Adhesion Related Disorder

Adhesion related disorder is a complex of symptoms related to adhesions. Patient’s primary complaint is usually chronic abdominal pain. Their symptoms can be primarily in one area of the abdomen but are often generalized, vague, crampy and difficult to define. Other intestinal problems can accompany the pain. Constipation or obstruction is sometimes encountered. Alternating constipation with diarrhea from partial obstruction can also be seen. Symptoms may also be related to the gynecologic orders in women as this disorder frequently affects women. Changes in the menstrual cycle, infertility, and pain with sexual intercourse can be encountered.

Other symptoms, not directly related to the adhesions, can also be encountered. Since ARD generally results in chronic problems, anxiety and depression can result. Strained relationships can occur especially when the disorder affects sexual function. Difficulty with conception can result. This further adds to the anxiety and problems with self esteem experienced by women who suffer with this disorder. Difficulty eating can result in poor nutrition, weakening suffers overall medical condition and can also lead to a decrease in immune function leading to many other illnesses.

Since many of the symptoms related to ARD are vague and wide spread and often include emotional factors, they are often difficult to diagnose. Symptoms of ARD will often be attributed to other abnormalities. Patient will often carry multiple diagnoses including chronic fatigue syndrome, endometriosis, irritable bowel syndrome, fibromyalgia, depression, anxiety, along with a whole host of other possible syndromes. While multiple disorders can certainly exist in one patient, the confusion over which abnormality is truly causing the symptoms adds to the frustration of ARD. This, unfortunately, adds to the discomfort experienced by those who suffer with adhesions.

What Are Adhesions?

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Adhesions are abnormal attachments between the organs inside the abdomen. They generally are composed of scar tissue that results from previous operations. Previous surgery is by far the most common cause of adhesions. Endometriosis, and other diseases can also cause adhesions.

Endometriosis is a condition where small bits of the lining of the uterus escape through the fallopian tubes to enter the abdominal cavity. These cells become implanted on the surface of the abdominal organs causing them to adhere to one another. This endometrial tissue is hormonally active, just as it was in the uterus, and can cause pain and bleeding in the abdomen. The adhesions caused by endometriosis then cause additional problems.

A wide spectrum of adhesions can be identified. Some adhesions appear like cellophane, and are very loose, filmy and flexible. Other adhesions can be very dense and inflexible appearing like leather. Still other adhesions produce very hard thickening of the tissues. This is especially common with other disorders that can invade the surrounding tissue such as endometriosis, inflammatory bowel diseases, and malignancy. The most severe adhesions occur when organs are not just adherent to one another but actually become fused. These become much more difficult to correct.

How do Adhesions Cause Problems?

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The internal organs are designed to move freely and slide over one another during normal daily movements. The intestines themselves are very mobile and move with peristaltic motion, squeezing food along as it is digested. Bodily movement such as twisting, bending, and stretching require that the organs move over one another to allow for flexibility of the body’s mid section. When internal organs adhere to one another this flexibility is lost. The normal body movements then can cause pulling and stretching of one organ against another resulting in pain. Normal organ function that requires movement can also pull and tug on these adhesions causing pain.

More severe symptoms can occur when intestines become twisted, pinched, or obstructed by tight bands of scar tissue. The scar tissue can interfere with the passage of food through the intestines causing bloating, stretching and squeezing type pain throughout the abdomen. If a complete obstruction results, severe pain, nausea, and vomiting can be encountered as the food backs up within the intestine, unable to pass through normally. The intestines can also have their blood supply compromised by scar tissue causing a lack of oxygen to the tissues, resulting in pain from ischemic changes similar to that encountered in the heart during a heart attack.

If metabolically active cells such as with endometriosis cause adhesions, these cells can themselves cause discomfort as they influence the organs that they are attached to. Blood inside the abdominal cavity from endometriosis can cause irritation and discomfort. Thickening of normally flexible tissues can cause discomfort when these tissues are required to expand and stretch. This occurs in and around the colon as formed bowel movements are passing through it, and pain occurs when this thickened tissue is unable to stretch. A similar result is seen with adhesions in and around the uterus and vagina which require flexibility during sexual intercourse. When thickening of these structures occurs it can cause discomfort.

There are also symptoms that result from adhesions that are not completely understood yet. There may be an inflammation resulting from adhesions that causes discomfort. The bodies own inflammatory response to these abnormal tissues could cause swelling and discomfort of the structures that they affect.

