Laparoscopic adhesiolysis in patients with chronic abdominal pain

An Approach to the Patient With Chronic Undiagnosed Abdominal Pain

Abdominal pain is a common reason for referral to a gastroenterologist. The workup of patients with chronic abdominal pain can be extremely challenging as clinicians are responsible for determining whether the patient can be observed or treated symptomatically or this abdominal pain heralds a more systemic disease. The differential is typically wide and given the innervation of the abdomen, localization of abdominal pain does not always provide clear insight into the etiology. This review attempts to help the gastroenterologist narrow down that broad differential and focus on key elements of the patient visit. We emphasize the importance of a detailed history from the patient, along with review-specific details of their history and physical examination that can clue one in about the etiology of the abdominal pain. We review the causes of diffuse abdominal pain that may not first be considered along with uncommon causes of localized abdominal pain. We also review the functional causes of abdominal pain and the importance of identifying these disorders, to avoid unnecessary testing that commonly occurs with these patients.

Role of the peritoneal cavity in the prevention of postoperative adhesions, pain, and fatigue

A surgical trauma results within minutes in exudation, platelets, and fibrin deposition. Within hours, the denuded area is covered by tissue repair cells/macrophages, starting a cascade of events. Epithelial repair starts on day 1 and is terminated by day 3. If repair is delayed by decreased fibrinolysis, local inflammation, or factors in peritoneal fluid, fibroblast growth starting on day 3 and angiogenesis starting on day 5 results in adhesion formation. For adhesion formation, quantitatively more important are factors released into the peritoneal fluid after retraction of the fragile mesothelial cells and acute inflammation of the entire peritoneal cavity. This is caused by mechanical trauma, hypoxia (e.g., CO₂ pneumoperitoneum), reactive oxygen species (ROS; e.g., open surgery), desiccation, or presence of blood, and this is more severe at higher temperatures. The inflammation at trauma sites is delayed by necrotic tissue, resorbable sutures, vascularization damage, and oxidative stress. Prevention of adhesion formation therefore consists of the prevention of acute inflammation in the peritoneal cavity by means of gentle tissue handling, the addition of more than 5% N₂O to the CO₂ pneumoperitoneum, cooling the abdomen to 30°C, prevention of desiccation, a short duration of surgery, and, at the end of surgery, meticulous hemostasis, thorough lavage, application of a barrier to injury sites, and administration of dexamethasone. With this combined therapy, nearly adhesion-free surgery can be performed today. Conditioning alone results in some 85% adhesion prevention, barriers alone in 40%-50%.

Adhesions after abdominal surgery: a systematic review of the incidence, distribution and severity

Abdominal adhesions are associated with increased postoperative complications, cost and workload. We performed a systematic review with statistical pooling to estimate the formation rate, distribution and severity of postoperative adhesions in patients undergoing abdominal surgery. A literature search was carried out for all articles reporting on the incidence, distribution and severity of adhesions between January 1990 and July 2011. Twenty-five articles fulfilled the inclusion criteria. The weighted mean formation rate of adhesions after abdominal surgery was 54 % (95 % confidence interval [CI] 40-68 %), and was 66 % (95 % CI 38-94 %) after gastrointestinal surgery, 51 % (95 % CI 40-63 %) after obstetric and gynaecological surgery and 22 % (95 % CI 7-38 %) after urological surgery. The mean overall severity score was 1.11 ± 0.98 according to the Operative Laparoscopy Study Group classification. Laparoscopic surgery reduced the adhesion formation rate by 25 % and decreased the adhesion severity score (laparoscopic; 0.36 ± 0.69 vs. open; 2.14 ± 0.84) for gastrointestinal surgery. Our results demonstrate that the incidence and severity of abdominal adhesions varies between surgical specialties and procedures. An increased awareness of adhesions can help in identifying the underlying mechanisms of adhesion formation and novel therapeutic approaches, while also improving the surgical consent process.

Adhesion awareness: a nationwide survey of gynaecologists

OBJECTIVE

Adhesions and related complications lead to substantially increased morbidity and mortality which increase medical costs. We investigated the awareness of adhesions among Dutch gynaecologists and gynaecology residents.

STUDY DESIGN

A survey, assessing knowledge and opinion about adhesions, was sent to a randomly selected group of 381 gynaecologists and 256 residents. In addition, the informed consent process and application of anti-adhesive agents were questioned.

RESULTS

The response rate was 56.9%. Complications due to adhesions were highly underestimated, leading to low knowledge scores (mean score 35.1%). Of all respondents 73.8% agreed that adhesions exert a clinically relevant and negative effect, but only 51.2% expressed a positive opinion on adhesion prevention. This correlated with a stronger belief in the clinically relevant and negative effects of adhesions and the opinion that adhesion prevention belongs to standard care (ρ=0.212, p<0.001; ρ=0.495, p<0.001). Of all respondents 31.4% expressed a positive attitude towards anti-adhesive agents and 19.8% expressed a negative one. A negative attitude correlated with a negative view in terms of cost-benefits (ρ=0.245, p<0.001). Although 43.5% had used anti-adhesive agents in the past year, 20.9% had used them before but stopped using agents in the past year. Only 5.2% routinely included adhesions or related morbidity in the informed consent.

CONCLUSIONS

Awareness of adhesions is limited and informed consent is provided inadequately. Implementing adhesion prevention is related with awareness of adhesions. These findings underline the need to embed adhesions, related morbidity and prevention in educational programmes.

