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ADHESIONS

ADHESIONS. MYTHS & FACTS Tamer Abdelrazik. AIMS. EPIDIMIOLGY AETIOLOGY THE CONSEQUENCES PREVENTION ADHESIOLYSIS (When & which). INTRODUCTION. Adhesions are abnormal attachments between tissues and organs (congenital or acquired)

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ADHESIONS

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  1. ADHESIONS MYTHS & FACTS Tamer Abdelrazik

  2. AIMS • EPIDIMIOLGY • AETIOLOGY • THE CONSEQUENCES • PREVENTION • ADHESIOLYSIS (When & which)

  3. INTRODUCTION • Adhesions are abnormal attachments between tissues and organs (congenital or acquired) • Acquired adhesions are due to trauma to peritoneum (surgery or inflammation) • Factors that influence adhesions formation: • Ischemia • Exposure to infection • Abrasions • Dissection • Heat • Light • Electrocautery • Suturing

  4. INTRODUCTION • Adhesions are extremely common after surgery (60- 90%) • Many adhesions have little or no effect • Can lead to short and long term complications • Small bowel obstruction • Fertility related • Chronic pelvic pain • Readmission after open surgery and laparoscopy • High coast (1994: £ 67 million )

  5. Epidemiology The Surgical and Clinical Adhesion Research Study (SCAR): (n 29 790) “The extend of the problem of adhesions following open surgery over 10 years” Used the Scottish National Health Service Medical Records

  6. 34.7% (10 326) readmissions for complications directly or possibly related to adhesions. • Mean of readmissions episodes (2.1) • 22.1% of readmissions occurred in first year

  7. Adhesions in Gynaecological Surgery:Sub analysis of SCAR Study • 8489 open gynaecological procedures • Directly related readmissions: 3/100 • Overall readmissions (directly related, potentially related or operations potentially complicated by adhesions:) 64% • High Readmissions after procedures on ovaries and tubes .( 48% and 41%) • Adhesions complications can present 10 years after initial surgery • 16 % occurring in the first year

  8. SCAR 2 • SCAR 2 included both laparoscopy and open surgery (4 years) • Laparoscopy related readmission: 18/100 • Open surgery (17/100) • Certain surgical sites are associated with increases risks of adhesions

  9. So..... • Adhesions related readmissions presents a significant problem. • Readmission following either laparoscopic or open surgery are similar • There is a need to avoid adhesions • Development of guidelines to prevent & treat adhesions consequences

  10. THE CONSEQUENCES ! • Small bowel obstruction (2/3 of cases) • Chronic pelvic pain (2/5) • Fertility related problems (1-2/10)

  11. Prevention of Adhesions • Good Surgical technique • Application of anti-adhesion adjuvant Risburg 1997

  12. Good Surgical Technique • Gentle tissue handling • Meticulous haemostasis • Irrigation to minimise serosal drying • Avoiding intraperitoneal infection • Minimising foreign bodies • The use of fine nonreactive sutures • Taking care during cauterisation to prevent ischemia

  13. Anti-adhesions adjuvant(solutions & Drugs) • Drugs administered locally or systemically : • NSAIDs questionable efficacy • Corticosteroids poor efficacy, risks. (infections, delayed healing, incisional hernia) • Fibrinolytics impaired wound healing

  14. Adhesions reducing agents Should be safe, effective easy to use and cheap. • Physical barriers (e.g. Surgirap, Spry gel) • Solutions: • Dextrane (no evidence) • Adapt (icodextrin 4% ) (insufficient evidence) • Hyaluronic acid agents (may reduce) Metwally ME, Watson A, Lilford R, Vanderkerchove P. Fluid and pharmacological agents for adhesion prevention after gynaecological surgery. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD001298. DOI: 10.1002/14651858.CD001298.pub3.

  15. Adhesiolysis • Two RCTs, one using laparotomy and the other using laparoscopy: • No deference in pain-score except in the subgroup of women with severe adhesions Ref: Stones W, Cheong YC, Howard FM, Singh S. Interventions for treating chronic pelvic pain in women. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD000387. DOI: 10.1002/14651858.CD000387.

  16. Adhesiolysis • Another RCT in 2006 (116 cases): Randomization after a diagnostic laparoscopy: • 27% in each arm had significant improvement in pain score (1 year F/U) • In the adhesiolysis group (n: 52) • 2 small bowel perforations • 1 haemorrhage • 1 paralytic illius • 1abdominal abscess Swank DJ et al 2003

  17. Adhesions related syndromes • Residual ovary syndrome • Retained ovary syndrome

  18. Conclusions • Post operative adhesions have serious consequences • Good surgical techniques are the gold standard in preventing adhesions • No strong evidence to support the use of anti adhesions agents • Adhesiolysis for pain is useful in certain conditions

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