Adhesions are one of the best hidden secrets or enigmas of modern medicine
The word adhere literally means to stick or to bind together. When tissue that is normally not connected grows together, it is called an adhesion. It is also commonly referred to as scar tissue. Adhesions are fibrous tissues (scar tissue) that cause organs within the body to adhere to other internal organs that are not nor
mally connected. Adhesions may appear as thin sheets of tissue similar to plastic wrap or as thick fibrous bands. Adhesions may involve the female reproductive organs (ovaries, Fallopian tubes) can and do cause infertility, dyspareunia (painful in*******se) 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. HOW COMMON IS THE PROBLEM OF ADHESIONS? Adhesions are a widespread problem and develop following any type of pelvic or abdominal surgery. The rate of adhesion formation after surgery is surprising given the relative lack of knowledge about adhesions among doctors and patients alike. Adhesions have been shown to develop in up to 93% of surgical patients. This number increased in patients with major and multiple procedures respectively. Similarly, some studies 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. The incidence of adhesions has increased with the rise in gynaecological procedures. It has been shown that between 60 to 90 % of women suffer post operative adhesions following major gynaecological surgery. WHAT IS THE IMPACT OF ADHESIONS ON PATIENTS AND SURGEONS? The Impact of Adhesions on Patients:
Adhesive Disease accounts for 49-74% of small bowel obstructions. Adhesive Disease accounts for 15-20% of infertility cases. Adhesive Disease accounts for 20-50% of chronic pelvic pain cases. Reduced quality of life. Loss of work days and productivity
Increased risk, complexity and complications during subsequent surgery. One study showed a 19% rate of adhesion-related bowel perforation during subsequent/secondary operations. Bowel perforations occur even more frequently (33%) during surgery for SBO. Patients with adhesion-related perforations had significantly higher postoperative complications (leaks, wound infections, hemorrhages and length of stay). The Impact of Adhesions on Surgeons:
Increased reoperative times
Increased risk of enterotomy
Increased level of surgical complexity
HOW DO ADHESIONS OCCUR? Rarely adhesions are present from birth. Adhesions commonly form in the abdominal-pelvic cavity as a result of inflammation, injury or following surgery - as part of the body’s completely natural and normal healing process. Usually they occur as part of the healing that takes place after surgery, particularly abdominal surgery. Adhesions can also form after inflammation in the abdomen or pelvis. Adhesions develop as the body attempts to repair itself. This normal response can occur after surgery, infection, trauma, or radiation. Repair cells within the body cannot tell the difference between one organ and another. If an organ undergoes repair and comes into contact with another part of itself, or another organ, scar tissue may form to connect the 2 surfaces. BIOCHEMICAL EVENTS LEADING TO FORMATION OF ADHESIONS
During the body’s reaction that leads to an adhesion, chemicals called inflammatory mediators and histamines are released from the blood (more specifically the blood’s mast cells and leukocytes). This allows leukocytes, red blood cells and platelets to concentrate at the injury site in a bundle called a fibrinous exudate. A variety of other factors are at play in the system such as as prostaglandins, bradykinin, chemotactic agents, lymphokines, seretonin and transforming growth factor. At this point in time fibrinolysis may clear the fibrinousexudate. In order for this to occur, plasminogen must be converted to plasmin by tissue plasminogen activator (t-PA). There is constant interplay between the t-PA and plasminogen-activator inhibitors. Unfortunately surgical trauma normally decreases t-PA activity while simultaneously increasing plasminogen activator inhibitors. If this occurs, the fibrinous exudate is transformed into an organized adhesion where fibers of collagen are deposited. Blood vessels begin to form, which leads to an adhesion.