Two Cases of Laparoscopic Adhesiolysis for Chronic Abdominal Pain without Intestinal Obstruction after Total Gastrectomy

Chronic abdominal pain remains a challenge to all known diagnostic and treatment methods with patients undergoing numerous diagnostic work-ups including surgery. However, the surgical treatment of patients with chronic intractable abdominal pain is controversial. There has been no discussion of the indications for adhesiolysis in cases of obstruction or strangulation of the bowel, and adhesiolysis by laparotomy has never gained acceptance as a treatment modality for chronic abdominal pain. One of the reasons for this lack of acceptance is the high complication rate during and after adhesiolysis. Laparoscopic surgery has been accepted as a technique for diagnostic and therapeutic procedures in general surgery. Laparoscopy allows surgeons to see and treat many abdominal changes that could not otherwise be diagnosed. Here we report two cases of successful symptomatic improvement through laparoscopic adhesiolysis for chronic abdominal pain without intestinal obstruction after total gastrectomy.

Clinical features and outcome of patients with inflammatory bowel disease who use narcotics: a case-control study

BACKGROUND

The role of narcotic use in patients with inflammatory bowel disease (IBD) is poorly defined. We sought to determine the clinical features of patients with IBD who use narcotics and factors associated with the discontinuation of narcotics.

METHODS

A centralized index was used to identify 100 cases (patients with IBD receiving narcotics) and 100 matched controls evaluated in an IBD clinic between 1999 and 2002. Associations of clinical factors with case or control status were summarized as overall percentages and assessed using conditional logistic regression. Associations within cases were assessed using Fisher's exact test.

RESULTS

Review of 361 charts identified 100 patients with IBD receiving narcotics (cases). One hundred matched controls were then identified. Cases were significantly associated with: female gender (64% cases versus 45% controls, P = 0.01), >or=2 IBD-related surgeries (42% versus 17%, P < 0.001), moderate-to-severe pain (93% versus 20%, P < 0.001), and moderate-to-severe symptoms (83% versus 33%, P < 0.001). Significant associations were detected for depression (42% versus 19%, P < 0.001), anxiety (19% versus 7%, P = 0.02), history of abuse (sexual, emotional, or physical, 17% versus 3%, P = 0.006), and for substance abuse (excluding alcohol) (14% versus 1%, P = 0.01). Of 39 cases that returned for follow-up, 22 (56%) had discontinued narcotics. Discontinuing narcotics was associated with medical treatment adherence (100% versus 53%), none-to-mild pain (73% versus 18%), and none-to-mild clinical activity (80% versus 24%).

CONCLUSIONS

Narcotic use in IBD patients is associated with female gender, >or=2 previous surgeries, moderate to severe pain, and clinical disease activity, depression, anxiety, sexual, emotional and physical abuse, and substance abuse.

The difficult patient in gastroenterology: chronic pelvic pain, adhesions, and sub occlusive episodes

Chronic pelvic pain (CPP) with or without adhesions and symptoms of intestinal occlusion is a complex but relatively common complaint. The etiology and pathophysiology of CPP and adhesions are unclear, as is their possible relation. However, it is evident that continuous abdominal pain leads to evident suffering and disability. Unfortunately, there is little proof or evidence of success for many of the currently used diagnostic and therapeutic interventions. Laparoscopy is neither the ultimate evaluation nor the panacea for CPP or intra abdominal adhesions. An integral approach to CPP has shown beneficial results. In this multidisciplinary approach dealing with the pain is far more important than finding an organic cause and cure for the pain. Equal and simultaneous attention is paid to psychosocial, sexual and somatic aspects. The treatment of adhesions depends on the extent of symptoms and complaints. Because of the questionable relation between adhesions and pain, and the probability of reformation and de novo adhesion formation after surgery, adhesiolysis should be avoided. Even for patients with signs and symptoms of small bowel obstruction a conservative treatment is often justified. These patients require careful evaluation and management. Frequent reassessment is important to rule out impending strangulation, complete obstruction or perforation. Water soluble contrast can be useful to justify prolongation of conservative treatment and by that postpone unnecessary surgery. Most adhesive small bowel obstructions resolve following conservative treatment. The unsolved questions about etiology, diagnosis, treatment and prevention, and the great individual and community burden of CPP and adhesions clearly show that further research is needed.

Peritoneal transforming growth factor beta-1 expression during laparoscopic surgery: a clinical trial

BACKGROUND

Transforming growth factor-beta 1 (TGF-beta1) is a growth factor involved in various biologic processes, including peritoneal wound healing and dissemination of malignancies. Laparoscopic surgery is evolving rapidly, and indications are increasing. The peritoneal TGF-beta1 expression during laparoscopic surgery is unknown.

METHODS

For this study, 50 patients scheduled for laparoscopic cholecystectomy were randomized into five groups, then surgically treated with various pressures, light intensities, and dissection devices. Peritoneal biopsies were taken at the beginning and end of surgery. Tissue concentrations of total and active TGF-beta1 were measured using enzyme-linked immunosorbent assay (ELISA) techniques.

RESULTS

There was no significant difference in either total or active TGF-beta1 concentration between peritoneal biopsies taken at the start of surgery and samples taken at the end of the procedure. Patients who underwent surgery with the ultrasonic scalpel had significant lower levels of both active (p < 0.005) and total (p < 0.01) TGF-beta1 at the end of surgery than patients treated with electrocautery. Patients who had surgery with a high light intensity had significantly lower levels of total TGF-beta1 levels (p < 0.005) with an unchanged active part than patients who had surgery with low light intensity.

CONCLUSION

The choice of dissection device and the light intensity used in laparoscopic surgery affect peritoneal TGF-beta1 concentrations, indicating that peritoneal biology can be affected by laparoscopic surgery. Because TGF-beta1 is involved in various biologic processes in the peritoneal cavity, this observation may have important clinical consequences.