Guest Author - Heather C. Guidone

Adhesions. Sometimes you don´t even know you have them. Other times they make you feel like your entire pelvis is Crazy Glued together, and to make even the slightest movement would be crippling. But what are they, really? And what can be done about them??

As the name would suggest, adhesions are ´sticky surfaces that bind together.´ Our pelvic organs and abdominal cavity are protected by a thin membrane called the peritoneum. When the peritoneum suffers damage, such as following surgery, infection or through a chronic disease process like Endometriosis, Fibrin (a sticky protein-like substance) is released and accumulated on the injured surface. The injured, Fibrin-covered surface then sticks to other areas of the pelvic cavity. The subsequent bands that form between these surfaces are called adhesions. These adhesions can bind, obstruct, twist and otherwise impair organs and delicate tissues. Endometriotic implants can also become trapped inside the adhesions, making it difficult to detect and remove such lesions.

In the case of surgical adhesions, the process begins immediately following the operation.(1) With progressive irritation such as in Endometriosis, the process is ongoing and can result in extensive, fibrous bands throughout the pelvis, literally trapping organs in place or adhering them to pelvic sidewalls.

Approximately 30% of adhesion cases are symptomatic,(2) resulting in chronic pelvic pain, bowel obstructions, painful intercourse and even infertility. Adhesive disease accounts for 49-74% of small bowel obstructions; 15-20% of infertility cases; and 20-50% of chronic pelvic pain cases.(3) Adhesions can also cause future surgical procedures to be more complicated.

Symptoms of adhesions range from acute, crampy pain to chronic pelvic discomfort. In cases where the intestines are involved, nausea, bloating, abdominal distention and vomiting can occur. Patients experiencing a sudden inability to pass fecal matter or gas and are very ill with nausea or vomiting should see their physician as soon as possible to rule out a bowel obstruction.(4) Abdominal and pelvic adhesions rarely show up on x-rays or diagnostic tests, and exploratory surgery may be required to rule them out.

Treatments for adhesions generally include:

Taking a "wait and see" approach to determine if symptoms lessen over time;
Adopting any number of alternative therapies, such as deep tissue massage, acupuncture, biofeedback and hypnosis;
Use of medications like analgesic pain relievers or anti-inflammatories; and
Surgery, including hysterectomy in some severe cases. Most adhesions can be removed laparoscopically through a process called adhesiolysis, which simply means cutting through the fibrous bands and freeing up the pelvic organs. With surgery, of course, there is always the risk that more adhesions will begin forming immediately at the end of the operation.

While there are no absolute ways to prevent adhesions from forming, experts suggest that utilizing meticulous surgical techniques can reduce tissue trauma and hence, reduce the number of adhesions that subsequently form. Laparoscopy is the recommended surgical modality, as unlike more invasive abdominal procedures, it seems to cause very little adhesion formation.(5) The next step commonly taken to reduce adhesion formation is the use of barrier products.
Barrier products are substances that are placed intrapelvically at the end of the surgery. Before the development of today´s progressive substances, physicians tried various materials and methods to prevent adhesions from occurring, including: animal membranes, gold foil, mineral oil, silk, rubber, teflon and even amniotic membranes. One archaic method of prevention even involved having patients ingest iron filings and then moving a magnet around on the abdomen to keep the bowel from sticking!(6)

Today´s barriers are lightweight solid, semisolid or liquid products that protect the injured areas. Many barriers dissolve in the body over time. No product prevents adhesions in every patient, and product availability varies from country to country. Products currently available and those under development include:

Interceed™ (Johnson & Johnson/Ethicon Corporation) - oxidized regenerated cellulose; absorbed within 4 weeks. Available in the US.

Seprafilm™ (Genzyme Corporation) - sodium hyaluronate and carboxymethylcellulose; becomes a hydrated gel 24 to 48 hours after placement. Components are excreted in approximately 28 days. Available in the US.

Hyskon™ (Medisan Pharmaceuticals Corporation) - water soluble glucose polymer left in the abdomen as a "puddle;" prevents sticking by causing tissue to literally slide around. Absorbed in 5 to 7 days. Available in the US.

Preclude™ (WL Gore Corporation) - made from Gore-Tex™, a version of teflon. Preclude™ does not dissolve and may require subsequent surgery to remove it.

Flo-Gel™ (Alliance Pharmaceutical Corporation) - sterile gel mainly consisting of Poloxamer 407.

Adcon P™ (Gliatech) - proprietary gel absorbed by the body within approximately 4 weeks.

Repel™ and Resolve™ (Life Medical Sciences Company) - bioresorbable polymer films and viscous gels.

Intergel™ (LifeCore Biomedical Corporation) - based on a proprietary process combining iron with hyaluronan to form ferric hyaluronan.

Adhesion barriers are a big business. The U.S. market for adhesion prevention materials such as the above is estimated at a staggering $500-600 million. No surprise, general surgery and Gynecology comprise the largest segments of this market.(7)

One little-used method of prevention involves the instillment of large volumes of saline solution directly into the pelvic area, on the premise that this therapy will reduce adhesion formation. To date, this practice has not been supported by empirical data.

One groundbreaking approach currently under research involves the application of a special antibody solution at the end of surgery. According to research being conducted at the University of North Carolina at Chapel Hill, the solution neutralizes alpha-v/beta-3 integrins, which are proteins involved in the wound healing process. The antibody LM609, developed by Dr. David Cheresh of The Scripps Institute, was tested on experimental animal models in a UNC-CH study led by Dr. Bruce Lessey. Results showed "fewer, less extensive and less dense post-surgical adhesions as compared to animals treated with a control antibody." Dr. Lessey noted, "we propose to use LM609...in a randomized, prospective trial of adhesion prevention in women undergoing laparoscopy for Endometriosis and/or pelvic adhesive disease." If shown to be efficacious, a larger multi-center approach will be organized.(8)

References:
1) Marvin L. Corman, M.D., University of California
2) "Adhesion Barriers Present an Emerging Market Opportunity," by Laura Wilkes
3) Genzyme Biosurgery, 1 Kendall Square, Cambridge, MA 02139
4) & 5) "Pelvic Adhesive Disease: Hidden Scars Take Their Toll," by Gerard DiLeo, M.D., F.A.C.O.G.
6) "A Patient´s Guide to Adhesions & Related Pain," by David Wiseman, M.D., and the International Adhesions Society
7) "The Adhesion Prevention Opportunity," Medical Data International, Inc. 1999
8) "Antibody Solution may Prevent Adhesions after Surgery," Leslie Lang, UNC-CH School of Medicine, EPT. 22, 1999- #560


Copyright ©2001 by Heather C. Guidone. All rights reserved. Do not reproduce without express permission.