High resolution ultrasound for pre-operative detection of intraperitoneal adhesions: An invaluable diagnostic tool for the general and laparoscopic surgeon

Ultrasound assessment of abdominal adhesions in neonates: data over dogma for re-operative timing

INTRODUCTION

Neonatal abdominal reoperation is difficult and can be complicated by abdominal adhesions. Identifying patients who could safely undergo early reoperation would save TPN and central line days, decrease associated infection and liver injury, and NICU and hospital length of stay. We sought to determine if ultrasound (US) could accurately assess the location and severity of adhesions in neonates as an objective dynamic marker capable of informing reoperation timing.

METHODS

After IRB approval, we conducted a prospective observational study including neonates undergoing abdominal operations. Patients received surgeon-performed US approximately every 2 weeks until reoperation or discharge. Adhesions were assessed in five zones: right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), left lower quadrant (LLQ) and peri-incision (INC).

RESULTS

Over a 6-month study period, 16 neonates were enrolled. Median gestational age was 34 weeks at birth and median weight 2.2 kg. 6 underwent reoperation within initial NICU admission. At time of operation US correctly identified the absence or presence and severity of adhesions in: RUQ (3/3); RLQ (6/6); LUQ (4/5); LLQ (6/6); and INC (5/5).

CONCLUSION

US can identify location and severity of post-operative adhesions in neonates, potentially identifying patients who can safely undergo reoperation earlier than predetermined wait periods.

LEVEL OF EVIDENCE

IV.

Ultrasound Visceral Slide Assessment to Evaluate for Intra-abdominal Adhesions in Patients Undergoing Abdominal Surgery - A Systematic Review and Meta-analysis

OBJECTIVE

Abdominal entry at the time of laparoscopy is a critical step with a risk of injury to underlying viscera owing to bowel adhesions. Ultrasound can be used as a preoperative tool to assess the slide of viscera underneath the abdominal wall to detect adhesion-free areas. The objective of this systematic review and meta-analysis was to determine the diagnostic accuracy of preoperative visceral slide assessment with ultrasound to detect intra-abdominal adhesions, compared with the gold standard of intraoperative findings.

DATA SOURCES

Using Cochrane, Medline PubMed, Embase, and Google Scholar electronic databases, 3737 articles were screened in April 2020 using a query that included variations of "adhesions" and "ultrasound." Reference lists of relevant articles were searched for further articles.

METHODS OF STUDY SELECTION

Prospective and cross-sectional studies in English that included patients at risk for intra-abdominal adhesions who underwent preoperative ultrasound visceral slide assessment and subsequent intraoperative assessment of adhesions were selected. Two reviewers independently selected 25 articles, extracted data, and assessed bias using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

TABULATION, INTEGRATION, AND RESULTS

Twenty-five articles reported on 1609 patients and 5812 assessed abdominal areas, with considerable heterogeneity of described abdominal areas and degrees of adhesions. Meta-analysis was performed for 21 studies. The periumbilical area was assessed specifically for bowel adhesions in 890 patients in 12 studies, with a 12.0% bowel adhesion rate. Ultrasound assessment for periumbilical bowel adhesions had a combined sensitivity of 95.9% (95% confidence interval, 82.7%-99.1%), specificity of 93.1% (85.1%-96.9%), positive predictive value of 60.4% (44.2%-74.7%), and negative predictive value of 99.2% (97.9%-99.7%) with low heterogeneity (I² = 16%).

CONCLUSION

Visceral slide assessment with ultrasound has a high negative predictive value for the absence of periumbilical bowel adhesions in patients at risk for adhesions and can function as a useful tool to detect adhesion-free areas to allow for safe laparoscopic entry.

The role of non-invasive imaging techniques in detecting intra-abdominal adhesions: a systematic review

BACKGROUND

Intra-abdominal adhesions after surgery are highly prevalent. Adhesions implicate complications during subsequent surgery and can cause chronic abdominal pain. The objective of this review was to investigate the usefulness of non-invasive diagnostic methods for detection of adhesions.

METHODS

We searched the electronic databases: MEDLINE, Embase, and The Cochrane Central Register of Controlled Trials for studies investigating the use of non-invasive diagnostic imaging techniques for detecting adhesions. Main outcome was the sensitivity and specificity of each technique. We used the Quality Assessment of Diagnostic Accuracy studies tool to assess bias.

