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Adhesion (medicine)

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Adhesion (medicine)

Adhesions are fibrous bands[1] that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.

Pathophysiology

Adhesions form as a natural part of the body’s healing process after surgery in the same way that a scar forms. The term "adhesion" is applied when the scar extends from within one tissue across to another, usually across a virtual space such as the peritoneal cavity. As part of the process, the body deposits fibrin onto injured tissues. The fibrin acts like a glue to seal the injury and builds the fledgling adhesion, said at this point to be "fibrinous." In body cavities such as the peritoneal, pericardial and synovial cavities, a family of fibrinolytic enzymes may act to limit the extent of the initial fibrinous adhesion, and may even dissolve it. In many cases however the production or activity of these enzymes are compromised because of injury, and the fibrinous adhesion persists. If this is allowed to happen, tissue repair cells such as macrophages, fibroblasts and blood vessel cells, penetrate into the fibrinous adhesion, and lay down collagen and other matrix substances to form a permanent fibrous adhesion. In 2002, Giuseppe Martucciello's research group showed a possible role could be played by microscopic foreign bodies (FB) accidentally contaminating the operative field during surgery[2]. These data suggested that two different stimuli are necessary for adhesion formation: a direct lesion of the mesothelial layers and a solid substrate (FB).

While some adhesions do not cause problems, others can prevent muscle and other tissues and organs from moving freely, sometimes causing organs to become twisted or pulled from their normal positions.

Regions affected

Adhesive capsulitis

In the case of adhesive capsulitis of the shoulder (also known as frozen shoulder), adhesions grow between the shoulder joint surfaces, restricting motion.

Abdominal adhesions

Abdominal adhesions (or intra-abdominal adhesions) are most commonly caused by abdominal surgical procedures but may also be caused by pelvic inflammatory disease or endometriosis. The adhesions start to form within hours after surgery and may cause internal organs to attach to the surgical site or to other organs in the abdominal cavity. Adhesion-related twisting and pulling of internal organs can result in complications such as infertility and chronic pelvic pain. Surgery inside the uterine cavity (e.g., suction D&C, myomectomy, endometrial ablation) can result in Asherman's Syndrome (also known as intrauterine adhesions), a cause of infertility.

Small bowel obstruction (SBO) is another significant consequence of post-surgical adhesions. A SBO may be caused when an adhesion pulls or kinks the small intestine and prevents the flow of content through the digestive tract. It can occur 20 years or more after the initial surgical procedure, if a previously benign adhesion allows the small bowel to spontaneously twist around itself and obstruct. SBO is an emergent, possibly fatal condition without immediate medical attention. According to statistics provided by the National Hospital Discharge Survey approximately 2,000 people die every year in the USA from obstruction due to adhesions.[3] Depending on the severity of the obstruction, a partial obstruction may relieve itself with conservative medical intervention. However, many obstructive events require surgery to lyse the offending adhesion(s) or resect the affected small intestine.

Pericardial adhesions

Adhesions forming after cardiac surgery between the heart and the sternum place the heart at risk of catastrophic injury during re-entry for a subsequent procedure.

Peridural adhesions

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

Peritendinous adhesions

Adhesions and scarring occuring around tendons after hand surgery restrict the gliding of tendons in their sheaths and compromise digital mobility.

Association with surgery

A study in Digestive Surgery showed that more than 90% of patients develop adhesions following open abdominal surgery and 55%–100% of women develop adhesions following pelvic surgery.[4] Adhesions from prior abdominal or pelvic surgery can obscure visibility and access at subsequent abdominal or pelvic surgery. In a very large study (29,790 participants) published in British medical journal The Lancet, 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.[5] Over 22% of all readmissions occurred in the first year after the initial surgery.[5] Adhesion-related complexity at reoperation adds significant risk to subsequent surgical procedures.[6]

Before the availability of adhesion barriers, adhesions were documented to be an almost unavoidable consequence of abdominal and pelvic surgery, and occurred in as much as 93% of all patients undergoing abdominal surgery.[7]

Types

Types of adhesions:

  1. Fibrinous adhesions. These are causes of early postoperative obstruction which settles down within 3–5 days. The majority of fibrinous adhesions will disappear in due course of time.
  2. Fibrous adhesions. If the infection is continuous or if foreign[clarification needed] is present, the fibrinous material is converted into fibrous material.

References

  1. ^ "adhesion" at Dorland's Medical Dictionary
  2. ^ Torre M, Favre A, Pini Prato A, Brizzolara A, Martucciello G.(2002 Dec)."Histologic study of peritoneal adhesions in children and in a rat model"Pediatr Surg Int.18(8):673-6. Epub 2002 Sep 24
  3. ^ See article at: www.adhesions.org/ardnewsrelease092303.pdf
  4. ^ Liakakos, T; Thomakos, N; Fine, PM; Dervenis, C; Young, RL (2001). "Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management". Digestive surgery. 18 (4): 260–73. doi:10.1159/000050149. PMID 11528133.
  5. ^ a b Ellis, H; Moran, BJ; Thompson, JN; Parker, MC; Wilson, MS; Menzies, D; McGuire, A; Lower, AM; Hawthorn, RJ (1999). "Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study". Lancet. 353 (9163): 1476–80. doi:10.1016/S0140-6736(98)09337-4. PMID 10232313.
  6. ^ Van Der Krabben, AA; Dijkstra, FR; Nieuwenhuijzen, M; Reijnen, MM; Schaapveld, M; Van Goor, H (2000). "Morbidity and mortality of inadvertent enterotomy during adhesiotomy". The British journal of surgery. 87 (4): 467–71. doi:10.1046/j.1365-2168.2000.01394.x. PMID 10759744.
  7. ^ Adhesion prevention: a standard of care. 1999 - 2003 Medical Association Communications. American Society of Reproductive Medicine. http://www.cmecorner.com/macmcm/asrm/asrm2002_02.htm

See Also

Active Release Technique

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