Wednesday, November 9, 2016

Do postoperative adhesions cause abdominal pain?

A reader asks whether I think adhesions cause postoperative abdominal pain and if so, how should they be treated?

I have always been skeptical (no surprise) about blaming adhesions for pain.

If adhesions cause abdominal or pelvic pain, what is the mechanism? We know that the intestine can be handled, cut, and cauterized without causing pain. What about tugging or pulling on the bowel? Would that cause pain? I doubt it. How much tugging or pulling can take place within the confines of the peritoneal cavity anyway? A literature search did not turn up any studies on  the mechanism of adhesions causing pain.

UpToDate, the online medical textbook, has a section on this topic. It doesn't address how adhesions cause pain but does discuss the evidence that reoperating on patients with adhesions is not worthwhile.

Although some observational studies claim that lysis of adhesions can decrease chronic pelvic or abdominal pain, at least three randomized controlled trials found little value in performing adhesiolysis except possibly in patients with vascularized adhesions, which would be difficult to diagnose preoperatively.

There are significant risks in performing laparotomy and lysis of adhesions including injury to bowel and the high likelihood of creating more adhesions.

Prevention of adhesions with potions or sheets of difficult-to-handle materials is the Holy Grail of abdominal surgery. As far as I know, none of the many products purported to prevent adhesions has reliably done so.

While investigating this topic, I found a blog post touting a polyethylene glycol solution called SprayShield for adhesion prevention when used before closing the abdomen. A couple of anecdotes were cited.

Two research papers are widely quoted as evidence supporting the use of SprayShield. The first was in an online journal called Wideochir Inne Tech Maloinwazyjne [Polish for "Videosurgery and Other Mini-invasive Techniques”]. It was a randomized, controlled, single-blind trial of eight patients undergoing diverting ileostomy who received SprayShield and three who did not. Adhesions were assessed at the time of ileostomy reversal.

The results were as follows: "In patients who received SprayShield the time required to mobilize the ileal loop at the ileostomy closure was slightly shorter and the incidence and severity of adhesions were somewhat lower vs. control subjects (NS)" meaning not significant.

The second, from Germany and published in Archives of Gynecology and Obstetrics, was a randomized trial of patients undergoing gynecologic surgery—nine received SprayShield and six did not. For the main outcomes—incidence, severity, and extent of uterine adhesions—"no significant differences were found between the two study groups."

A observational study in France involved 20 patients who were having gastric band removal and application of SprayShield with gastric sleeve resection or bypass planned at a later date. It was registered at and apparently completed at the end of 2014, but a PubMed search using the name of the principal investigator was fruitless. The study has apparently not been published.

The first generation predecessor of SprayShield, Confluent SprayGel, was blamed for causing painful internal scarring due to an ingredient—methylene blue. One account says that at reoperation the reproductive organs of some women appeared "super-glued together." Covidien, maker of both products, changed the name and formula, and SprayShield contains a vegetable dye instead of methylene blue.

The evidence for SprayShield in preventing adhesions is not strong. The product was never FDA approved for use in the United States and probably never will be.

The first scientist who discovers a safe and effective way to prevent the formation of adhesions after abdominal or pelvic surgery should be awarded a Nobel Prize.


Korhomme said...

Adhesions: Harold Ellis in the UK demonstrated that they were a response to devitalised areas, ischaemic areas. The adhesions, in this view, were beneficial, giving a vascular supply to an area which would otherwise die.

Apart from adhesions around the ovary preventing ovuation, and adhesions causing bowel obstruction, I simply cannot believe that scar tissue, which is what adhesions are, can be the cause of chronic pain.

Anyone who has had an abdominal operation will have some adhesions. They may be a convenient excuse for 'chronic pain', but they aren't the cause. This is simply false reasoning; just because adhesions are present does not mean that they are the cause of the symptoms.

And yes, I have ranted about this for decades.

KJ said...

If the adhesions were just present and not attached to any thing (organs, muscles, peritoneum) then I would agree with you. However, when you have adhesions attached from one side of your stomach to the other, forming a giant cobweb, strangling organs, gluing them to each other, and pulling them out of place. It causes unbelievable pain. It may be indirectly, but the adhesions are still responsible. If they weren't there, then no pain would exist.

Korhomme said...

