INCIDENCE AND PREVENTION OF POSTOPERATIVE ADHESIONS

 

About Authors:
1Robin Sharma*, 1Ajay Kumar, 2Dr. Bharat Prashar
1M.Pharm (Pharmacology)
2Head of Pharmacy Department
Manav Bharti University, Solan.
*sharmarobin@hotmail.com

ABSTRACT
Postoperative adhesions are a significant health problem with major implications on quality of life, health care and expenses on treatment. The purpose of this review was to investigate the incidence of post operative adhesions and the treatment measures such as efficacy of preventative techniques and adhesion barriers. The National Library of Medicine, Medline and A-Z databases were used to identify articles related to postoperative adhesions. Ileal pouch–anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous haemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material such as powdered gloves have been published. Laparoscopic techniques, result in fewer adhesions than laparotomy techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose, have been shown to reduce adhesions (class I evidence). Postoperative adhesions are a significant health problem after the surgery. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions and post operative adhesions.

Reference Id: PHARMATUTOR-ART-1435

Introduction
Adhesions are fibrous bands that connect anatomic sites at locations where there should not be connections. Post-operative adhesions account for more than 90% of the total intra-abdominal adhesions [1-9]. The development of post-operative adhesions after upper and lower abdominal surgery is part of the daily life of every digestive surgeon. Despite this, there are very few good quality longitudinal studies that permit an appreciation of the frequency of adhesion formation or of adhesion-related complications. Meanwhile post-operative adhesions are the cause of considerable direct and indirect morbidity, and their prevention can be considered a major public health issue. And yet, in France at this time, there is no validated recommendation neither concerning the prevention of adhesions, more particularly, concerning the use of a variety of commercial anti-adhesion products that have been marketed for at least a decade. Intraperitoneal adhesions develop between deperitonealized surfaces of abdominal organs, mesenteries, and the abdominal wall; the most common site of adhesion formation is between the greater omentum and the anterior abdominal wall [10,11]. Despite the frequency of adhesions and their direct and indirect consequences, there is only one published recommendation (from the gynecologic literature) concerning the prevention of peritoneal adhesions [12]. Faced with a very heterogeneous literature, it was proposed that a working group review the literature and provide answers to four questions:
· What factors contribute to the formation of adhesions? (pathophysiology, types of     interventions);
·  What is the incidence of post-operative adhesions? (after upper or lower abdominal surgery, after laparotomy or laparoscopy);
· What are the medical and surgical consequences of post-operative adhesion formation? (direct and indirect consequences);
·  What measures are available to prevent post-operative adhesions? (surgical technique and pharmacologic methods)

Incidence of adhesions
An assessment of how many people develop adhesions after surgery was performed in a post-mortem series by Weibel and Majno in 1973 [13]. In cadavers with no preceding abdominal surgery, adhesions were found in 28%, and in those that had had abdominal surgery 67% had adhesions. Where minor abdominal surgery had been performed, adhesions were present in about 50%. If major surgery had been undertaken adhesions were present in 76%, and in cases of multiple abdominal surgery 93% had adhesions present. The incidence of adhesions in a live population has been examined [10]. Inflammatory adhesions in patients who had not undergone any preceding abdominal surgery were found to be present in 10%. In patients who had had previous abdominal surgery, postoperative adhesions were found in 93% and inflammatory adhesions in 20%. Congenital adhesions were identified in less than 1%. The difference in the incidence of adhesions between the two studies is due to a difference in the age groups between the post-mortem and live studies. In the post-mortem study inflammatory adhesions were rarely seen in those under the age of 60 years. The mean age of patients without earlier abdominal surgery in the live study was 63 years. In patients who had had surgery the mean age was 75 years and therefore they were far more likely to have had intra-abdominal inflammatory episodes that resulted in adhesions, such as cholecystitis and diverticulitis.

Economical Burden of Adhesions
Problem associated with post operative adhesions pose a significant financial burden as they increase the surgical work load and utilize limited health resources [14]. Awareness concerning economical consequences resulting from adhesions is rising [15]. A Swedish study estimated the cost incurred for total care, including sick leave expenditure, for adhesive small bowel obstruction was at least US $ 20 million a year. Another study in United States looked at 1988 cases of abdominal adhesions associated complications and found that hospitalization and treatment cost was up to US $ 1.2 billion [16]. These studies did not include out patients and indirect cost such as loss of function due to long term disabilities. Although these added costs due to adhesions do not apply to cardiac surgery, they are very evident in other specialities such as general surgery.

Physiology and Physiopathology
The mechanism of adhesion formation is largely due to insufficient fibrinolysis at the site of visceral or parietal peritoneal injury resulting in incomplete resorption of local fibrinous deposits [17,18]. Thus, post-operative adhesions are the consequence of abnormal peritoneal cicatrisation: the lack of early post-operative fibrinolysis (in the first 48 hours) allows cellular infiltration of the initial fibrinous matrix. This leads to the formation of adhesions that, by the seventh day, are composed of an extracellular collagenous matrix infiltrated by fibroblasts (occasionally associated with painful nerve endings), smooth muscle cells, and neovascularization; this assemblage is coated with a mesothelial lining. Technical operative factors resulting in tissue trauma (electrocoagulation, ultrasonic tissue transection, laser energy versus sharp dissection with scissor and scalpel) [19,20] as well as residual microscopic or larger foreign bodies are determining risk factors for adhesion formation [21].

Intra-abdominal infections with inflammation and radiation tissue damage also contribute to adhesion formation. Finally, the presence of hemoperitoneum seems to potentiate adhesion formation in conjunction with the above-mentioned factors.

Figure 1 : A schematic illustration of process in adhesion formation.

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