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Adhesive Small Bowel Obstruction: Epidemiology, Biology and Prevention

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Adhesive Small Bowel Obstruction: Epidemiology, Biology and Prevention Surgical Biology for the Clinician Biologie chirurgicale pour le clinicien Adhesive small bowel obstruction: epidemiology, biology and prevention Jo-Anne P. Attard, MD; Anthony R. MacLean, MD Intraabdominal adhesions develop after abdominal surgery as part of the normal healing processes that occur after damage to the peritoneum. Over the last 2 decades, much research has gone into under- standing the biochemical and cellular processes that lead to adhesion formation. The early balance be- tween fibrin deposition and degradation seems to be the critical factor in adhesion formation. Although adhesions do have some beneficial effects, they also cause significant morbidity, including adhesive small bowel obstruction, infertility and increased difficulty with reoperative surgery. Several strategies have been employed over the years to prevent adhesion formation while not interfering with wound healing. This article summarizes much of our current understanding of adhesion formation and strategies that have been employed to prevent them. Les adhérences intra-abdominales font leur apparition après une chirurgie à l’abdomen dans le cours des mécanismes de guérison normaux suivant un dommage au péritoine. Au cours des deux dernières dé- cennies, on a effectué beaucoup de recherches afin de comprendre les phénomènes biochimiques et cel- lulaires à l’origine de la formation d’adhérences. L’équilibre précoce entre le dépôt de fibrine et sa dégradation semble jouer un rôle critique dans la formation d’adhérences. Même si les adhérences ont certains effets bénéfiques, elles causent aussi une morbidité importante, y compris l’occlusion de l’in- testin grêle, l’infécondité et les difficultés accrues dans le cas d’interventions chirurgicales ultérieures. On a suivi au fil des ans plusieurs stratégies pour prévenir la formation d’adhérences sans nuire à la guérison de la plaie. Cet article résume une grande partie des connaissances actuelles au sujet de la for- mation d’adhérences, ainsi que les stratégies que l’on a suivies pour les prévenir. ostoperative adhesions form af- the current available methods of It is estimated that 93% to 100% Pter trauma to the peritoneal cav- prevention. of patients who undergo transperi- ity and are a result of the biochemi- toneal surgery will develop postoper- cal and cellular response that occurs Background ative adhesions.5 The extent of adhe- in an attempt to repair the peri- sion formation varies from one toneum. Although there are benefi- Peritoneal adhesions can be defined patient to another and is most depen- cial effects to adhesions, they are the as abnormal fibrous bands between dent on the type and magnitude of leading cause of small intestinal ob- organs or tissues or both in the ab- surgery performed, as well as whether struction after abdominal surgery dominal cavity that are normally sep- any postoperative complications de- and can be the source of significant arated.1–3 Adhesions may be acquired velop.6 Another surgical factor that morbidity, in some cases leading to or congenital; however, most are ac- has been shown to contribute to ad- mortality. This review aims to pro- quired as a result of peritoneal injury, hesion formation is intraperitoneal vide general surgeons with a broad the most common cause of which is foreign bodies, including mesh, glove overview of what is currently known abdomino-pelvic surgery.4 Less com- powder, suture material and spilled about adhesions, the cellular and monly, adhesions may form as the gallstones.7 Fortunately, most pa- molecular events that are involved result of inflammatory conditions, in- tients with adhesions do not experi- in their formation, the latest re- traperitoneal infection or abdominal ence any overt clinical symptoms. For search developments in this area and trauma.4 others, adhesions may lead to any Department of Surgery, University of Calgary, Calgary, Alta. Accepted for publication June 17, 2005 Correspondence to: Dr. Anthony R. MacLean, Department of Surgery, Foothills Medical Centre, 1403–29th St. N.W., Calgary AB T2N 2T9; [email protected] © 2007 Canadian Medical Association Can J Surg, Vol. 50, No. 4, August 2007 291 Attard and MacLean one of a host of problems and can be hesions, but it is not the only one, over a 10-year period were found to the cause of significant morbidity and and the adverse effects of adhesions be directly related to adhesions, and mortality.8 are not limited to the gut.4 For ex- 3.8% of these admissions required ample, in the gynecological litera- operative management.8 In 1994, the Adhesions and small bowel ture, it has been found that adhe- estimated financial impact for direct obstruction (SBO) sions are a leading cause of secondary patient care owing to adhesion- infertility in women (responsible for related disorders in the United States Intraabdominal adhesions are the 15%–20% of cases)18 and, although was