October, 2013 Journal Club
Moderator: Dr. James M. Becker
Article: Adhesiolysis Related Morbidity in Abdominal Surgery. ten Broek, Richard P. G.; Strik, Chema; Issa, Yama;
Summary: Peritoneal adhesions are the nemesis of the abdominal surgeon and are largely an iatrogenic condition created for the most part by prior abdominal operations. Peritoneal adhesions develop after at least 90% of operations in the abdominal cavity. It has been estimated that the economic burden of adhesive bowel obstruction in the United States is at least $2 billion annually and that this goes up substantially when other complications of adhesions are accounted for. While bowel obstruction is the most dramatic complication of adhesions, this may represent the tip of the iceberg. Of even greater importance may be chronic abdominal pain, infertility in women and difficult and dangerous reoperative surgery. This manuscript addresses the impact of adhesiolysis and related organ injury on morbidity and socioeconomic costs. This was a prospective cohort study comparing surgical procedures with and without adhesiolysis on the incidence of inadvertent bowel injury, overall surgical complications and cost. Seven hundred fifty-five operations were evaluated with approximately 63% patients requiring adhesiolysis. This cohort was compared to the remaining 27% of patients that did not require lysis of adhesions. The two populations were compared using univariate and multivariate analysis. The analysis found that adhesiolysis was associated with a significant increase in the incidence of sepsis, intra-abdominal complications, wound infections as well as longer hospital stay and higher hospital cost. Given the significant morbidity associated with adhesiolysis the authors recommend that surgeons have a greater awareness of this major clinical burden and that patients be carefully informed about both the risk of developing adhesions following abdominal operations and the potential morbidity associated with adhesiolysis.
1.) What is currently known about the pathogenesis of adhesions and current clinical means available to prevent or reduce adhesion development?
2.) What intraoperative steps can be taken to reduce the morbidity of adhesiolysis?
3.) What counseling should patients be given prior to abdominal operations in regards to the risk of adhesion formation and the burden of adhesiolysis once abdominal adhesions are encountered?
4.) What is the role of laparoscopic surgery in reducing the incidence of adhesions or improving the results and safety of adhesiolysis?
Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.