Diagnosis

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Evaluation of patients with ARD begins with careful review of their medical history. This often includes multiple previous operations indicating the possibility of adhesion formation. Correlation of these symptoms with other activities such as movement, eating, sexual activity, or relation to the menstrual cycle is often useful at differentiating underlying causes of the symptoms. Since these symptoms are often long standing, it is likely that other medical evaluations have been carried out, and these are also reviewed. Review of previous attempts at correcting the symptoms is also useful. Careful review of the patient’s medical history relating to other medical problems is also important to help identify any other causes symptoms other than adhesions.

A thorough physical examination by a qualified physician, who is cognoscente of adhesion related problems is important. Inspection of abdominal scars for possible hernia, poor healing, thickening, or other problems is necessary. Review of appropriate x-rays, CAT scans, ultrasounds and other x-ray tests can be helpful. A thorough gynecologic evaluation with a gynecologist is also important in women, especially when symptoms relate to their gynecologic system. It is important to note that results of these tests and examinations can suggest adhesions, but there is no one x-ray or other test that will clearly identify adhesions as the cause of symptoms.

Diagnostic laparoscopy or needleoscopy can be performed to identify the presence of adhesions. Laparoscopy is a form of surgery where a small tube is used to enter the abdomen. A telescope, referred to as a laparoscope, is then placed through this tube and the internal abdomen can be inspected. The abnormal adherence of internal organs can be clearly seen. Needleoscopy is a form of laparoscopy that uses very small instruments approximately the size of a needle, or roughly 3 mm. This is a relatively new procedure that can be used to explore the abdominal space very easily with minimal side effects, and can even be done using local anesthesia, where standard laparoscopy generally requires general anesthesia in most cases.

An important part of the evaluation during the diagnosis phase is to be sure that there are no other medical problems causing the symptoms other than the adhesions. Evaluations for other problems such as gallbladder disease, stomach ulceration, gastritis, or gastroesophageal reflux disease (GERD) along with a variety of other gastrointestinal, gynecologic, and urologic problems must be tested for. If these are found, they can be treated and relief of symptoms may occur. After all other problems have been ruled out or treated, treatment of adhesions can take place.

Treatment

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There are no known medical treatments for adhesions. Once they are formed, there is no medicine that can dissolve them to make them go away. Symptomatic treatment with pain medicine, anti-nausea medication, hormonal treatments for endometriosis, among others, are sometimes helpful at controlling the symptoms of ARD.

The main stay of treatment for adhesions is surgical therapy called adhesiolysis, or lysis of adhesions. This requires cutting the abnormal connections between the intra-abdominal organs to once again separate them. In the past this was done using an open surgical incision. Unfortunately, since surgery itself is the cause of adhesions, performing surgery to correct it was often unsuccessful as the adhesions simply re-formed.

Now with the introduction of laparoscopic surgery, however, the adhesions can be divided using laparoscopic techniques with very little recurrence. It has been shown that using laparoscopic surgery greatly reduces the re-formation of adhesions, making it possible to divide the adhesions formed by previous operations without them again re- forming. Laparoscopic adhesion surgery is very specialized and requires a great deal of robotic laparoscopic surgical skill, on the part of the surgeon. It also requires specialized surgical instruments including the laparoscopic and needlescopic instrumentation along with the use of lasers and ultrasonic dissection devices. For these reasons, many surgeons do not pursue surgical treatment of ARD and patients should instead seek out an experienced ARD surgical team.

An important factor in the treatment of ARD is prevention. A number of new techniques and devices are being developed to reduce the amount of adhesions that occur following surgery. Laparoscopy has been a major advancement in this endeavor. Many new laparoscopic surgical techniques are replacing standard open surgical alternatives, which hopefully will reduce the amount of ARD seen in the future. Even very large operations, which have been difficult to perform laparoscopically, can now be carried out using Hand Assisted Laparoscopic techniques. (See www.dexteritysurgical.com for more information) This significantly reduces the size of the incision and decreases the amount of intra-abdominal adhesions for larger operations that previously required standard open operations. For those operations that still require a large open incision, there are new materials being developed that are used to cover the intra-abdominal organs to decrease the amount of inflammation that results from the healing process, and thereby limit the amount of adhesion formation. Many of these materials are experimental, but there are some promising new products now available to surgeons.

laparoscopic Lysis of Adhesions

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Laparoscopic lysis of adhesions or laparoscopic adhesiolysis is the primary treatment for ARD. (See picture gallery) For the operation, the patient is placed under general anesthesia in an robotic laparoscopic Operating Room where the necessary instruments are available. A number of small holes ranging between and 3 to 10 mm (1/8 to 3/8 of an inch) are made in various locations on the abdomen. Small tubes, or trocar sleeves, are placed through these small incisions to keep the skin, fatty tissue, and muscle open for the introduction of instruments into the abdominal space. Carbon dioxide is pumped in through one of these tubes to inflate the abdomen giving the surgeons room to work. A laparoscope is introduced through one of these tubes, which is attached to a powerful light system and digital camera system. This allows for the intra-abdominal space to be viewed on a television monitor alongside the patient. The surgical team, which generally consists of the primary surgeon, an assistant surgeon, a physician’s assistant, and a scrub nurse, then carry out the operation. The operation consists of dividing the abnormal connections (adhesions) between the various intra-abdominal organs. Depending on the severity of the adhesions, this operation may last anywhere between 1-6 hours with a common average time being approximately 2 hours. Once all of the adhesions are divided and the intra-abdominal space is completely free, the small tubes are removed and the small skin incisions are sewn shut using absorbable suture on the skin that does not need to be removed.

Recovery is variable depending on a variety of patient characteristics, including the severity of the adhesions. A hospital stay of between 1-3 days is typical. The hospitalization is required for observation while the patient returns to eating and activity to be sure that there are no problems that develop and to see that the internal organs, primarily the stomach and intestines, return to their normal function now that they are freed from the adhesions.

Risks of laparoscopic lysis of adhesions include general medical complications, general surgical complications, and problems specific to adhesiolysis. General medical complications include heart attack, pneumonia, blood clots, and stroke, along with many other medical problems. These are dependent on the patient’s overall medical history and are generally the result of the stress placed on the patient’s system by the surgery itself and primarily by anesthesia. This requires a complete medical evaluation by a person’s doctor to determine their readiness for surgery. A person who has multiple medical problems including previous heart attacks, lung problems, diabetes, or other problems have increased risk of undergoing any type of surgery and require medical stabilization prior to their surgery. People who are otherwise healthy have very little risk of general medical complications.

Complications that are common to any surgical procedure include bleeding, infection, and incisional hernias. Bleeding can occur during or after the operation, and in rare cases may require transfusion or re-operation to control bleeding. Bleeding complications are somewhat reduced with adhesion surgery because generally adhesions contain minimal blood vessels, and major organs are not being cut into. Infection can result after any operation. Infection can result inside the abdomen causing abscess formation. This also is extremely rare, but can require that a catheter be placed to drain infection or re-operation to drain infection may be necessary. Adhesiolysis carries a very low risk of infectious complications, again because the internal organs are not being entered directly. Infection at the small skin incisions is possible but these are rare due to their very small size. When infection at an incision occurs it is generally easily resolved with oral antibiotics, again because the incisions are so small. Whenever the abdominal wall is cut through during a surgical operation it must heal to re-form a complete abdominal wall. When healing of the muscular layer is incomplete, a hole can result causing herniation of the intra-abdominal contents out through that hole. This is termed an incisional hernia. This is possible with laparoscopic incisions although it is rare because of their small size. When it occurs, it will generally require re-operation to repair the muscle layer under the incision at a later date. Hernias can present significant problems if intra-abdominal organs, such as intestines, become stuck in the hole in the muscle in which case emergency surgery is required to repair hernia. Fortunately, laparoscopy has greatly reduced the incidence of this complication as well.

The most important complication that relates specifically to the adhesion surgery is injury to the organs on which the adhesions have formed. The extent of adhesions and the type of adhesions found determines the amount of risk. Loose filmy adhesions are divided fairly easily and carry a very low risk. Thick, leathery adhesions carry a somewhat greater risk but can still be divided safely. When adhesions are so severe that structures become fused, it becomes very difficult to divide these structures without some risk of entering one or the other of the fused organs. While injury to an internal organ is rare in the hands of an experienced laparoscopic surgeon, it is possible, and needs to be considered when weighing the risks of surgery. When injury to organs occurs, it can most frequently be dealt with by repairing the injured organ using laparoscopic techniques. This often adds little or no postoperative problems. In rare cases it can require additional surgery, and can require that an open operation be performed. Injury to the intestines can cause leakage of intestinal fluid, which contains bacteria, which can raise the risk of infection. This all underscores the need to seek out surgeons experienced with this procedure.

Related Links

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  1. The International Adhesion Society - http://www.adhesions.org
  2. The Roses Adhesion Disorder Project - http://www.pathwaystohope.org
  3. Robotic Laparoscopic Surgeons - http://www.adlap.com
  4. Community Medical Center, Scranton, PA - http://www.cmchealthsys.org
  5. Ethicon Endosurgery Adhesion Information - http://www.adhesions.com