David Wiseman, Ph.D., M.R.Pharm.S. Presents "Prevention of Post-Surgical Adhesions"

Wednesday, April 1, 1998 7:00pm

In Attendance:

Drwiseman	Agustin	Roberta
Mary_s	Vgates	Babydoc
Barbaran	Sues	Cardinal

Drwiseman: "Well I suppose I should begin by welcoming everyone to our first chat on ADHESIONS."

Roberta: "Yes David. Please tell us about your work and interest in the study of adhesions."

Drwiseman: "I've been working in the field of post-surgical adhesions now for over 10 years"

Drwiseman: "Previously I worked for J&J were I worked on INTERCEED, which was released in 1989"

Drwiseman: "I now have a development company which consults and collaborates with a number of medical device and pharma companies to produce products for adhesions."

Vgates: "INTERCEED is?"

Drwiseman: "Perhaps my biggest pleasure in all of this is trying to help patients (usually women) who suffer form the effects of adhesions"

Drwiseman: "INTERCEED is a product used by GYNs to prevent adhesions. It is a barrier which is placed at the site of surgery"

Drwiseman: "One of the reasons I'm here today is to kick off what I hope will be a dialog with sufferers of adhesions."

Barbaran: "How has INTERCEED changed surgery outcomes in regards to adhesions?"

Roberta: "Dr Wiseman is interested in building an online registry for sufferers of adhesions that would allow them to emerge as a group and have a voice."

Barbaran: "Is there hope for sufferers of adhesions post surgery David?"

Vgates: "That would be really great, this is such an obscure disease!"

Agustin: "Dr. Wiseman, in how many days is INTERCEED absorbed?"

Barbaran: "Dr Agustin do you have many patients that suffer from adhesions?"

Vgates: "Can we describe INTERCEED a little more? Is it actually a barrier? How does it prevent adhesions?"

Agustin: "Not too many, but it is an interesting subject. I read one of his clinical studies."

Roberta: "Within 30 days of surgery Agustin according to a demonstration I saw at ASRM. This is the key time when Adhesions can begin to grow."

Vgates: "My physicians used some sort of material in 1992, was that probably INTERCEED?"

Drwiseman: "INTERCEED increases the adhesion free outcome at a single surgical site from 25% to 50%. This seems to be consistent over several studies"

Drwiseman: "The label says it is completely gone after 28 days. There are cases where it stays around longer particularly if there has been blood in the field"

Vgates: "What about cases where abnormal scar tissue development seems to be the issue? I have microabcess pyoderma."

Drwiseman: "If it was 1992 it probably was INTERCEED: by the way I'm not a paid advertiser for INTERCEED."

Roberta: "INTERCEED* (TC7) Absorbable Adhesion Barrier is the first surgical adjuvant specifically indicated for the reduction of adhesions in gynecologic pelvic surgery over raw surfaces. INTERCEED Barrier breaks down to form a protective coating during the critical healing time when adhesions may occur. It is absorbed from the site of implantation within four weeks."

Mary_s: "What is it made of/from?"

Drwiseman: "Well done Roberta you have read the package insert (impressed with speed)"

Drwiseman: "Valerie: explain your question a little more"

Agustin: "Dr. Wiseman. What is the difference between INTERCEED and INTERGEL"

Drwiseman: "INTERCEED is made of oxidized regenerated cellulose: a type of rayon that dissolves in the body"

Drwiseman: "INTERCEED is a fabric made of ORC you must put is directly over the site of surgery"

Drwiseman: "INTERGEL is a viscous liquid (I also worked on that). They are applying about 300ml into the pelvis to coat vital organs"

Vgates: "Well, apparently my prolific generation of adhesions is caused by abnormal scar tissue development. Biopsy of the vaginal cuff showed microabcess pyoderma, a rare scar tissue problem."

Drwiseman: "The idea behind INTERGEL is that you don't need to know where the adhesions will form"

Babydoc: "Is Intergel available yet? Not familiar with it?"

