Adhesions, more Information

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From an article in the July 2005 issue of Harvard Health Letter:

Postoperative adhesions

Ways to treat or prevent this outcome include further surgery, barrier agents,

and - perhaps, surprisingly - Celebrex.

Three years ago, B. had surgery to remove an ovarian cyst. The

45-year-old Seattle resident felt some discomfort afterward, and tried a special

massage therapy that had helped her sore wrist. But the pelvic pain only got

worse and started to wake her up at night. " It felt like something was grabbing

and pulling, and I couldn't get it to unpull, " she says.

A colonoscopy showed no problems, so doctors performed a laparoscopy,

threading a slender video camera through a small incision into the abdomen to

look for adhesions, the scar tissue that often develops after abdominal surgery.

What happened next often occurs: The surgeon found an adhesion, this one

extending from 's abdominal wall to her colon, and cut it away.

The pulling sensation eased. But pain is complex and pinpointing its cause is

often difficult. For , it reared up again, this time in her back.

How adhesions form

The peritoneum (pronounced peri-toe-NEE-um) is a membrane that lines the

inside of the abdomen, supporting the abdominal organs and keeping them in

place. It also produces a lubricating fluid that makes the organs slippery, so

they slide easily against each other and the abdominal wall. This support and

the lubrication are important because while the small intestine and other organs

need support, they also must be able to move freely in order to function

properly.

Stuck on you

Bands of sticky scar tissue called adhesions often form after abdominal

surgery.

Peritoneal tissue is delicate. Any surgery can damage it, even when performed

through a small incision, using a laparoscope. And the damage isn't just from

the incision. The irrigating fluid used in surgery, or tiny bits of gauze - even

the powder on surgical gloves - can irritate the peritoneum, causing

inflammation and tiny amounts of bleeding.

Bleeding from the peritoneum - or from abdominal organs - results in small

deposits of fibrin, the sticky protein that is one of the main components of

blood clots. Other factors in the blood tend to break fibrin down, but the

trauma of surgery, an infection, or oxygen-poor blood can disrupt that process.

When that happens, it gives cells called fibroblasts an opening. They migrate to

the area and busily replace fibrin with collagen, the fibrous tissue found in

tendons and other connective tissue. Adhesions are made primarily of the

collagen generated by these opportunistic fibroblasts. Some adhesions are

stringy or form thick bands. Others are more diffuse and almost seem to glue

organs to one another or to the abdominal wall.

The beginnings of adhesion formation may occur right during surgery. How much

they grow and how extensive they are may change over the coming weeks and

months. But whether they occur at all is usually determined within the first few

days after surgery.

The surgery isn't the only cause. Infections or inflammatory conditions, such

as appendicitis, Crohn's disease, or diverticulitis cause adhesions, too.

Adhesions also form in response to endometriosis, a condition in which cells

from the lining of the uterus (endometrium) also grow on structures outside the

uterus.

Bowel obstructions

Most people who have abdominal surgery develop adhesions, and usually they

aren't a problem. They don't cause any harm or produce any symptoms. But some

adhesions interfere with the normal function of an organ - a problem that may

develop years after surgery.

The small intestine is particularly vulnerable because it needs to be mobile

so it can push digested food on through. If an adhesion is attached to the small

intestine, it may twist and kink, causing a blockage. In the developed world,

surgical adhesions are the leading cause of intestinal obstructions. For women,

postoperative adhesions affecting th e ovaries and fallopian tubes are a common

cause of infertility.

For bowel obstructions, the choice is fairly straightforward: Cut the

adhesions. That will free up the kinked or twisted intestine and end the

obstruction. But as with all surgery, there are risks, and bowel perforation is

a possibility. Cutting adhesions can sometimes help with infertility if it frees

up the ovaries and the fallopian tubes, although good data demonstrating that

surgery is effective are hard to come by.

