"Prevention of Post-Surgical Adhesions" hosted by David Wiseman, Ph.D.

Chat Log - 060298

<Drwiseman> Do you have any questions about adhesions?

<Herto> Yes, how can you avoid them in surgery?

<Drwiseman> That's the $64,000 question. The first answer, and I do not mean to be funny here, is surgery absolutely necessary? Sometimes it isn't and one should be aware of that. Second of all the surgeon must practice delicate technique. Thirdly, adhesion barriers should be used, although they are not 100% effective.

<Drwiseman> This of course is a simplistic answer. I would say though the two main points are the surgeons' technique and the use of barriers. The surgeon must of course be familiar with barriers and their proper use.

<Drwiseman> The two barriers available in the US both have their problems and the should must know how to use each appropriately.

<Drwiseman> Do you have any specific surgery lined up, or have you had surgery recently?

<Herto> What type of barriers?

<mary_s> What are the main problems with these?

<Drwiseman> The two barriers available in the US are: INTERCEED, made by Johnson & Johnson: the problem here is that the surgeon must be sure to stop even the tiniest amount of bleeding.

<Drwiseman> The other product, Seprafilm, made by Genzyme, is somewhat brittle to use and must be handled delicately. I understand that Genzyme is developing a more supple form of their product which handles more easily.

<mary_s> What happens if there is some small amount of bleeding when INTERCEED is placed?

<Drwiseman> INTERCEED, although not indicated for use in laparoscopy in the USA, is used like that. Seprafilm is too brittle for insertion through a laparoscopic cannula.

<Drwiseman> If INTERCEED gets bloody (it turns black) it simply does not work.

<mary_s> Do these barriers breakdown over time or are they permanently placed?

<Drwiseman> Both barriers break down over time. I think both make the claim that they are completely gone on a microscopic level after 28 days. They are certainly gone by visual inspection after about 7.

<Drwiseman> Anyway the news of the week: 1. ADCON L received approval for use against spinal adhesions last week here in the USA. And secondly, INTERGEL, a slightly runny gel, was released in Europe yesterday. This is for pelvic adhesions.

<Herto> When do you use barriers, always?

<mary_s> Wonderful news about INTERGEL - I haven't heard of the other product though.

<Drwiseman> When? One should probably use barriers after any surgery where adhesion formation will cause problems afterwards.

<Drwiseman> Some people may say this is after any kind of surgery, but others use the term "high risk" procedures. High risk here means high risk of adhesions causing a problem.

<Drwiseman> Here we mean: pelvic infertility surgery, surgery for small bowel obstruction, myomectomy (fibroid removal).

<mary_s> Like pelvic adhesions causing fertility problems?

<Drwiseman> Lower down on the list is hysterectomy and possibly even repeat c-section.

<Drwiseman> Yes, adhesions can cause problems of infertility, although there are many other causes of infertility.

<Herto> And pain.

<Drwiseman> Pain certainly. 90% of my email from patients are from people with pain.

<Drwiseman> Herto: are you suffering from adhesion related pain?

<mary_s> I have a friend who had ovarian drilling done 8 years ago and her adhesions are so bad she had to go the IVF route. Her ovaries are entangled in adhesions.

<Drwiseman> That's right, some people have likened this to tangling some rope up and then pouring glue on the rope.

<Drwiseman> How about Hmd: do you have any adhesion stories you want to relate?

<Herto> No I’m a gynecologist.

<Drwiseman> Well let me share with you some email that I received this month. Perhaps this will start off some comments:

Dr. Wiseman-- I have been reading the transcripts of the Wednesday night chats at OBGYN.net I wish I could make to one of the sessions. I may

reschedule some things to do so. Until then, I have a question about

adhesions that I cant seem to get info from my dr on. I was diagnosed with endo last May via laparoscopy. I had adhesions binding my large intestine to my pelvic wall which seems to explain my low back/pelvic pain. After the surgery, I never had relief. I just had a second lap last month where he found adhesions (denser this time) in the same place and no endo to speak of. I had about 2 days of relief and its all back now. My dr says he only cut the adhesions, didn't remove them because that is unnecessary since they don't reform unless there is infection and that once cut, the tension is relieved and the adhesions can't re-attach. I have read otherwise: that they can reform within 3 days and that if not removed the sticky "tags" can reattach. What's the truth?? I asked him about using a product like INTERCEED and he said laps aren't invasive enough to justify it....again, what are the facts??

<Hmd> I continue to search for whatever info is available. I read somewhere that in order to get rid of adhesions that the adhesions should be clipped at both ends...not just in the middle. Is there any truth to this?

<Drwiseman> Hmd: re clipping at both ends. If the adhesion is a long band then it should be completely removed. Although there is no real firm data on this, some people think that to leave a tag hanging so to speak is a source for inflammatory mediators.

<Hmd> Now another things...my blood sedimentation rate has been consistently about 85. I understand that this indicates inflammation...from the adhesions?

<Drwiseman> Here's the answer I gave:

Many thanks for your email. Let me start off by saying that I am not an MD and cannot offer you medical advice. I can try to answer your questions generally. (Q) My dr says he only cut the adhesions, didn't remove them because that is unnecessary since they don't reform unless there is infection and that once cut, the tension is relieved and the adhesions cant re-attach. (A) You are correct. Adhesions can and do reform at least 75% of the time even when there is no infection. This is well documented in the medical literature. (Q) What's the truth?? I asked him about using a product like INTERCEED and he said laps aren't invasive enough to justify it....again, what are the facts?? (A) I'm not sure I understand what the doctor's answer was here. Try and rephrase this and may be I can help.

<Drwiseman> Note that this correspondent raises an important question put by many surgeons: that is if they do laparoscopy, adhesions will be less.

<mary_s> But this isn't necessarily true, is it?

<Drwiseman> Perfect lead in Mary: in fact for the main types of adhesions,

adhesion formation after laparoscopy seems just as high as in laparotomy.

<Annor> I have a question. Can you see adhesions on a transvaginal sonogram?

<Herto> No.

<Drwiseman> There are some people who claim to be able to see adhesions via TVS. However resolution is not good enough for routine use.

<Annor> What is being seen as white bands on the sonogram? Doc said possible adhesions.

<Hmd> How can a person with adhesions locate a surgeon who will use

INTERCEED laparoscopically?

<Annor> Is it good guess work?

<Drwiseman> I can believe that. And certainly that might be enough to arouse suspicions, but I don't think anyone is using TVS definitively to diagnose adhesions.

<Annor> Oh, it was not only to diagnose adhesions........

<Drwiseman> In a way it is good guess work, but no more than any other diagnosis. If a patient is complaining of pain, has had prior surgery etc. and there are bands on a TVS, then there is a good chance she has adhesions.

<Drwiseman> Annor: the TVS is used to look at other pelvic anomalies, cysts, fibroids etc.

<mary_s> