Adhesions

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We have received several questions about peritoneal adhesions and the complications they cause, for example pain and intestinal obstruction. We are in the process of preparing a comprehensive review of this common problem to include in our open learning series. In the meantime here is a brief overview of peritoneal adhesions - what they are, what causes them, the consequences, and what can be done to alleviate the problem. (Adhesions may form elsewhere such as around the heart, lungs, spinal cord, or tendons serving the fingers, but these variants will not be considered here - only peritoneal adhesions.) At the end of this summary we have provided several links to web-based resources that specialise in adhesions - click on these to find up-to-date information on this topic.

Peritoneal adhesions - what are they?

Normally, the stomach, much of the intestines, and some other organs such as parts of the female reproductive system are able to slip and slide in relation to each other. This relative movement is facilitated by the organs and the inside of the abdominal wall being covered with a shiny membrane called the peritoneum. There is a film of fluid between adjacent layers of peritoneum - the peritoneal fluid - and this also lubricates the relative movement. The freedom to move helps normal functions such as the process of digestion, enabling waves of muscular contraction to pass along the gut wall and propel the food within the lumen.

Sometimes, however, parts of the peritoneum become "stuck together", and this can interfere with normal function. The problem arises when areas of peritoneum are damaged - either by accidental injury, during an operation, or as a result of infection - and become inflamed. When it is inflamed, the peritoneum becomes "sticky" and attaches itself to other areas of peritoneum. This may be a transient attachment, followed after a few days by separation, or it may become a permanent adhesion complete with fibrous scar tissue. The formation of adhesions can interfere with normal functions, and may lead to pain, intestinal obstruction, and infertility.

The Causes of Peritoneal Adhesions

Adhesions occur in response to peritoneal injury. Most adhesions are the result of procedures such as handling and incisions made during abdominal surgery. Weibel and Majno (1973) found that 67% of patients who had undergone surgery had adhesions. This figure increased to 81% and 93% for patients with major and multiple procedures respectively. Menzies and Ellis (1990) found that 93% of patients who had undergone at least one previous abdominal operation had adhesions, compared with only 10% of patients who had never had a previous abdominal operation. Other adhesions are the result of endometriosis (the spread of endometrial tissue from the lining of the uterus out into the peritoneal cavity), infections producing peritonitis, and some kinds of cancer.

The Consequences of Peritoneal Adhesions

The main consequences of peritoneal adhesions are chronic abdominal pain and the possibility of obstruction of the intestines. Of all cases of small bowel obstruction, two-thirds of cases involve adhesions (Ellis, 1997). Adhesions involving the ovaries and fallopian tubes can in addition cause infertility and dyspareunia (painful intercourse). The pain produced by adhesions may be due to traction (pulling) of nerves or distention of an obstructed part of the intestines. Not all adhesions cause pain, however.

Alleviating the Problems caused by Peritoneal Adhesions

Emotional stress contributes greatly to the patient’s perception of pain and her/his ability to deal with the pain (Rosenthal et al, 1984). Pain may be controlled to a more acceptable level by drug treatments, physical therapy, exercise and dietary changes. In extreme cases where bowel function is disturbed, comprehensive nutritional support is a necessity.

Adhesiolysis (cutting of adhesions) provides relief in some cases, but there is quite a high risk that new adhesions will form (Daniell, 1989; Steege and Stout, 1991; Peters et al, 1992; Menzies, 1993; Frey et al, 1994; Mueller et al, 1995). For example, when adhesions were cut to relieve intestinal obstruction, obstruction recurred in up to one-fifth of cases. At the moment several therapeutic approaches are used to reduce the suffering caused by adhesions. Hopefully ways will be found in the future to prevent the formation of adhesions in the first place, and promising results are being gained by the use of adhesion barriers (see below).

Adhesion Barriers

Various methods have been tried to reduce the risk of adhesion formation (Wiseman, 1994), but until recently with little success. However, progress is now being made by the use of different types of synthetic membrane that can be placed over damaged peritoneum during an operation with the aim of preventing the formation of adhesions. Two that are quite widely used are Interceed (Johnson & Johnson) and Seprafilm (Genzyme Corporation). Several other products are still being tested. They include: Sepracoat (Genzyme), Preclude (WL Gore), Adcon (Gliatech), Repel and Resolve (Life Medical Sciences), and Intergel (LifeCore Biomedical).

Useful Links

(The four links above will open in new browser windows.)