Drwiseman: "INTERGEL is not available. They have released some preliminary data on it and more is expected in June."

Barbaran: "Is INTERGEL what it 's name sounds like, a gel?"

Drwiseman: "Lifecore will submit their PMA in June -Sept and if all goes well it will be approved in about 2 years."

Babydoc: "Do we know if keloid formers have increase in intra-abd. adhesions?"

Drwiseman: "INTERGEL is a gel: rather like KY jelly. For more info you can track press releases at the lifecore site: http://www.lifecore.com."

Drwiseman: "There has not been an association shown between keloid formers and adhesions."

Mary_s: "Would this be used during any type of surgery - a c-section for example?"

Drwiseman: "I'm trying to answer Valerie’s q about excessive scar: Val - if we don't get to it let’s do it off line afterwards. You know where to get me"

Vgates: "Do you think then that microabcess pyoderma is not the cause of my adhesions?"

Roberta: "How does a woman going for her first surgery know if she's at risk for adhesions?"

Drwiseman: "Mary: INTERGEL could use used after any kind of surgery (I don't know what FDA will allow) however the issue of adhesions and c sections is a controversial one. I would be interested in some clinical opinions here also."

Babydoc: "Good question--any genetic predisposition?"

Vgates: "Good question Babydoc! My Mom and Sister have adhesions!!"

Drwiseman: "To answer Roberta and Barb: it seems that almost everyone will form adhesions - according to some postmortem studies of road traffic accident cases. The question is which ones will cause the problems."

Babydoc: "Have seen less adhesions after C/S when peritoneum is left open and one layer uterine closure."

Drwiseman: "In GYN surgery for example (first time) 75% of ovaries operated on will form adhesions"

Barbaran: "So, I could have them from a hysterectomy of 12 years ago and Not Know It"

Drwiseman: "Thanks Babydoc for the info on C section. I was saying that in C section the problem of adhesions is controversial . It seems that although adhesions form, they do not become problematic until several c/s have been done - about 3-4."

Vgates: "Why do they become so diffuse in some patients? I have adhesions from the diaphragm down."

Drwiseman: "Then the perceived need for a barrier is greater. With 1-2 time c/s the perceived need is less."

Babydoc: "I agree--I think Ethel Kennedy had 10 C/S."

Drwiseman: "Yes you almost certainly will have had from a hysterectomy 12 years ago but don't know it. There are many people walking around quite happily with adhesions and don't know it. Sometimes it takes years for a problem to manifest itself."

Drwiseman: "Ethel Kennedy would have been a good candidate for an adhesion barrier"

Mary_s: "Once the adhesions have formed, is surgery the only option to remove them?"

Mary_s: "IF problematic, that is."

Drwiseman: "This is from a lady talking about her grandmother in law and you can see how long it can take for the problems of adhesions to manifest themselves. ‘I have some questions regarding adhesions. Let me give you some background. My husbands grandmother is 90 yrs old and back in the 1950's she had gall bladder surgery. Then about 10 years or so ago she had to have additional surgery for the adhesions to relieve the pain she was having because of the adhesions. She is now in a tremendous amount of pain again. We would like to go with the least evasive procedure that can be done considering she is 90 years old.

Babydoc: "Does electrocautery increase adhesions?"

Vgates: "Mine started very shortly after my septic pregnancy! Within 2-3 years!"

Babydoc: "infection will increase risk."

Barbaran: "Can anyone Escape getting them?"

Drwiseman: "Electrocautery: does it increase adhesions compared to what? Cautery will cause thermal damage quite some distance from the site of use. There have been studies comparing the damage caused by e/c vs say a harmonic scalpel. My suggestion is NOT to use e/c for hemostasis but to use thrombin or chemical means"

Vgates: "What about laser?"

Drwiseman: "Infection will undoubtedly increase risk, If you have a disease that makes you prone to infection, then I would imagine that your chance of adhesions will increase."