The false reasoning is of the 'post hoc, ergo hoc' type.

You have had an operation. [True]
You have therefore adhesions [Almost certainly true]
You have bellyache [True]
Therefore, your bellyache is caused by adhesions [False]

I had a laparotomy nearly 70 years ago, for an intussception. Therefore I have adhesions. I don't have chronic belly ache. Why not?

Sorry, you have touched a very raw spot in my psychology. I do believe that gentle handling of the bowels, and the use of damp swabs in all circumstances will reduce adhesions.

Skeptical Scalpel said...

KJ, if adhesions weren't attached to anything, they wouldn't be adhesions. Adhesion (def): "an abnormal union of membranous surfaces due to inflammation or injury." They aren't giant cobwebs and they rarely strangle bowel.

Kor, A belief is not a fact. If all it took to reduce adhesions were gentle handling and damp swabs, everyone would use those techniques. In fact, most surgeons already do.

Korhomme said...

Skepto, yes I am very biased and freely admit it; and, you may have noticed, it is a hobby horse.

As for the 'gentle handling' and 'damp swabs', I learned this when working on the European continent. In the UK I'd never seen this done. When I returned I tried very hard to get juniors to do this; but they clearly felt I was a maverick, and when my back was turned they were all recidivists.

(As an aside; much of what I saw on the Continent seemed very similar to US practice and surgical culture. I could never establish whether the US had learned from Europe, particularly Germany, or vice-versa.)

artiger said...

Common referral to my office..."My doctor (or midlevel) said my stomach pain was from my adhesions".

In the absence of obstruction, I tell them this is simply not true. I hate to say it, but it is sometimes an underhanded attempt to dish a patient away from the referring provider's care. You know, if you operate on them, every single problem thereafter is a byproduct of the surgery. No thank you.

If I remember nothing else from residency, it was the following two quotes:

"Operations for pain produce more pain...for both the patient and the surgeon."

"There is no one more enthusiastic than a primary care doctor (provider) trying to convince you to operate."

Skeptical Scalpel said...

Kor, we all have our biases.

Artiger, I agree. We had a saying, "When you operate for pain, you get pain."

KJ said...

In the case I am referring to, the cause was peritonitis, not one surgery that caused some scar tissue at a certain site. The description I posted was an almost direct quote from a top surgeon and top GI doc at the Mayo Clinic. Additionally, there is photographic evidence they exist because the surgery to remove the infection was done laparoscopically and several pictures were taken that show the adhesions forming everywhere.

Definition: Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connects tissues not normally connected. Another cause is infection, such as peritonitis.

They attach normally separated organs to each other and can cause major problems for the affected patients by giving rise to small bowel obstruction, chronic pelvic pain, dyspareunia, infertility, and higher complication rates in subsequent operations. They are also a frequent source of medicolegal conflict.

This blog is a great example of the conflict in the medical field regarding adhesions.

I did a quick pubmed search and found several other definitions for them as well. The articles I looked at state they exist, can cause a lot of problems or no problems and anywhere in between, and that no concrete agreed upon definition from the medical community exist yet. However, just because people don't think they exist or cause problems, doesn't mean they don't actually exist or cause problems. Hundreds of years ago, bacteria and virus existed caused illnesses, pain, suffering, and death, and yet no one knew of them.

This holds true for doctors either not believing they are there, not wanting to try to fix the problem, and/or docs tired of getting referrals of patients who have them, etc. If you think it's frustrating as a medical professional to deal with them, try being a patient who does. It is a life sentence. There is no cure where the probable result is more adhesions

What evidence does the medical profession need to believe that abdominal adhesions cause pain and suffering? The consensus seems to be that 50-100% of surgical patients will have adhesions as a result of surgical operations. What other possibilities are there that explain the pain and suffering?

Cutter said...

I always make sure to counsel patients that adhesions cannot be "removed", only rearranged. When you divide the abnormal attachment between loops of bowel, you immediately create 2 raw surfaces that will likely attach to 2 new sites (essentially doubling the number of adhesions). This usually cuts through the illogic of operating on nonobstructive adhesions. Until the magic adhesion prevention/dissolving substance is invented, this is the state of affairs.

