium cells were more continuous and complete in animals treated with paeoniflorin. Our study suggests that paeoniflorin can be used to ameliorate peritoneal adhesions via anti-oxidative stress and anti-inflammatory actions during the postoperative period.

Laparoscopy or laparotomy as the way of entrance in myoma enucleation

PURPOSE

Uterine myomas are the main cause of benign uterine diseases in premenopausal women. Objective of the present paper is to investigate the current best treatment modalities of myomas, depending on age of the patient and her desire to preserve fertility, as well as on clinical presentation of this pathology, such as size, number, and location of fibroids and, furthermore, on surgical experience of the gynecologist.

METHODS

The design of our work is a systematic literature review of existing studies, reviews, and meta-analysis conducted in PubMed and Cochrane Library to identify relevant literature. Commonly, the myomectomy is to be recommended in women desiring to preserve fertility when myomas are associated with symptoms such as excessive bleeding, pelvic discomfort, or palpable abdominally fibroids. The decision of surgical approach for myomectomy should be individualized, depending on size and location, as well as on surgeon's experience. The different modalities of myomectomy, laparoscopic, hysteroscopic, robotic-assisted, or laparotomic are in detail presented in the paper, according to Society of Obstetricians and Gynecologists of Canada (SOGC) clinical practice guidelines and taking into consideration possible concerns of myomectomy such as uterine rupture, development of adhesions, and myomas' recurrence.

Modified Adenovirus Reduces De Novo Peritoneal Adhesions in Rats and Limits Off-Target Transfection. Role of EZH2 in Adhesion Formation

AIM OF THE STUDY

Adenovector encoding tissue plasminogen activator (tPA) was shown to reduce experimental peritoneal adhesion. We investigated the targeting potential of our modified adenovector, its ability to reduce adhesions and the epigenetic role of histone methyltransferase EZH2 in adhesion formation.

MATERIALS AND METHODS

Control lacZ, nonmodified tPA or modified tPA vectors were instilled in the peritoneal cavity after injury in de novo adhesions or after lysis of adhesions in recurrent adhesions. Adhesion severity was scored and adhesions and liver tissues were examined for adenovirus E4 gene and tPA mRNA expression. Levels of tPA, plasminogen activator inhibitor-1 (PAI-1), transforming growth factor-β1 (TGF-β1), and EZH2 expression were measured.

RESULTS

E4 transcripts were detected in adhesions of nonmodified and modified and in livers of nonmodified but not in livers of modified de novo adhesions. Both nonmodified (p = 0.021) and modified vectors (p = 0.036) reduced the severity of de novo adhesions compared to lacZ vector. Levels of tPA in nonmodified (p = 0.021) and modified adhesions (p = 0.001) were elevated while PAI-1 (p = 0.013 and p = 0.001, respectively) and TGF-β1 levels (p = 0.002 and p = 0.016, respectively) were reduced compared with lacZ group. All vectors were not expressed in recurrent adhesions and severity score were not different among groups. EZH2 levels were elevated in de novo nontreated (p = 0.001) and was further increased in recurrent (p = 0.001) nontreated adhesions compared with noninjured peritoneum.

CONCLUSION

Modified adenovirus successfully targeted de novo adhesions but not liver tissues and reduced the severity of de novo adhesions. EZH2 is involved in the development and progression of peritoneal adhesions.

Bowel obstructions and incisional hernias following trauma laparotomy and the nonoperative therapy of solid organ injuries: A retrospective population-based analysis

BACKGROUND

Small bowel obstruction (SBO) and incisional hernia (IH) represent the most common long-term complications of laparotomy. They may also be more common among injured patients than for elective/nontrauma emergency scenarios. Unfortunately, the population-based incidence of SBO and IH following trauma laparotomy is unknown. The aim of this study was to define the long-term, population-based incidence of SBO and IH following both trauma laparotomy as well as the nonoperative therapy of solid organ injuries.

METHODS

All injured patients admitted to a Level 1 trauma center (2002-2013) who underwent (1) a laparotomy or nonoperative care of (2) splenic and/or (3) hepatic injuries were linked with the Alberta Health Services Discharge Database to identify all readmissions for subsequent SBO and/or IH within the province. Standard statistical methodology was used (p < 0.05).

