Transcript Tamer Abdel razik - erc

MYTHS & FACTS
Tamer Abdelrazik
AIMS
 EPIDIMIOLGY
 AETIOLOGY
 THE CONSEQUENCES
 PREVENTION
 ADHESIOLYSIS (When & which)
INTRODUCTION
 Adhesions are abnormal
 Ischemia
attachments between
tissues and organs
(congenital or acquired)
 Acquired adhesions are
due to trauma to
peritoneum (surgery or
inflammation)
 Factors that influence
adhesions formation:
 Exposure to infection
 Abrasions
 Dissection
 Heat
 Light
 Electrocautery
 Suturing
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 )
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
 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
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
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
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
THE CONSEQUENCES !
 Small bowel obstruction (2/3 of cases)
 Chronic pelvic pain (2/5)
 Fertility related problems (1-2/10)
Prevention of Adhesions
 Good Surgical technique
 Application of anti-adhesion adjuvant
Risburg 1997
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
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
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.
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.
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

Adhesions related syndromes
 Residual ovary syndrome
 Retained ovary syndrome
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