Drwiseman: "Laser I think can cause a wider range of damage sometimes than e/c. I must caution you in making general conclusions about laser vs e/c vs anything else. It depends to a large degree on who is using the instrument and how they have set it up. You can turn up the "juice" (power settings)on any instrument and misuse it."

Vgates: "And amount of adhesions will increase!"

Drwiseman: "Having said that there are some studies which compare different kinds of lasers and electrocautery for the damage they cause under controlled conditions"

Vgates: "So why do so many surgeons use laparoscopy and laser lysis for treatment?"

Drwiseman: "I think Valerie, that it is fair to say that the more damage the more chance of adhesions."

Mary_s: "Sounds like an unending cycle - very frustrating."

Vgates: "Agreed, after all my laparscopies and laparotomies the damage must be great!"

Roberta: "Can anything be done once the cycle has been set up to break it?"

Drwiseman: "Again I caution you in making conclusions. I have heard it said (and written in studies) that e/c is just as effective and sometimes more controllable than laser. Unfortunately (and I have heard this form surgeons themselves) that LASER is a very sexy word and hospital administrators want to say they have one because it sound like they are on the cutting (joke)edge."

Babydoc: "Older studies tried anti-inflammatory drugs and steroids without much success."

Drwiseman: "Now we're coming to the real reason why we're here"

Drwiseman: "I agree with babydoc about the use of drugs - they haven’t been shown to be too successful."

Agustin: "Agustin, Teodoro and Marta Mendez agree with you, Dr. Wiseman"

Vgates: "There is nothing that can be done, is there Dr. Wiseman?"

Drwiseman: "How to break the cycle. I know it doesn’t help Valerie, but patients need to be given adhesion prophylaxis early on. Even if the risk of adhesions is small. That will help prevent these BIG problems down the line."

Drwiseman: "Obviously Valerie in your case I can't comment specifically. But there are some doctors who will operate on patients such as you and provide an adhesion product such as INTERCEED or Seprafilm."

Vgates: "Yeah, and we need to get that information out to prevent other persons like me!! My physician's idea of treatment is narcotics and reduction in physical activity."

Mary_s: "So then your quality of life suffers Valerie!"

Drwiseman: "However the dangers of operating on a patient will multiple diffuse adhesions are great and in many cases only done if there is acute obstruction."

Vgates: "No Mary! I won't let it!!"

Drwiseman: "But as Valerie says this is little comfort to a patient like Valerie who may live (?) in absolute misery and desperation."

Mary_s: "Good for you ;-)"

Drwiseman: "I think you have hit on one of the key issues here and that is the management of the patient as a whole."

Sues: "I have heard that Interceed is not used anymore in well known Endometriosis clinics. Can you explain why?"

Vgates: "I'm not miserable or desperate Dr. Wiseman, resigned would be a good word for it!! But I would sure like to do anything to help prevent others from following my course!!"

Drwiseman: "Many surgeons will only look at the pelvis as an isolated set of tissues. I think there are many things we can do to support patients such as Valerie."

Drwiseman: "One thing that I'm looking to do is to set up a patient support group. The key element here is SUPPORT because for many people adhesions have led them into isolation."

Babydoc: "Chronic pain centers may be a help--often treat "whole" person."

Drwiseman: "A second thing is that I have HEARD that some alternative therapies (chiropractic, homeopathy) have worked on some patients. I would be interested in investigating them more thoroughly"

Drwiseman: "There are now, as babydoc says, a few Chronic pain centers that treat patients such as these, but information has not been codified on how exactly to treat these patients as a whole."

Vgates: "Yeah, we've talked about the things I'm trying Dr. Wiseman! Babydoc, where would one get information on these pain centers?"

Babydoc: "Usually at teaching or academic centers--University centered."

