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Adhesion study Adhesion study

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Unread 08-18-2004, 01:36 AM
Adhesion study

In this months Annals of Surgery, there's an interesting report for those of us dealing with adhesions.

Norwegian researchers tracked a group of 500 patients who had been operated on for adhesion-related small bowel obstruction. Approximately half the group was female. They followed these patients for up to 40 years, tracking incidence of repeat obstruction due to adhesions, time out from original surgery (for 346 of these patients had a history of some sort of abdominal surgeries), and pain reporting.

Here's a couple of things I found interesting: first of all, out of those 346, 83 had GYN surgery as their initial "event." If you think about these numbers, maybe half of that 346 being female, it means that 50% (give or take) of the women in the study had had GYN surgery.

Of further interest: their adhesion-related obstructions occurred up to seven years out from surgery. This was the longest term seen: i.e., a woman who'd had her surgery for an appendectomy was likely to present with obstruction relatively early (mean was something like 2 years). But those of us with GYN surgeries could have problems up to seven years off .

Another note: those with "band" adhesions did better overall than those with "matted" adhesions (like I've got, with my vagina glued to my rectum, etc.; these are common to those of us with endo). And only a very small percentage of these 500 patients needed re-operation for another obstruction (but if they did, they did better with surgery than with "conservative" management).

Also fascinating: years later, the number reporting "no more pain than normal," (which the authors point out is likely to be more pain than the "background" population) was 60%; of the 40% who reported continuing pain, about half rated it as "moderate."

So, what does this say to me? Let me see if I can try to make some sense of this:
  • The common wisdom is that more surgery causes more adhesions (and in fact, many of the small bowel obstruction patients had had multiple surgeries). Does this mean that adhesiolysis is worth doing, to prevent obstruction down the road? or will you increase your risks of this type of obstruction?
  • Type of adhesions makes a difference in the outcome. Those of us with endo are more likely to have the matted type; if your surgery was due to fibroids, or prolapse, your adhesions are more likely to be "band" type -- and more amenable to laparoscopic treatment.
  • Yes, small bowel obstruction is rare. But those of us who know that they have adhesions should still know what the symptoms are -- and get ourselves to the doctors early. Do NOT be put off by a doctor's statement that "your surgery was too long ago." Adhesions can cause problems at least seven years out (although I'd suspect that those of us who have adhesions know we do, regardless of what our doctors try to tell us).
  • 79 of the 208 patients who returned their questionnaire still felt that they had more pain than the normal population. Of these, about half rated it as "moderate" (which the authors admit may be due to under-reporting) and the other half rated it as "fairly strong." This still represents about 15% of this admittedly small population.
  • Repeat small bowel obstruction occurred as late as 20 years out, and the risk was definitely higher, with matted adhesions again being significantly more likely to cause problems. So again, any symptoms should NOT be ignored!

In a way, this gives me hope -- sure, there were people who had these problems, but they were only 15% of the people who had had problems. I don't know how many GYN procedures are done in Norway per year, but these obstructions are obviously a rare drop in that pond. OTOH, having endo, I know, is going to increase my risks for the matted type of adhesions (since that's what they found each time I had surgery) from the endo itself, not just the surgery and healing process.

Also, endo is a disease of inflammation -- it seems increasingly evident that endo thrives on inflammatory substances in pelvic fluid. So when those of us with endo do need surgery, it would be worth having a discussion with our surgeons about using the least "reactive" materials possible in sutures, etc. Some suture materials are known to be an irritant, causing localized inflammation; this is going to only increase the risks of scarring (IMHO).

Well, sorry about the megillah , but I thought my friends here would find this of interest! and forgive any incoherence; I was typing this as I watched the US Olympic womens' gymnastic team finals-- and was distracted

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Unread 08-18-2004, 06:49 AM
Adhesion study

Thanks for posting that! I was very interested to read about the study and the outcome. Kind of scary that you can have problems so many years down the line.

I was just having a discussion with an Oncologist last week about endo and how it changes a woman's body--our tissue shrinks in on itself (this is what the doc told me) and it makes it harder to operate on, we bleed easier and our adhesions are much denser and harder to "get rid of". He said docs see that you have endo and they don't want to operate because they know it will be more difficult. It made a lot of sense and now I realize who noone wants to operate on me.
Unread 08-18-2004, 07:47 AM
Fantastic Post

Audrey, what a great post for those of us suffering from adhesions? How does one get a copy of the Annals of Surgery? I see you work in the Health Care industry, as do I (albeit, Human Resources) so I imagine you might have picked up a copy through your work? One thing I've wondered that I'd like to hear your opinion about - - how does one know what kind of adhesions they have? Of course our operative reports state that, but, for instance, my report from my first lysis of adhesions (which, incidentally turned into a laparatomy, ugh!) 6 months post TAH states that my adhesions were "densely adhered". So, is that the band type or is that the matted type? Don't know. Also, I often hear adhesions referred to as "massive", or "dense" , or even "extensive" - - what's the difference? Anyway, I commend you and your research. You sound a lot like me in that you refuse to just "accept" your situation. Life goes on and we have to live the best life we can. The more educated we become about our issues, the better decisions we can make. Incidentally, how many surgeries have you had and do you believe the repeated surgeries have contributed to the extensiveness of your adhesions? Thanks again for your post and feel free to PM me.
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Unread 08-18-2004, 09:16 AM
Adhesion study


I subscribe to Medscape's update service; although I do cardiology (ultrasound), I have subscriptions to OB-GYN topics and general, as well. This one turned up on Medscape, since it appeared just this month.