US$1.3 billion.22 In Sweden, it is most common cause of SBO in in- controversial, there is evidence to estimated that the health care burden dustrialized countries, accounting for suggest that they may be a cause of owing to adhesive disease reaches approximately 65% to 75% of cases.5 longer-term abdominal and pelvic $13 million annually.23 As the cost of There is a wide range of values re- pain.19 For patients with chronic re- health care continues to escalate and ported in the literature for the risk of nal failure, adhesions may make peri- the number of patients requiring sur- developing adhesive SBO after toneal dialysis impossible, and their gical care increases with the aging transperitoneal surgery, depending presence may preclude the use of in- population, the financial burden of on the series of patients, how they traperitoneal chemotherapy in those adhesions will continue to expand. were evaluated and the types of sur- patients who are candidates.4,6 For Given the far-reaching consequences gical procedures performed. In gen- general surgeons, the presence of ad- of postoperative adhesions, it is im- eral, procedures in the lower ab- hesions often makes reoperative portant that they not be viewed as an domen, pelvis or both and those surgery difficult and may increase the inevitable consequence of surgery for resulting in damage to a large peri- complication rate of the intended which little can be done.24 This toneal surface area tend to put pa- surgical procedure.20 In the current knowledge should provide the impe- tients at higher risk for subsequent era of advanced laparoscopic surgery, tus for further research in this area, adhesive obstruction.4 It is estimated adhesions have taken on an even to improve our understanding of the that the risk of SBO is 1% to 10% af- greater significance, frequently mak- pathophysiology of adhesions and to ter appendectomy,9,10 6.4% after open ing laparoscopic approaches more enable the development of methods cholecystectomy,9 10% to 25% after difficult and, in some cases, entirely to alter the biological events that are intestinal surgery11,12 and 17% to 25% impossible.4 Even with open reopera- necessary for their formation. after restorative proctocolectomy tive surgery, extensive adhesiolysis is (IPAA).13–16 often necessary to ensure adequate Understanding the The relation between postoperative exposure, not uncommonly resulting pathophysiology of adhesion adhesions and intestinal obstruction is in prolonged operating times, in- formation not a new concept. In 1872, Thomas creased blood loss and other compli- Bryant described a fatal case of intesti- cations.4,20,21 Inadvertent enterotomy Holmdahl and Ivarsson25 have sug- nal obstruction caused by intra- is probably the best recognized com- gested that the inability to discover abdominal adhesions that developed plication of adhesiolysis, with an inci- effective ways to reduce or abolish after removal of an ovarian tumour.17 dence of approximately 20% in reop- adhesion formation over the years Since Bryant’s report, a significant erative surgery.20 These cases result in has been due to a lack of insight into amount of time and money has been a poorer outcome for the patient, the basic tenets of peritoneal tissue invested into research on intraabdom- with prolonged hospitalization and a repair. Only in the last 15 to 20 years inal adhesions, with a primary focus higher incidence of intensive care have researchers started to unravel on the development of methods to unit admissions.20 the complexities of this process, prevent their formation. Despite sub- which involves several different cell stantial work in this area, little Socioeconomic burden of types, cytokines, coagulation factors progress has been made; to this day, adhesive SBO and proteases, all acting together to no clinical standard exists for any pre- restore tissue integrity.25 Although ventive measure, either surgical or The consequences of postoperative our understanding is far from com- pharmacological, to control the for- adhesion formation have become a plete, studies of adhesion formation mation of postoperative adhesions.4 significant burden socioeconomi- thus far have determined what is be- cally, and the treatment of adhesion- lieved to be the central pathophysio- Other complications of related disease uses a significant por- logical mechanism leading to ad- adhesions tion of health care resources and hesion development.24,26 This is dollars.8 From a large-scale epidemi- discussed below. If effective preven- SBO is probably the most severe ological study in Scotland, for exam- tative and treatment strategies are to consequence of intraabdominal ad- ple, 5.7% of hospital readmissions be developed, a more comprehensive 292 J can chir, Vol. 50, No 4, août 2007 Adhesive small bowel obstruction understanding of this process at both nism, however, the response of the thrombin, which is necessary for the the cellular and the molecular level, peritoneum to surgical trauma is the conversion of fibrinogen to fibrin.27 as well as the identification of inflam- same25 (Fig.
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