RESULTS

Of 484 patients who underwent a trauma laparotomy, 29 (6%) and 42 (9%) required readmission for SBO and IH, respectively (0.13 SBO and 0.10 IH admissions per patient year). Patients who underwent nonoperative management of their liver and/or spleen injuries displayed long-term SBO rates of 1% (6 of 619) and 0.7% (4 of 606), respectively. The rate of SBO and IH in patients with unnecessary laparotomies was equivalent to therapeutic procedures (p = 0.183). Topical hemostatic agents, repeat laparotomies, and injury pattern did not alter SBO or IH rates (p > 0.05).

CONCLUSION

The population-based, long-term rate of clinically relevant SBO and IH following trauma laparotomies is 15%. This increases to 19% on a per-admission basis. Nontherapeutic scenarios, injury pattern, topical hemostatics, and open abdomens did not alter complication rates.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Effect of intraperitoneal curcumin instillation on postoperative peritoneal adhesions

OBJECTIVE

The aim of this study was to determine the effect of curcumin on adhesion formation in a rat cecum abrasion model.

MATERIALS AND METHODS

Thirty Wistar rats were randomized into three groups; the control group received saline, the curcumin group received 10 mg/kg of curcumin after cecal abrasion, and in the sham group the abdominal wall was closed without any abrasion to the cecum. On day 15, adhesions were assessed blindly using a standardized scale, and histopathological samples were taken and examined.

RESULTS

There were no incisional hernias or wound dehiscences in any animals of the three groups. A comparison of adhesion scores showed a significant difference between the curcumin (median = 1) and the control group (median = 2; p < 0.05). The grade of inflammation of the curcumin (median = 1) and the sham (median = 0) group was significantly lower than that of the control group (median = 3; p < 0.01 and p < 0.001, respectively). Hydroxyproline levels were significantly lower in the sham (48.3 ± 11.8 µg/mg) and the curcumin (63.8 ± 13.9 µg/mg) group compared to the control group (85.7 ± 22.1 µg/mg; p < 0.05).

CONCLUSION

These data suggest that curcumin, administered intraperitoneally, was effective in the prevention of peritoneal adhesion formation.

Comparison of 2 Different Barrier Solutions (icodextrin 4% vs. dextran 70) used as Adhesion-prevention Agents after Microsurgical Adnexal Operations

In this prospective randomized clinical trial, 2 different barrier solutions (icodextrin 4% vs. dextran 70) were compared with regard to their antiadhesive properties, their tolerance and their persistence in situ. To this end, 45 patients suffering from infertility due to adnexal adhesions with indication for microsurgical adhesiolysis were randomized to 2 treatment groups. In advance of abdominal closure, patients were randomized to receive either 1,000 mL of icodextrin 4% solution (n = 23) or 300 mL dextran 70 instillation (n = 22). Serial transvaginal ultrasonographic scans were conducted on days 1, 3, 5 and 7 after surgery to measure the remaining volumes of each barrier solution. Seven days after initial surgery, a second-look laparoscopy was performed; remaining fluids were aspirated and measured and adhesions were rescored (final adhesion score). Differences between treatment groups were not significant (p = 0.775). With regard to their tolerance, the advantages of the icodextrin 4% solution became obvious, as edema of vulva and abdomen occurred more frequently after dextran 70 instillation.

In conclusion, microsurgical adhesiolysis and application of icodextrin 4% solution or dextran 70 as adhesion-prevention agent resulted in reduction of incidence, extent and severity of adhesions. Both solutions were well tolerated.

Preoperative nomogram to predict risk of bowel injury during adhesiolysis

BACKGROUND

Inadvertent bowel injury during adhesiolysis is a major cause of increased morbidity and mortality following abdominal surgery. Identification of risk factors predicting this complication would guide preoperative counselling and surgical decision-making. The aim of this study was to identify predictive preoperative factors for inadvertent bowel injury occurring during adhesiolysis.

METHODS

All patients undergoing elective abdominal surgery between June 2008 and June 2010 were evaluated prospectively as part of the LAPAD study. Data on adhesiolysis and inadvertent organ injury were gathered by direct observation during operation. Univariable logistic regression was used to investigate factors that increased the risk of inadvertent bowel injury. Independent predictors of bowel injury were identified using multivariable logistic regression and used to create a clinical nomogram.