"Dense" adhesions would likely qualify to be "matted" -- remember that the researchers were Norwegian, and the terminology translates a bit differently! The reason endo is so problematic is that it creates its own blood supply (and nerve supply as well -- that's some new research too). I've had two diagnostic laparoscopies, first one thirty years ago, a laparascopic removal of ectopic pregnancy in the cul-de-sac, and then the hyst. The thinking is that the CO2 gas used in laparascopies can also cause irritation, leading to more inflammation. Since endo is caused, in part, by the conditions within the pelvis being "right" to allow it to grow (i.e. more inflammatory substances called cytokines), even my laps may have contributed! .

I haven't "accepted" anything -- my doctor and I know that I have these adhesions, and that they are pulling my intestines out of place. But the surgery, to my mind, would potentially create more trouble than my problems do now -- I can wait!!

I hope this helps,

Unread 08-18-2004, 10:43 AM

Interesting - - sounds like your doctor and my doctor are of the same school of thought. I've heard so many women talk about how their doctors say adhesions don't hurt, etc. My doctor is very aware of my situation and is working with me to the best of her ability but even she advises against more surgeries until and unless it's absolutely necessary. She says she has people who come back every one to two years wanting surgery just for pain control! That's illogical to me when you think about the fact that the pain control is only for a short period of time and then likely to be two-fold down the road. Anyway, I'm sure the surgeries might be more successful on women who have more filmy adhesions. I think my biggest obstacle is not thinking about what the adhesions are doing to my insides. Human nature is to associate the level of pain we have to the severity of the affliction. From what I understand that's not necessarily the case with adhesions.
Unread 08-19-2004, 02:56 AM
Adhesion study

Interesting post & insight ((Audrey) I can definately relate as my problems started with my Hyst then were only componded by 2 additional surgery one which was done emergency for a bowel obstructions mine being one in the large & one in the small bowel I have been dx'd as having dense adhesions & continue to suffer pain & problems over 4.5 yrs out *sigh* From all I have read over the yrs on Adhesions, I would personally never under go an elective Adhesion removal because of the proven Drs agree...

My heart goes out to all who suffer these dreadful creatures & the pain they cause but reports & studies like these give me hope that more & more is being done to learn about their prevention !!

Thanks again my friend

Unread 08-19-2004, 07:46 AM
How far out?

So, Sheri . . . how does your situation compare to the study that Audrey shared with us? How far out from your hyst was your bowel obstruction? Also, did you know you had adhesions prior to this event or was it only afterwards?
Unread 08-19-2004, 09:04 AM
Adhesion study

Hi ((Anita)),
Good questions! Lets see my Hyst was the beginning of all my Adhesion problems it was a TAH done on 01/04/00 < so I'm over 4.5 yrs Post-Op> on 03/31/00 I underwent an RSO to dx a large mass atop my right Ovary that was enlarged & covered in blood-filled cysts. The mass turned out to be Adhesions that were so dense they formed a mass adhering my Ovary to my Vaginal cuff, the Ovary was removed as well because of the extent of pain & problems it caused. On 5/09/00 I was admitted thru the ER for emergency surgery to remove the 2 obstructions that completely blocked things off..I spent almost 2 weeks in there because my system shut down, I developed Pnemmonnia & thrush from all the antibiotics I was NPO the entire time & prepped for more surgery twice...luckily my Surgeon stopped them each time
I have experienced more Partial Intermittant Obstructions than I can remember...I have been in Pain Mgmt since July 2000 to help keep the non-stop pain at I was 16 weeks out with the Obstructions & 4 plus yrs later am still being treated for pain levels that continue to worsen...

Hmm so how close to the study did I come I'd like to hear from others too...

Unread 08-19-2004, 11:05 AM

Yikes! You went through it, didn't you? Like you, I am not a candidate for more surgery. I'm assuming they took your other ovary in that surgery as well? I just wish I didn't have my gall bladder, ha! I hate the idea of them having to go back in after anything else!!
Unread 08-20-2004, 07:35 PM
Adhesion study

Can any of you share your symptoms? I have been struggling with a pulling/tugging/stinging pain in my lower right abdominal area on and off since early March. I also have some sharp pains throughout my abdomen and where my ovaries used to be. I am struggling with whether these pains are from healing, overdoing it, left over endometriosis, or adhesions. How do you find out you have them, or left over endo? I am 7 months post-op and don't know if this is all normal or something I should be concerned about. I would appreciate any feedback.

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