RESULTS

In total, 25 studies were included: 18 using ultrasound (US), 5 using magnetic resonance imaging (MRI), 1 using computed tomography (CT), and 1 using both US and MRI. A total of 2195 patients were included. Overall accuracy ranged between 76 and 100% for US studies and between 79 and 90% for MRI and was 66% for CT. Sensitivity ranged between 21 and 100% for US and between 22 and 93% for MRI and was 61% for CT. Specificity was 32-100% for US, 25-93% for MRI, and 63% for CT. Bias analysis revealed that in most studies, investigators were blinded to the reference standard but not to the index test and 11 of 25 studies had a high risk of selection bias.

CONCLUSIONS

Currently, abdominal US can be used to determine the presence of adhesions between bowel and the abdominal wall. MRI is also an accurate diagnostic modality and can in addition visualize adhesions between viscera, however, with a tendency to over diagnose adhesions. There is insufficient evidence to support CT as a diagnostic modality for adhesions.

Prediction of pelvic adhesions at repeat cesarean delivery through assessment of striae gravidarum score: A cross-sectional study

OBJECTIVE

To investigate the predictive value of the Davey Score for striae gravidarum (SG) on the presence of pelvic adhesions at repeat cesarean delivery (CD).

MATERIALS AND METHODS

The current study was a cross-sectional study conducted in a tertiary university hospital between November 2016 and March 2018. All women scheduled for elective CD were included if they had at least previous one CD with pregnancy in term fetus (37-40 weeks gestation. Preoperative evaluation of SG severity using Davey score, which is a validated scoring system, was done on the examination bed. Patients with no/mild striae (score 0-2) were classified as group (I) and women with severe striae (score 3-8) were classified as group (II). During surgery, pelvic adhesions were evaluated and classified according to the Nair's scoring system. The primary outcome was the difference in the rate of pelvic adhesions between both groups.

RESULTS

The study included 300 women; group I included 114 women and group II included 186 women. About 90% of women with severe striae versus 82.5% of women with no/mild striae were found to have adhesions (p = 0.035). Dense adhesions were significantly present in severe striae group (57.4%) versus (41.5%) in no/mild striae group (p = 0.022). The mean Davey score in women in group (II) was significantly higher than group (I) (4.25 ± 3.36 vs. 3.09 ± 2.95, p = 0.03). Nair's score had a significant positive moderate correlation with Davey score (r = 0.541, p = 0.016). According to the results of multivariate regression analysis, Davey score >2 was the only variable associated with increased risk of pelvic adhesions (p = 0.010).

CONCLUSION

Assessment of SG score in women with previous CD using Davey score might help to predict pelvic adhesions status before planning a new surgery.

Transabdominal ultrasound: Can it be used to detect and quantify adhesions/reported pain, following Caesarean section?

BACKGROUND

Caesarean section is common in the UK with post-procedural adhesions causing life-long clinical symptoms and impacting future pregnancies. This study's aim was to explore associations between these surgical adhesions, via transabdominal ultrasound findings, and perceived symptoms.

METHOD

Females demonstrating 1-3 transverse, lower-segment Caesareans were included. Visceral slide transabdominal ultrasound elicited positive adhesions (<1 cm movement) and negative adhesions (>1 cm movement). Scar tissue quality was assessed by the Patient and Observer Scar Assessment Scale (POSAS) and Numerical rating scales (NRS) described pain symptoms. The relationship between adhesions was explored using Fisher's exact test and multiple regression analysis.

RESULTS

Twenty-two subjects (mean-age 35) were recruited; twenty participants (91%) had undergone 1 Caesarean, one each of the remainder had undergone 2 and 3 Caesareans respectively. Increased Visceral slide (>1 cm) was seen as predictive of increased scar pain (R² = 0.76 (95% CI 0.12-0.28), P < 0.001).

CONCLUSION

Caesarean adhesion scans showed significant associations with pain symptomology. Comprehensive adhesion assessment needs to be developed to improve long term outcomes of adhesions. Transabdominal Ultrasound can be considered a useful, quick and non-deleterious alternative diagnostic tool to Laparoscopy, therefore preventing further adhesion formation.