RESULTS

Of 715 patients eligible for analysis, 48 (6.7 per cent) had inadvertent bowel injuries. In 42 patients the defect was detected during operation and in nine at a later time (3 patients had both). Bowel resection was required for almost two-thirds of the enterotomies. The number of previous laparotomies, anatomical site of the operation, presence of bowel fistula and laparotomy via a pre-existing median scar were independent predictors of bowel injury. A clinical scoring system was constructed using a nomogram incorporating these risk factors; this had a predictive discrimination, measured as the area under the receiver operating characteristic curve, of 0.85.

CONCLUSION

A nomogram based on four independent factors predicted the risk of inadvertent bowel injury.

REGISTRATION NUMBER

NCT01236625 (http://www.clinicaltrials.gov).

Peritoneal adhesions after laparoscopic gastrointestinal surgery

Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation, only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue. Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis. Moreover, several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact. Experimental data in animal models have suggested that CO₂ pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration. Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO₂, N₂O and O₂ seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum. However, these experimental data have not had a significant impact on the modification of laparoscopic instrumentation. In contrast, surgeons should train themselves to perform laparoscopy quickly, and they should complete their learning curves before testing chemical anti-adhesive agents and anti-adhesion barriers. Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation, but when these agents are used alone, the concentrations needed to prevent adhesions are too high and could cause major post-operative side effects. Anti-adhesion barriers have been used mainly in open surgery, but some clinical data from laparoscopic surgeries are already available. Sprays, gels, and fluid barriers are easier to apply in laparoscopic surgery than solid barriers. Results have been encouraging with solid barriers, spray barriers, and gel barriers, but they have been ambiguous with fluid barriers. Moreover, when barriers have been used alone, the maximum protection against adhesion formation has been no greater than 60%. A recent small, randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100% effective in preventing post-operative adhesion formation. Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points, such as reduced incidences of bowel obstruction and abdominal pain and increased fertility.

Adhesion awareness: a nationwide survey of gynaecologists

OBJECTIVE

Adhesions and related complications lead to substantially increased morbidity and mortality which increase medical costs. We investigated the awareness of adhesions among Dutch gynaecologists and gynaecology residents.

STUDY DESIGN

A survey, assessing knowledge and opinion about adhesions, was sent to a randomly selected group of 381 gynaecologists and 256 residents. In addition, the informed consent process and application of anti-adhesive agents were questioned.

RESULTS

The response rate was 56.9%. Complications due to adhesions were highly underestimated, leading to low knowledge scores (mean score 35.1%). Of all respondents 73.8% agreed that adhesions exert a clinically relevant and negative effect, but only 51.2% expressed a positive opinion on adhesion prevention. This correlated with a stronger belief in the clinically relevant and negative effects of adhesions and the opinion that adhesion prevention belongs to standard care (ρ=0.212, p<0.001; ρ=0.495, p<0.001). Of all respondents 31.4% expressed a positive attitude towards anti-adhesive agents and 19.8% expressed a negative one. A negative attitude correlated with a negative view in terms of cost-benefits (ρ=0.245, p<0.001). Although 43.5% had used anti-adhesive agents in the past year, 20.9% had used them before but stopped using agents in the past year. Only 5.2% routinely included adhesions or related morbidity in the informed consent.

CONCLUSIONS

Awareness of adhesions is limited and informed consent is provided inadequately. Implementing adhesion prevention is related with awareness of adhesions. These findings underline the need to embed adhesions, related morbidity and prevention in educational programmes.

Peritoneal adhesion index (PAI): proposal of a score for the "ignored iceberg" of medicine and surgery

Peritoneal adhesions describe a condition in which pathological bonds form between the omentum, the small and large bowels, the abdominal wall, and other intra-abdominal organs. Different classification systems have been proposed, but they do not resolve the underlying problem of ambiguity in the quantification and definition of adhesions. We therefore propose a standardized classification system of adhesions to universalize their definition based on the macroscopic appearance of adhesions and their diffusion to different regions of the abdomen. By scoring with these criteria, the peritoneal adhesion index (PAI) can range from 0 to 30, unambiguously specifying precise adhesion scenarios. The standardized classification and quantification of adhesions would enable different studies to more meaningfully integrate their results, thereby facilitating a more comprehensive approach to the treatment and management of this pathology.