Pain relief

More problematic are cases like 's - adhesions that don't seem to affect

the movement or function of any organ in an obvious way, but the person still

feels pain.

For years, doctors have debated whether adhesions alone can be a source of

pain, and whether surgeons can relieve the pain by cutting the adhesions.

Because chronic abdominal or pelvic pain can be so hard to treat, some doctors

have cut adhesions, figuring that even if there was a small chance of success,

it was worth it.

On the other hand, the value of surgery has been questioned because the

operation is likely to trigger the growth of more adhesions in the abdomen, so

what has been gained? Moreover, studies of pain treatments have consistently

shown a large placebo effect from an intervention. If individual patients feel

less pain after adhesions have been cut, it may have little to do with the

adhesions and everything to do with relief that something significant has been

done to help them.

In 2003, Dutch researchers published a study in the Lancet that tackled these

questions head-on. Diagnostic laparoscopy showed adhesions in 100 patients with

chronic abdominal pain. About half of them were given only the diagnostic

procedure; the other half, chosen at random, also had surgery to cut the

adhesions. Of course, the patients weren't told which group they were in.

A year later, 27% in both groups said their pain was much improved or had gone

away. The results look a little more favorable if you include the patients who

said their pain was improved (see chart). Still, the findings cast doubt on the

value of adhesion surgery for pain relief, especially when you consider that it

caused complications in five patients (10%). The researchers' conclusion:

Laparoscopic adhesiolysis (the medical term for cutting adhesions) cannot be

recommended as a treatment for adhesions in patients with chronic abdominal

pain.

This brings us back to . On the recommendation of her surgeon, she's now

seeing a physical therapist for her back pain. She wonders, though, whether the

adhesion surgery was worth it and whether she should have first tried the

measures suggested by a different doctor, such as taking birth control pills.

She has a history of endometriosis, and birth control pills suppress ovulation

and make bleeding lighter, which can sometimes help ease pain from the

condition. " I was in so much pain I just wanted to do something, " she says. " In

hindsight, maybe I should've talked to more doctors. "

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Prevention

Whatever the safety or effectiveness of treatment, it would obviously be

better to prevent adhesions from forming in the first place. Careful surgical

technique that avoids damaging and jostling tissue presumably helps reduce

adhesions. Because it is less invasive, laparoscopic surgery would also seem

likely to help, although the research on that question is mixed.

At one time, there was some hope that nonsteroidal anti-inflammatory drugs

(NSAIDs) would be the answer, because by inhibiting prostaglandins they slow

down the formation of the fibrin that gets the whole process started. Animal

studies were promising, but the results from human trials were not.

Doctors have tried using corticosteroids postoperatively, sometimes adding

antihistamines, but the results were too mixed for this to be embraced. There's

been a lot of interest in barrier agents - small, thin sheets of material

positioned to keep tissues from rubbing up against one another. The materials

used in barrier agents range from polytetrafluoroethylene (PTFE - the polymer

used to make Teflon and Gore-Tex) to mixtures of chemically modified sugars that

the body can absorb in a few days. Some of the early barrier agents actually

caused more adhesions. Even the best of these barrier agents haven't been fully

embraced by surgeons.

Now researchers at Harvard are investigating another possibility: COX-2

inhibitors. Celecoxib (Celebrex), the only drug in the class that's still on the

market, impedes the formation of fibroblasts, the cells that start the process

leading to adhesions. Drs. Arin Greene and Mark Puder, researchers at

Harvard-affiliated Children's Hospital Boston, published a study in the January

2005 ls of Surgery showing that mice treated with Celebrex formed fewer

adhesions during wound healing than those treated with other NSAIDs.

As of mid-2005, of course, there's a cloud over the COX-2 drugs because of

their cardiovascular side effects, but Dr. Puder believes the risk from taking

Celebrex for a week after surgery is likely to be small. In any case, his is

only a mouse study. Far more research needs to be done before we'll know how

much promise Celebrex has for preventing adhesions in people.