In the early weeks/months after an operation, adhesions are actually at their worst (as any surgeon who has had to go back in the abdomen can testify). When patients report (transient) pain relief after empiric adhesiolysis, they are feeling their best when the recurrent adhesions are actually at their worst. Unfortunately, the chronic pain that prompted the re-operation typically recurs.

Chronic, non-obstructive abdominal pain is a difficult problem that does not respond well to surgical intervention. If the chronic abdominal patient thinks they have it bad, they need to meet someone with an enterocutaneous fistula...

My favorite quote:

"There is no problem so severe that it can not be made worse with surgery"

artiger said...

I don't think anyone is arguing against causes of adhesions, just the results of them. Still, without obstruction or ischemia, I'm not operating on someone who is convinced that they have pain due solely to the mere presence of adhesions. Just because someone at Mayo thinks so doesn't make it so. Still, for those who cannot be dissuaded, there is some surgeon out there who wants to try to be the hero. All you have to do is find him/her.

Skeptical Scalpel said...

KJ, I am sympathetic to your situation. I agree that we don't know enough about adhesions. It may very well be that they cause pain, but no one knows why. That's why I wrote the post.

Cutter and Artiger have explained that doing more surgery can make things worse and I agree. I also agree that if a patient shops around enough, she will eventually find a surgeon who will operate.

William Reichert said...

It's a lot like operating on chronic back pain, I guess. The choice of procedures is limited only by the imagination.

KJ said...

I also do not believe surgery will usually fix the situation, although it may fix it in a small percentage of cases. I have read of some lucky people who did have the lysis and 10-20 years down the road, they are still ok. However, this is not the majority..not by a long shot, unfortunately. Of all the research I've done, there are 2 doctors that do enough of them to have the experience and technique to lead to more success than other docs. Way more research is needed not only how to get rid of them but also what the mechanism for pain is. There is no way that millions of people who have pain that came with the onset of adhesions (worldwide) are all wrong.

What I have been told the working theory is that the nerves are signaling pain because the adhesions are causing organs to shift out of position and that pulling on the peritoneal wall and muscle triggers this as well.

Interestingly, Eastern medicine seems to have some good information on how to prevent a lot of adhesions, but that discipline too is stumped when it comes to getting rid of them.

Serrapeptidase is an enzyme thought to dissolved adhesions over time. It is marketed by US Enzymes, under the name Serraxyme. I am not entirely convinced that it does actually dissolve them. I am leaning toward the probability that it softens them enough that they become more pliable, so they don't shift things out of place as much. I am led to this thought because after observing their effects for over 2 years, the pain was still present, but less so. Also, when the enzyme was discontinued a few time for 4-6 week periods, the pain started returning after the first 2 weeks, then back to full strength by 4 weeks. No other medical regiments were altered in anyway. Any other thoughts regarding this? Would this enzyme have some affect on something else that causes this specific type of abdominal pain?

Skeptical Scalpel said...

KJ, A brief search of the medical literature turned up nothing about serrapeptidase or serratia peptidase and the treatment of adhesions.

I can't conceive of any way that something you take by mouth would be absorbed intact into the bloodstream and go only to the abdomen to soften or dissolve adhesions.

If it makes you feel better, by all means keep taking it.

Anonymous said...

Anonymous Europe: Guys, I learned a lot just from reading your comments. I have to admit I cite Sceptical Scalpel a lot while I am working.:) I once took a look at the original colonisation/biggest minority' in each state map of the US, and found that a lot of the states were colonized by mostly Germans. It might also be that a lot of surgeons emigrated back in the day from Germany...

Skeptical Scalpel said...

I don't know about surgeons emigrating here from Germany, but in the 19th Century, any surgeon who wanted to get ahead in the US spent a year working with surgeons in Germany or Austria.

Anonymous said...

Anonymous Europe: I did not know that. Wow...
Now it is just the other way around.:D If you have any kind of US work experience, the market is yours in Europe. Especially if you did clinical work, not research..:)
BTW, how do you motivate yourself to do science? I am in love with staying in in the OR and rock it out (performing, assisting, I do not care as long as I am part of the team). But when it comes to science I just hate it, even though I have a PhD. Does it get any better with time? It is almost a physical strain for me to sit down and write a paper/ gather data. I just lack the motivation.
If you have any suggestions, I would be very grateful.