Remote efficacy for two different forms of hyaluronate-based adhesion barriers

BACKGROUND

Chemically modified sodium hyaluronate and carboxymethylcellulose (HA/CMC) membrane clinically reduces adhesion formation following surgery but was not designed for laparoscopic use. HA/CMC powder of identical chemical composition has been developed to allow for application laparoscopically. We compared the adhesion reduction efficacy of HA/CMC powder and film when applied directly to or remote from sites of surgical trauma. We also investigated the effect of the powder on wound healing.

MATERIALS AND METHODS

Two animal models of adhesion formation were used to evaluate efficacy: a rat peritoneal sidewall defect model and a rabbit cecal abrasion/sidewall defect model. The products were applied directly to the defect or the contralateral sidewall. Adhesions were examined seven days after surgery. In a separate study, the effect of the powder on healing was evaluated at 5, 7, and 28 days using a rat incisional wound strength model.

RESULTS

HA/CMC powder and film, when applied directly to the peritoneal defect, significantly reduced adhesions relative to the untreated control in both models. Remote applications of HA/CMC powder also reduced adhesions. In contrast, remote applications of HA/CMC film had no effect. HA/CMC powder did not significantly alter incisional wound strength at any of the timepoints tested.

CONCLUSION

In our preclinical models, HA/CMC powder had similar adhesion reduction efficacy to HA/CMC film when applied directly to sites of trauma. In addition, HA/CMC powder reduced adhesions remote from the application site. Importantly, HA/CMC powder did not impair incisional wound healing. On the basis of these results, future investigation of HA/CMC powder is warranted.

Singapore's anatomical future: quo vadis?

The disciplines of anatomy and surgery are not dichotomous since one is dependent on the other. Traditionally, surgeons predominantly taught gross and clinical anatomy. In this review, we examine the context of how human anatomy is taught nowadays. In essence, we discovered that there are certain discernable trends consistently observable between the American and British systems. In Singapore, the British Russell Group first influenced its education landscape but now more so by the American Ivy League. Singapore now has three medical schools all offering differing anatomy curricula, which serves as an opportune time for it to consider if there is a best approach given that the practice of surgery is also evolving in parallel. This review discusses the various pedagogies and issues involved, and will serve as a forum and stimulus for discussion. By tweaking the curriculum correctly and the lessons learnt, future doctors and surgeons in training will receive a better anatomical education, not just in Singapore but the world in general. Key recommendations include the use of body painting, clay, plasticine to facilitate the learning of anatomy, and the implementation of a body donation program. Furthermore, strategic mergers with key stakeholders will also ensure the survival of the discipline.

Is Patient Education About Adhesions a Requirement in Abdominopelvic Surgery?

Background: Over the past decades, our knowledge and understanding of adhesions and adhesion-related complications has increasingly grown and it has become evident that adhesions have significant implications for patients, physicians and the healthcare system. The question arises whether this has resulted in greater awareness of adhesion-related problems among practicing physicians and appropriate patient education on this topic in daily practice. The following article provides a brief overview of the important subject of adhesions, discusses current awareness of adhesions among patients and doctors and addresses the consequences of failure to provide patient education and consent from a medical perspective. Methods: Selective literature searches were conducted in PubMed and the Cochrane Library. A patient information and consent form was developed based on several years' experience and expertise in the field of adhesions. Results: Adhesions are the most common type of complication in abdominopelvic surgery today, with devastating consequences for some patients. Surveys investigating the awareness of adhesions among physicians and patients clearly showed that even well-informed physicians fail to educate their patients adequately. Such failure could potentially lead to successful medical malpractice lawsuits against doctors. Conclusion: Considering their clear clinical impact, adhesions and related consequences should always be discussed with patients preoperatively. A newly developed consent form that specifically addresses adhesion formation may serve to thoroughly educate patients preoperatively and to adequately document the process of doing so.

Secular trends in small-bowel obstruction and adhesiolysis in the United States: 1988-2007

BACKGROUND

Postoperative adhesions are common after surgery and can cause small-bowel obstruction (SBO) and require adhesiolysis. The impact that laparoscopy and other surgical advances have had on rates of SBO and adhesiolysis remains controversial. This study examines trends in discharges from US hospitals for SBO and adhesiolysis from 1988 to 2007.