References

Questions sent to us on the subject of Peritoneal Adhesions and their consequences:

  1. Which adhesion prevention product do you most recommend?

  2. I have a history of bowel obstructions and adhesions. Should a doctor do what is best for the patient even if the patient’s chances can turn into a total colostomy?

  3. Sixteen months ago I had a very large tumour removed from my intestines, thankfully benign. I am now in the permanent situation of getting bouts of severe pain several times a month.

  4. How long after an operation to relieve adhesions should the bowel become active and what are the expected outcomes?

Responses:

Which adhesion prevention product do you most recommend taking into consideration the ideal barrier: (1) safe & effective; (2) absorbable; (3) permits peritoneal healing; (4) non-inflammatory; (5) ease of use; (6) no suturing necessary; and (7) compatible with laparoscopy? Most of the adhesion prevention products are in clinical development with a few currently available, Interceed, Preclude, Seprafilm I, Adcon-L, FocalSeal-L, Floseal. Which product do you like the most?

6th July 1999

We are not in a position to comment on the relative merits of the products you have listed. It will be best if you review the publications that are available so far regarding their use - sample references are listed below - and contact the manufacturers for any further information they might have. A literature survey has been carried out recently by Farquhar et al (1999) in the context of pelvic surgery in women. They concluded that Interceed reduced the incidence of pelvic adhesion formation, both new formation and re-formation following laparoscopic surgery and after laparotomy. They suggested that Gore-Tex was more effective than no barrier or Interceed in preventing adhesion formation, but found its usefulness limited by the need for suturing and later removal. The evidence relating to the effectiveness of Seprafilm was less clear-cut.

Interceed absorbable adhesion barrier is composed of oxidized regenerated cellulose. (The same material is also present in Surgicel, which for over 35 years has been in use as a haemostat in abdominal surgery.) Interceed is absorbed over several days and produces only a minimal inflammatory response. Gore-Tex surgical membrane is made from polytetrafluoroethylene and has a pore size of less than 1 micron. It is non-inflammatory but non-absorbable, and requires suturing or stapling in place. Seprafilm bioresorbable membrane is composed of sodium hyaluronate and methylcellulose. It is resorbed in the peritoneal cavity within seven days.

References

I am a white, 42 female with a history of bowel obstructions and adhesions. Just last year I had chronic pain due to adhesions which ended up in surgery. Two days after that I ended up back in hospital with a bowel obstruction and had to have another surgery. I was left with 3 1/2 feet of my small intestines and removed some of my large intestines and colon. this is my third bowel obstruction. At this time I have back to chronic pain which had been diagnosed again as adhesions. I am on pain medicine on a regular basis, can't sleep or find any relief.

Doctors say there is nothing they can do. I say they can go in and do what they can even if I have a history of bowel obstructions. I know my chances and am willing to take them. Should a doctor do what is best for the patient even if the patient’s chances can turn into a total colostomy? I am at my wits end and it is affecting me physically and mentally: not sure of how much more I can stand. Any input would be appreciated.

8th April 2000

Clearly this is a very distressing situation for you. Each operation has been carried out to try and reduce a problem, and in the process has created a new problem. Unfortunately this is often the case where abdominal surgery is involved because each operation carries a high risk of inducing the formation of new peritoneal adhesions. There could be several reasons why your doctors are reluctant to carry out a further operation - perhaps they feel that it could carry the risk of making things worse within your abdomen rather than better, or that perhaps your general health is currently not good enough to justify putting you through yet another major operation. That is of little comfort to you since you are left to endure chronic, unrelenting pain and the associated toll on your physical and mental health.

Considerable efforts are being made to find a solution to the adhesions problem. The key will be to find an operative technique that can significantly diminish the risk of inducing new adhesions. Progress is being made, and several adhesion barriers are now being marketed that may be able to reduce the adhesion risk. To find out the latest information about these, try visiting some of the internet sites listed in the introductory summary (above). These contain comprehensive and up-to-date information about what adhesions are, how they occur, what can be done to prevent their occurrence, and what can be done when they have occurred. This knowledge may help you in your discussions with your doctors - there may be some options available to you of which you are currently unaware. If nothing else, you will discover that you are not alone in your suffering. Have you considered seeking a second medical opinion about your situation? That can also be helpful when there seems to be no progress. We do hope you will be able to find relief from the pain and suffering you are experiencing.