Skeptical Scalpel said...

"How do you motivate yourself to do science?" Good question. Either you have a question that needs an answer and you want to find it out for yourself (better way) or you do it because it is required to advance your career (what many people do).

I don't know if it gets better with time or not. It is useful to have a mentor who can stimulate and guide you through the process. I was fortunate enough to find such a person and he taught me how to do research and write a coherent paper.

I think that if you do not start doing and publishing research as a resident, it is very difficult to try to start a a practicing surgeon with no experience with research.

Anonymous said...

Anonymous Europe:Thank you very much for your advice. Looks like this is rather a personality thing...:)... I guess, I will just stick to surgery.:)

Anonymous said...

I have had success softening scars and adhesions using DMSO 50/50, high dose fish oil and juicing turmeric and ginger.

Skeptical Scalpel said...

Are you serious or just trolling me?

artiger said...

Probably both, Scalpel

Skeptical Scalpel said...

I'm voting for the latter.

Anonymous said...

adhesion is wide spectrum from causing nothing to mils intermittent pain and discomfort to partial obstruction to complete obstruction .these symptoms are unpredictable can occur in days ,weeks ,months , decades after surgery .every case is different and the rules that apply to one case dosen't necessarily apply to other

Skeptical Scalpel said...

The post is about operating on patients with abdominal pain only as a result of adhesions, not bowel obstruction. Here is what I wrote.

"UpToDate, the online medical textbook, has a section on this topic. It doesn't address how adhesions cause pain but does discuss the evidence that reoperating on patients with adhesions is not worthwhile.

"Although some observational studies claim that lysis of adhesions can decrease chronic pelvic or abdominal pain, at least three randomized controlled trials found little value in performing adhesiolysis except possibly in patients with vascularized adhesions, which would be difficult to diagnose preoperatively."

Anonymous said...

It's hard to believe today that this many educated people try to rely on past studies to answer an individualized cause / effect as destructive as bowel and abdominal adhesion causing pain.

A scar on your wrist won't likely cause much pain, but then if you flex the wrist and attach the base of the thumb to the lower forearm, you'll know pain not long after as a result of musculature becoming altered, atrophied and dysfunctional not to mention tension and tearing on limited use or spasm.

Now place that among musculature in the intestines and mobility as a function of digestion, then innervate the scar tissue with misaligned nerves attempting to reconnect across the formed collagen latices structures in scarring. When stricture or mechanical strain begin to constrict and strain other less innervated but encapsulated nerve bundles, do we really think this is going to be a benign result?

It will be different for every patient and every surgery no matter how many (n) subjects one places into a follow up. The simple fact that there is greater post operative pain for surgeries as a whole is likely the most significant proof necessary, well before looking at bowel strangulation or loop fixations, etc.

It's exactly this kind of broad spectrum thinking that western medicine contaminates by, giving rise to surgeon's lumping everyone into a categorical assignment which impedes progress toward an eventual FACTUAL finding and improved process. When you learn to think and are educated in a narrow, linear path, you make linear mistakes. Nature is NOT linear by any manner of perception.

The follow on is doctor's justifying their adopted presumptions by leaning on their credentials as if those can some how justify an ignorant, categorical assumption; monkey see, monkey do medicine.

These are some of the same specialists who still think chronic opioid use is a solution to chronic pain, absent the understanding of receptor evolution and the increased long term plateau of chronic rebound pain, worse than the initial pain. Most on opioid medication beyond 15-30 days learn this the hard way and many fail to ever escape, eventually elevated to the worst of the worst - methadone.

I have to wonder how many posters here even ever really think through the response they wrote to measure if their reply makes sense or not. It's tantamount to breeding ignorance into the evolution of science to avoid the loss of chronic patients paying their office bills through socialized insurance in a debt based fiat economy.

Just sad. One cannot justify false rationalization and above all we still "can't fix stupid". Perhaps this is why MD's as a whole tend to not live as long as the general population as a sound starting point of categorical observation.

Woefully Anonymous

Skeptical Scalpel said...

Nerves are not found in adhesions. The bowel does not have pain nerves. You can open a colostomy with cautery at the bedside and the patient will not feel anything.

Whether doctors live longer than the general public is debatable. You can find studies saying yes or no. Here's one that says they outlive other professionals

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