METHODS

We performed an analysis of secular trends for SBO and adhesiolysis, using the National Hospital Discharge Survey. Spearman correlation coefficients were calculated to assess trends over time.

RESULTS

Rates of SBO were stable over time (ρ = .140; P = .28). Adhesiolysis rates were stable over time (ρ = -.18; P = .17), although there were significant downward trends in patients older than age 65 (ρ = -.55; P = .01) and age 15 to 44 (ρ = -.84; P < .01).

CONCLUSIONS

There has been no significant change in overall rates of SBO or adhesiolysis from 1988 to 2007. For adhesiolysis, there were decreasing trends when stratified by age. Further research is required to understand the factors associated with adhesion-related complications.

Prevention of peritoneal adhesions: a promising role for gene therapy

Adhesions are the most frequent complication of abdominopelvic surgery, yet the extent of the problem, and its serious consequences, has not been adequately recognized. Adhesions evolved as a life-saving mechanism to limit the spread of intraperitoneal inflammatory conditions. Three different pathophysiological mechanisms can independently trigger adhesion formation. Mesothelial cell injury and loss during operations, tissue hypoxia and inflammation each promotes adhesion formation separately, and potentiate the effect of each other. Studies have repeatedly demonstrated that interruption of a single pathway does not completely prevent adhesion formation. This review summarizes the pathogenesis of adhesion formation and the results of single gene therapy interventions. It explores the promising role of combinatorial gene therapy and vector modifications for the prevention of adhesion formation in order to stimulate new ideas and encourage rapid advancements in this field.

A review of the problematic adhesion prophylaxis in gynaecological surgery

Background

Adhesions lead to considerable patient morbidity and are a mounting burden on surgeons and the health care system alike. Although adhesion formation is the most frequent complication in abdominal and pelvic surgery, many surgeons are still not aware of the extent of the problem. To provide the best care for their patients, surgeons should consistently inform themselves of anti-adhesion strategies and include these methods in their daily routine.

Methods

Searches were conducted in PubMed and The Cochrane Library to identify relevant literature.

Findings

Various complications are associated with adhesion formation, including small bowel obstruction, infertility and chronic pelvic pain. Increasingly, an understanding of adhesion formation as a complex process influenced by many different factors has led to various conceivable anti-adhesion strategies. At present, a number of different anti-adhesion agents are available. Although some agents have proved effective in reducing adhesion formation in randomised controlled trials, none of them can completely prevent adhesion formation.

Conclusion

To fulfil our duty to provide best possible care for our patients, it is now time to regard adhesions as the most common complication in surgery. Further research is needed to fully understand adhesion formation and to develop new strategies for adhesion prevention. Large clinical efficacy trials of anti-adhesion agents will make it easier for surgeons to decide which agent to use in daily routine.

In-hospital small bowel obstruction after exploratory laparotomy for trauma

BACKGROUND

The purpose of this study was to examine the incidence and risk factors of in-hospital small bowel obstruction (SBO) after exploratory laparotomy for trauma.

METHODS

A retrospective review of patients surviving over 72 hours after an exploratory laparotomy for trauma. Patients with intestinal obstructive symptoms were reviewed by a consensus panel, which evaluated the clinical, laboratory, and radiologic findings to validate the diagnosis of SBO.

RESULTS

A total of 571 patients met inclusion criteria. The incidence of early SBO was 3.9%, with 22.7% of these patients requiring surgical intervention. Patients with gastrointestinal (GI) perforation had a significantly higher incidence of SBO, compared with those with no GI perforation (5.7% vs. 1.3%, p = 0.007). A forward logistic regression identified the presence of a GI perforation as the only factor independently associated with early SBO (adjusted odds ratio: 4.39; 95% confidence interval: 1.28-15.15; p = 0.019). The overall hospital stay was significantly longer for SBO patients (27.0 days ± 26.7 days vs. 16.0 days ± 22.8 days; adjusted mean difference: 11.5; 95% confidence interval: 1.6-21.3; p = 0.022). Development of SBO increased the cost by 59.7%.

CONCLUSION

The incidence of in-hospital SBO after laparotomy for trauma is significant at 3.9%. The presence of a GI perforation is independently associated with the development of this complication. Over a fifth of patients with early SBO will require a surgical intervention. The use of preventive strategies may be justified in selected, high-risk patients to reduce the burden associated with early SBO.

