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Adhesions

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Fibrous bands between two or more adjacent anatomic structures.

Common cause of small bowel obstruction but a very rare cause of large bowel obstruction.

May be congenital, related to trauma, inflammation or iatrogenic in nature.

Refers to scarring that fuses two tissues in the body that are normally separate.

Adhesions are fibrous bands that form between tissues and organs, often a result of injury during surgery.

There are three general types of adhesions: filmy, vascular, and cohesive.

The pathophysiology of these adhesions are similar.

Filmy adhesions usually do not pose problems, but vascular adhesions are problematic.

Can occur anywhere in the body.

Most commonly occur in the abdomen.

Usually harmless, but can cause pain, inability to pass normal stools and gas, and vomiting.

Adhesions may follow intraabdominal surgery, as internal scar tissue that connects tissues not normally connected.

They form as a natural part of the healing process after surgery.

The scar extends from within one tissue across to another.

Adhesions usually across a space such as the peritoneal cavity.

Typically occurs when two injured surfaces are close to one another.

The approximation of surfaces
often causes inflammation and causes fibrin deposits onto the damaged tissues.

A connection of the two adjacent structures occur where damage to the tissues manifest.

Fibrin seals the injury and builds the fledgling adhesion.

In the peritoneal, pericardial, and synovial cavities, fibrinolytic enzymes act to limit the extent of the initial fibrinous adhesion, and may even dissolve it.

The production or activity of these enzymes can be compromised because of injury, and the fibrinous adhesion persists.

Tissue repair cells including macrophages, fibroblasts, and blood vessel cells penetrate the fibrinous adhesion and lay down collagen to form a permanent fibrous adhesion.

Adhesions may not cause problems, but others may prevent tissues and organs from moving freely.

Adhesions sometimes cause organs to become twisted or pulled from their normal positions.

Types of adhesions include:

Adhesive capsulitis with adhesions growing between the shoulder joint surfaces, restricting motion.

Abdominal adhesions are most commonly caused by abdominal surgical procedures.

Intraabdominal adhesions begin to form within hours of surgery.

Adhesions may cause internal organs to attach to the surgical site or to other organs in the abdominal cavity.

The adhesions may cause twisting and pulling of internal organs that may result in abdominal pain or intestinal obstruction.

A significant result of post surgical adhesion formation is small bowel obstruction.

When an adhesion pulls or kinks the small intestine and prevents the flow of content through the digestive tract a small bowel obstruction may result.

Adhesion obstruction may occur as long decades after the initial surgical procedure.

A small bowel obstruction is a surgical emergency.

Approximately 2,000 people die every year in the USA from obstruction due to adhesions.

Partial bowel obstruction may resolve
with conservative medical intervention.

Many obstructive events require surgery to loosen or dissolve the offending adhesion or to resect the affected small intestine.

Pelvic adhesions typically affect reproductive organs and are a source of concern in reproduction and as a cause of chronic pelvic pain.

Intrauterine surgeries such as suction dilation and curettage, myomectomy, and endometrial ablation may result in Asherman’s syndrome, known as intrauterine adhesions, a cause of infertility.

Adhesions may cause distortion of the normal tubo-ovarian relationships and may prevent an ovum from traveling to the fimbriated end of the Fallopian tube.

There is little evidence for the surgical principle that using less invasive techniques, introducing fewer foreign bodies, or causing less ischemia reduces the extent and severity of adhesions in pelvic surgery.

Adhesions may form between the heart and the sternum after cardiac surgery, and place patients at risk of catastrophic injury during a subsequent procedure.

Adhesions as epidural fibrosis may occur after spinal surgery that restricts the free movement of nerve roots, causing tethering and leading to pain.

Adhesions occurring around tendons restrict the gliding of tendons in their sheaths and compromise mobility.

Adhesion barriers during surgery may help to prevent the formation of adhesions.

Two methods are approved for adhesion prevention: Intercede and Seprafilm.

A study found that Seprafilm is twice as effective at preventing adhesion formation when compared to just surgical technique alone.

Surgical humidification therapy may also minimize the incidence of adhesion formation.

To reduce the formation of adhesions following abdominal surgery, hydroflotation, in which the organs are separated from one another by being floated in a solution.

Laparoscopic surgery reduces the risk for creating adhesions.

Measures during surgery to help prevent adhesions: handling tissues and organs gently, using starch-free and latex-free gloves, not allowing tissues to dry out, and shortening surgery time.

Because, ultimately adhesions are unavoidable from surgery and the main treatment for adhesions is more surgery.

There are no diagnostic tests available to accurately diagnose an adhesion.

Intestinal obstructions caused by adhesions, however, may be seen in an X-ray.

More than 90% of people develop adhesions following open abdominal surgery and that 55–100% of women develop adhesions following pelvic surgery.

Adhesions from abdominal or pelvic surgery may subsequently obscure visibility and access at subsequent abdominal or pelvic surgery.

In a study of 29,790 participants 35% of patients who underwent open abdominal or pelvic surgery were readmitted to the hospital an average of two times after their surgery, due to adhesion-related or adhesion suspected complications: Over 22% of all readmissions occurred in the first year after the initial surgery.

Adhesions related adds significant risk to subsequent surgical procedures.

The omentum is very susceptible to adhesion formation.

Studies have shown that up to 92% of post-operative adhesions were found in the omentum.

The omentum is the site most responsible for spontaneous adhesion formation.

The long-term use of a wrist splint during recovery from carpal tunnel surgery may cause adhesion formation.

Adhesions are often asymptomatic.

Adhesion symptoms vary depending on where the adhesion occurs.

Adhesion symptoms: pain on stretching or exercising, pain during intercourse, chest pain, tenderness or abdominalbloating, cramps after eating, constipation, inability to pass stool or normal stools, gas, and vomiting.

Risk Factors: Abdominal surgery, appendicitis, ruptured appendix, radiation treatment, , gynecological or abdominal infections, diverticulitis, gallbladder inflammation, and pelvic inflammatory disease.

A partial abdominal obstruction can sometimes be treated with conservative measures, while complete gastrointestinal obstruction requires surgical relief.

10% of abdominal adhesions occur in people who have not undergone surgery. 

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