Sixteen months ago I had a very large tumour removed from my intestines, thankfully benign. It had been growing probably for some years and had developed its own blood/nerve system and over a period of at least three years had erupted internally and had given rise to several false diagnoses by my GP (spastic colon, irritable bowl syndrome, all on my medical records). As I am generally fit my body was able to win each time and thankfully in the end the tumour was recognised and removed (it was about to explode). I am now in the permanent situation of getting bouts of severe pain several times a month either from being seated, driving or bent over for a relatively short length of time. Even a sudden movement can result in a sharp pain and once triggered a dull ache that can last for several days at a time usually finishing with two days of diarrhoea.

I have a Critical Illness policy with an insurance company (Scottish Amicable European) and they have refused to pay out even when I say it is impossible to do my job, and that sitting at a computer or working as an arts photographer puts undue pressure on the internal scar tissue on the intestine which then gives pain and then I presume swelling and in turn restricts my bowel movements. The insurance company say it is not a permanent situation but frankly I have over the months felt little or no change. How long is permanent before they recognise the situation I am in? Very soon I will have to cut the monthly payments for this policy as my money runs out with day to day living and then they will have a perfect right to discontinue the policy!!

My consultant wants to go back in and repair a post-operative hernia to my stomach muscle and whilst in there have a look and perhaps re-do the operation to the intestine. Frankly I don't like the idea of anyone going back into my intestines again, especially if the scar tissue would just be re-created, even the Registrar at the Hospital has confirmed this is very likely.

I have noted that other people on the web have had similar problems with scar tissue after operations. What I urgently need is as much evidence as possible. The hospital registrar when I saw him openly stated that I probably have adhesions and further operations might not remove them only create more. Please advise.

20th March 2000

You have identified several problems: the bouts of pain that are brought on by particular activities and sometimes followed by diarrhoea, the unwillingness of the insurance company to accept that you are incapacitated in the long term, and your hesitation regarding the possibility of further surgery in case it creates new adhesions and causes additional post-operative problems.

In your negotiations with your insurers it will be worth being aware that post-operative adhesions and the problems they bring are surprisingly common - most abdominal operations carry the risk of inducing adhesions, some of which can be troublesome. (This has already been pointed out by your hospital registrar - it must feel like a Catch-22 situation for you when a new operation is being considered.) For this reason, insurers will be extremely hesitant to pay up because they are afraid of opening the floodgates of potential claims. It will be worth communicating with other adhesions sufferers to see if any have found a way to exert more leverage on insurance companies in situations like yours. You will find opportunities for discussion at some of the specialised websites given in the introduction to adhesions above (you may have found these already), together with other useful information.

This knowledge should help you in your discussions with your surgeon - there may be some options available to you of which you are currently unaware. If nothing else, you will discover that you are not alone in your suffering. Your consultant surgeon is in a good position to advise you about whether further surgical intervention is justified. He/she should be able to help you weigh up the advantages and disadvantages of having an operation compared with the possible outcome of the more conservative approach that you currently favour. You may also want to consider seeking a second medical opinion - this can be helpful when it is difficult to come to a conclusion.

We do hope you will be able to find relief from the pain and suffering you are experiencing.

My mother had bowel cancer 3 years ago, which was treated with an operation and a course of radiotherapy and chemotherapy. An ileostomy bag was in place for six months after the operation, which again was removed successfully. Recently a cyst was found in the throat this was removed with no complications. The day after the operation severe vomiting occurred. This lasted for two to three weeks, as the GP assumed it was an allergic reaction to the anti-biotics which were prescribed after the operation.

After going into hospital due to severe cramps and severe vomiting. After various tests the case is a bowel adhesion, this operation has been carried out. No food as yet been taken, and no wind has been passed. How long after this type of operation should the bowel become active and what are the expected outcomes from this type of operation?

2nd April 2000

We can only generalise from experience - the following comments are meant only as background information and may not be relevant in your mother’s case.

The length of time before peristaltic activity returns to the bowel following abdominal surgery differs from one person to another. A great deal depends on the age of the person, the length of time taken to perform the operation, and the amount of pain control in the form of opiate analgesia administered during both the intra-operative and post-operative periods. The degree of handling of the bowel by the surgeon during the operation can also influence the rate of return of function. As a general rule the period before peristalsis resumes is 3 to 7 days. The outcomes to be expected from this type of operation are best discussed with either the surgeon who performed your mother's operation or her general practitioner. Through their close involvement with your mother's care they are well placed to advise you.

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