In this volume of the Journal of Clinical Gastroenterology, Paajanen et al1 report on their experience with 72 patients with intractable chronic abdominal pain who were considered for adhesiolysis. Sixty-one patients underwent surgery, and 85% of these patients had intra-abdominal adhesions. Of interest, 8 patients had no previous abdominal surgery. The authors do not comment on the cause of adhesions in these patients. Most adhesions were between the abdominal wall and abdominal viscera. Thirty-three percent of patients were pain-free during a mean follow-up of 3.7 years, 46% were reported to have diminished pain, and 19% still had chronic abdominal pain, which limited their lifestyle. Forty-four percent of patients required further medical care for intractable abdominal pain. The authors conclude that laparoscopy is a valuable aid in the management of patients with chronic abdominal pain and a negative diagnostic workup.
It has been well established that about 90% of patients following on abdominal surgery will later develop abdominal adhesions.2,3 The majority of patients presenting for evaluation of abdominal pain will have had a previous laparotomy. This means that most patients who are being evaluated for abdominal pain are likely to have adhesions. Does this mean that adhesions are the cause of their abdominal pain? Before embarking on the procedure of laparoscopy and adhesiolysis, it is prudent for the surgeon to carry out a very careful evaluation of the patient to exclude other causes for the abdominal pain. Narcotic-seeking behavior should be identified. Diagnostic tests such as upper and lower endoscopy, abdominal x-rays, CT scans, and a careful clinical examination may reveal other causes for the abdominal pain. Jay A. Redan (personal communication, Laparoscopy and SLS report, Vol. 3) states that patients should be categorized according to the presence or absence of previous abdominal or pelvic surgery. Furthermore, evidence for bowel obstruction should be sought. If bowel obstruction is identified, this makes the search for adhesions more legitimate. A further strategy would be to group patients into those with abdominal wall, interloop, or pelvic adhesions. When a clear cause of abdominal pain has been identified, such as partial small bowel obstruction, tumor, endometriosis, or other gynecologic cause, appropriate therapy should be carried out. It seems logical that abdominal wall adhesions might be more likely to cause pain due to tugging on the parietal peritoneum. Adhesiolysis should theoretically help in alleviating this pain. Interloop adhesions may cause partial or complete bowel obstruction. Regarding pelvic pain, it is of interest that 50% of patients who have had an open abdominal hysterectomy during their lifetime will require hospitalization for adhesion-related complications.4 This may be a reflection of the enthusiasm of gynecologists to embrace this diagnosis or the propensity for pelvic adhesions to be symptomatic.
This initial analysis will leave a number of patients without a clear cause for their abdominal pain, and adhesions may be suspected as the cause. The decision to carry out an abdominal exploration should be carefully considered, as the study of Paajanen et al reveals that 2 patients had significant complications requiring conversion to open laparotomy. Furthermore, adhesiolysis will potentially produce two raw surfaces where only one was present before, compounding the risk of pain from subsequent adhesions. It therefore makes little sense to divide an innocent adhesion, which can then double the risk of future adhesion-related complications. Ideally, patients should undergo awake laparoscopy to identify whether an adhesion is indeed causing pain when tension is placed on the adhesion. This is very difficult to do because of intolerance to awake laparoscopy. Because of the difficulty of carrying out prospective, randomized trials with adhesiolysis, it is impossible to apply exact science to this subject. The ideal situation would be to carry out laparoscopy without adhesiolysis in one half of the patients and compare the result to those who have had adhesiolysis. This would be ethically difficult to justify.
It is clear that many patients will receive a placebo effect after adhesiolysis. Swank et al5,6 found that 50% of patients who underwent a laparotomy for pain and did not undergo adhesiolysis experienced relief of their symptoms. This indicates the magnitude of the placebo effect of laparotomy. It is possible that the achievement of a placebo effect may be desirable, since the patient who is told that no adhesions are present, or that adhesions have been divided, will feel less anxious, and this may decrease the effect of psychogenic pain or pain from irritable bowel. In view of the fact that almost 75% of patients will achieve relief of pain after adhesiolysis, it seems likely that a large number of these will have achieved their pain relief as a placebo effect.
Because of the high rate of adhesion formation after laparotomy, surgeons should be aware of the need to prevent postoperative adhesion formation. This can be achieved by careful tissue handling, avoidance of foreign bodies including long sutures and large devascularized tissue stumps distal to ligatures, care in the management of spilled gastrointestinal content, removal of all gallstones during laparoscopic cholecystectomy, lavage of blood or bile, and avoidance of desiccation of exposed bowel during the surgical procedure. Attempts have been made to decrease adhesions by routine lavage of the abdomen with either saline or even steroid-containing solutions and by placement of commercially available anti-adhesion products. It is not clear how effective these maneuvers are in preventing adhesion formation.
There are some surgeons who are enthusiastic about adhesiolysis in patients with chronic abdominal pain and yet others who regard adhesions as never being the cause of chronic abdominal pain. The reality probably lies somewhere between these two extremes. Because of the uncertainties associated with adhesiolysis, we would advocate a cautious approach to the surgical management of abdominal pain when no obvious cause can be found.
1. Paajanen H, Julkunen K, Waris H. Laparoscopy in chronic abdominal pain: a prospective non-randomised long-term follow-up study. J Clin Gastroenterol
2. Holmadahl L, Risberg B, Beck DE, et al. Adhesions: pathogenesis and prevention [Panel discussion and summary]. Eur J Surg Suppl
3. Ellis H. Medicolegal consequences of postoperative intra-abdominal adhesions. J R Soc Med
4. Lower AM, Hawthorn RJ, Ellis H, et al. The impact of adhesions on hospital readmissions over 10 years after 8849 open gynecological operations: an assessment from the Surgical and Clinical Adhesions Research Study. Br J Obstet Gynaecol
5. Swank DJ, Swank-Bordewijk SC, Hop WC, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomized controlled multi-center trial. Lancet
6. Swank DJ, van Erp WF, Repelaer Van Driel OJ, et al. A prospective analysis of predictive factors on the results of laparoscopic adhesiolysis in patients with chronic abdominal pain. Surg Laparosc Endosc Perc Tech