What's up, Doc? Reaction to surgery causes abdominal and pelvic adhesions
Q: My doctor said I may have abdominal adhesions after having my appendix removed. What are these?
A: Adhesions are basically scar tissue inside your body that may stick (adhere) to body tissue and/or organs. They may occur in your abdomen, your pelvis (especially in women), your chest (for example in the pleura, which is the sac around your lungs), the pericardium (the sac around your heart) and possibly other locations.
I will focus on abdominal and pelvic adhesions because they're by far the most common.
Surgery almost always causes at least some scar tissue, and hence possibly adhesions, because of the body’s reaction to, and healing after, surgical intervention. Adhesions may also be caused by scarring as an inflammatory reaction to infection, an autoimmune/other condition, radiation treatment, certain medications and/or other causes.
Abdominal adhesions are the most common type of adhesion causing medical issues.
Abdominal surgeries, whether open (where the surgeon cuts through the skin to directly visualize and physically treat the structures/organs that are the focus of the surgery) or laparoscopic (where the area of focus of the surgery is visualized using small fiber-optic cameras on the end of thin tubes inserted through small holes made through the skin, and then physically treated specialized laparoscopic surgical instruments also inserted through small holes made in the skin) will cause abdominal adhesions in 50% to 90% of patients. Because of the less invasive nature of laparoscopic surgeries, symptomatic adhesions are less frequent and typically less extensive afterward, but are still pretty common.
In addition, about 10% of patients who have never had abdominal surgery develop abdominal adhesions from inflammatory conditions such as diverticular disease, Crohn’s colitis, peritonitis (from any cause), and/or many other conditions.
Some infants are born with abdominal adhesions.
Pelvic adhesions are common after pelvic surgery, and may also occur from non-surgical causes such as PID (pelvic inflammatory disease from an infection, often a sexually transmitted disease), endometriosis (where endometrial tissue that is normally on the inside of a woman’s uterus occurs in other locations in the pelvis and/or abdomen), ectopic pregnancy and/or from many other causes.
Luckily, most adhesions do not cause symptoms or problems, and are not of clinical concern. When adhesions do cause problems, the issues depend on the location and extent of the adhesions.
Abdominal adhesions may cause symptoms when the bands of scar tissue "grab" a section of the patient’s 20-plus feet of small intestines (these are basically a coiled tube in the abdomen through which food, fluids, air and stool must pass, and where nutrients are absorbed into the body):
This can cause pain (sometimes chronic, episodic), bloating, constipation, nausea/vomiting and/or other symptoms if it causes a blockage (complete or partial) by "choking off" an area of the intestines and hence obstructing the passage of food/fluid/air/stool (called an SBO or small bowel obstruction).
If the "grab" is more forceful and/or of longer duration, it may inhibit blood supply to that area of the intestines, which is an emergency condition that can lead to many complications and even death if not treated.
Other complications from abdominal adhesions may also occur.
Pelvic adhesions may compromise the function of a woman’s reproductive system causing infertility (adhesions may be responsible for up to 10% of cases of female infertility) and/or cause other complications.
The presence of adhesions is suspected based on the patient’s risk factors and clinical symptoms. Although certain imaging/other tests may help identify acute complications (for example, X-rays or a CT scan to evaluate abdominal pain may demonstrate an SBO), they do not directly "visualize" the adhesions themselves.
The presence of adhesions may be directly visualized:
During a surgical intervention for an emergent/urgent condition(s). For example, if a patient’s SBO does not respond to more conservative treatments such as "decompressing" the gastrointestinal tract with gentle/continuous suction utilizing a tube placed through their nose to their stomach, the patient may require surgery.
Patients with recurrent/problematic symptoms or complications, such as infertility thought to possibly be due to pelvic adhesions, chronic episodes of abdominal pain or certain other indications may benefit from an exploratory laparotomy, which is a surgical intervention, whether open or laparoscopic, in which the patient’s internal structures/organs are visualized.
Because most patients with adhesions do not have symptoms or complications, no treatment is usually needed. However, if adhesions cause an acute and severe complication (for example, one study showed that almost 15% of patients developed an SBO within two years of an open abdominal surgery), then appropriate treatment, possibly including surgery, may be indicated. During this surgery any adhesions identified are lysed (usually mechanically by dissecting them away, but sometimes using an electrocautery or other device). Lysis of adhesions discovered during an exploratory laparotomy is standard; hence, this is simultaneously a diagnostic and treatment procedure.
However, there are possible complications of these interventions. Any surgical intervention can possibly cause bleeding, infection, unintentional damage to an organ, etc. And as noted above, scarring from any surgical intervention, including those to diagnose and treat adhesions, may cause more adhesions. Therefore, the risks and benefits of addressing adhesions that are causing any non-emergent issue(s) need to be carefully weighed to make the best decision for each patient.
Seeing all of this, it's natural to ask how adhesions can be minimized? This may be done by:
Avoiding any unnecessary interventional procedures.
Having any required procedure done in as minimally invasive a way as possible (so utilizing laparoscopic and other less invasive techniques when possible).
Using surgical techniques to minimize scar tissue formation and complications, including being as gentle as possible; avoiding anything that may cause inflammation (for example, talc powder on surgical gloves); minimizing bleeding/infection and anything else that may increase scarring; placing a specialized material around the intestine (for example, Seprafilm) at the completion of the surgery to minimize adhesion band formations (when this is indicated); as well as other possible techniques.
Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.
This article originally appeared on MetroWest Daily News: Dr. Jeff Hersh addresses abdominal and pelvic adhesions