Adhesion awareness: a national survey of surgeons

Background

Postoperative adhesions are the most frequent complication of abdominal surgery, leading to high morbidity, mortality, and costs. However, the problem seems to be neglected by surgeons for largely unknown reasons.

Methods

A survey assessing knowledge and personal opinion about the extent and impact of adhesions was sent to all Dutch surgeons and surgical trainees. The informed-consent process and application of antiadhesive agents were questioned in addition.

Results

The response rate was 34.4%. Two thirds of all respondents (67.7%) agreed that adhesions exert a clinically relevant, negative effect. A negative perception of adhesions correlated with a positive attitude regarding adhesion prevention (ρ = 0.182, p < 0.001). However, underestimation of the extent and impact of adhesions resulted in low knowledge scores (mean test score 37.6%). Lower scores correlated with more uncertainty about indications for antiadhesive agents which, in turn, correlated with never having used any of these agents (ρ = 0.140, p = 0.002; ρ = 0.095, p = 0.035; respectively). Four in 10 respondents (40.9%) indicated that they never inform patients on adhesions and only 9.8% informed patients routinely. A majority of surgeons (55.9%) used antiadhesive agents in the past, but only a minority (13.4%) did in the previous year. Of trainees, 82.1% foresaw an increase in the use of antiadhesive agents compared to 64.5% of surgeons (p < 0.001).

Conclusions

The magnitude of the problem of postoperative adhesions is underestimated and informed consent is provided inadequately by Dutch surgeons. Exerting adhesion prevention is related to the perception of and knowledge about adhesions.

Adhesion formation after intracapsular myomectomy with or without adhesion barrier

OBJECTIVE

To show the prevention of adhesion formation by placing an absorbable adhesion barrier after intracapsular myomectomy.

DESIGN

Prospective blinded observational study.

SETTING

University-affiliated Hospitals.

PATIENT(S)

Patients ≥ 18 years old with single or multiple uterine fibroids removed by laparoscopic or abdominal intracapsular myomectomy.

INTERVENTION(S)

A total of 694 women undergoing laparoscopic or abdominal myomectomy were randomized for placement of oxidized regenerated cellulose absorbable adhesion barrier to the uterine incision or for control subjects without barriers. The presence of adhesions was assessed in 546 patients who underwent subsequent surgery.

MAIN OUTCOME MEASURE(S)

The primary and secondary outcomes of the analysis were the presence and severity of adhesions for four groups: laparotomy with barrier, laparotomy without barrier, laparoscopy with barrier, and laparoscopy without barrier.

RESULT(S)

There was a higher rate of adhesions in laparotomy without barrier (28.1%) compared with laparoscopy with no barrier (22.6%), followed by laparotomy with barrier (22%) and laparoscopy with barrier (15.9%). Additionally, the type of adhesions were different, filmy and organized were predominant with an adhesion barrier, and cohesive adhesions were more common without an adhesion barrier.

CONCLUSION(S)

Oxidized regenerated cellulose reduces postsurgical adhesions. Cohesive adhesions reduction was noted in laparoscopy.

Implications of late complications from adhesions for preoperative informed consent

The process of informed consent is a critical aspect of the doctor-patient relationship. Doctors have a professional duty to provide patients with sufficient information if a treatment is associated with a significant risk. NHS guidelines advise doctors to mention risks that occur more frequently than 1-2% or risks that are serious even if the likelihood is very small. In the case of abdominal and pelvic surgery, risks can broadly be divided into early and late complications. Early complications, such as bleeding and infection, have a close temporal relationship with the operation. Such complications are routinely mentioned during the consent process. In contrast, postoperative adhesions cause changes in the normal anatomy that can adversely affect function many years and even decades after the original operation, leaving patients at lifelong risk for late complications. These late adhesive complications, namely bowel obstruction, mechanical female infertility and chronic pain, are often neglected during the consent process. However, the risks to patients from late adhesive complications are serious and well in excess of the accepted threshold where it could be considered a breach in the duty of care not to inform patients. This is reflected by a number of claims against the NHS based on consent issues regarding late adhesive complications of surgery. Therefore, late complications of surgery from adhesions should be included in the pre-operative consent process. This would decrease litigation costs but more importantly also underpins the doctor-patient relationship.