Drwiseman: "I have hear recently about a center in Birmingham AL: it is run y a Dr. Paul Perry(?) who heads up the International Pelvic Pain society: http://www.pelvicpain.org/. I have only just heard about it and I have an appointment to speak with Dr. Perry net week"

Vgates: "We have KU School of Medicine in Wichita, should I try there?"

Agustin: "Dr. Mendez asks if you have tried osteopathic/homeopathic centers?"

Drwiseman: "Certainly. Let me know if you have any success"

Babydoc: "Have seen several patients with fibromyalgia helped."

Drwiseman: "Yes I would like to know more about osteopathy/homeopathy"

Vgates: "I've done my own homeopathic treatment, finances are a concern!"

Vgates: "I can tell you that aquatherapy does help some, spas, massaging shower heads, those type of things. There are several herbs that help some too!"

Drwiseman: "Someone asked a q about why INTERCEED is not used much in some places: it is a complex answer. Several years ago the product was given a bad and unjustified wrap from which it did not recover. It is somewhat difficult to use in some cases, especially where bleeding cannot be controlled completely. IN endo CASES, especially where extensive excisions are done, bleeding cannot always be controlled to the degree that is required for INTERCEED to have an effect."

Vgates: "I've been doing some research on Bloodless Surgery, deep pelvic massage as a means of loosening and softening adhesions!"

Agustin: "Dr. Mendez T.: Acupuncture alternatives are good to!"

Drwiseman: "Which herbs? I also read a paper a while back on spa therapy for people with pain. It seemed to work"

Drwiseman: "Dr. Mendez: you have any details of the acupuncture therapies (perhaps you can email me afterwards - synechion@aol.com)"

Vgates: "I use Buckthorn Bark tea for bowel strictures, Mulilen, Fevervew and Valerian teas are also good for sleep and pain relief without narcotic side effects!!"

Vgates: "Yeah, Dr. Wiseman, I'd like that information about acupuncture therapies also!!"

Mary_s: "Dr. W, can pregnancy cause existing pelvic adhesions to loosen?"

Drwiseman: " I missed your comment about deep massage: again another treatment worth trying. I must of course caution you about all of this. If it works for you GREAT. But for the medical community to take it up requires some further degree of clinical evidence from clinical studies. That is something a patient support group may sponsor."

Babydoc: "Pregnancy will often stretch adhesions--may increase pain."

Roberta: "OBGYN.net is doing coverage of the Chronic Pain Conference in Denver next weekend including interviews with Dr. Perry."

Roberta: "It will be in next Wednesday's UPDATE."

Cardinal: "Do additional surgeries cause more adhesions after having them removed a couple of times?"

Vgates: "Someone needs to take it up Dr. Wiseman! Sometimes I feel like I'm wandering around looking for something that does not exist!! I know I'm not the only one who feels that way!!"

Roberta: "Valerie. Barbara will write to you to get you involved in this initiative for Adhesions at OBGYN.net if you are interested."

Vgates: "Thanks Roberta!! I'm very interested!!"

Barbaran: "Valerie my email address is barbara@obgyn.net"

Agustin: "Dr. Wiseman, this chat has been excellent."

Drwiseman: "Sure - you mean next Wednesday? Let’s talk"

Barbaran: "I have learned a lot David. Thank you."

Drwiseman: "Dr. Olmos thank you for your kind comments"

Mary_s: "Dr. Wiseman thank you for hosting tonight. I have a friend who can use the info I have learned from you!"

Drwiseman:"Well it looks as though we need to wrap up. Any last comments from everyone - I'm particularly interested in Valerie’s comments"

Agustin: "Dr. MendezT:Dr. Wiseman, the chat has been excellent, I have your email"

Roberta: "Yes Dr, Wiseman. We are pulling a log of this session and will have it edited for reprint on OBGYN.net THANK YOU!!! EXCELLENT!"

Barbaran: "Dr. Wiseman this has been wonderful for everyone"

Drwiseman: "Thanks Barb"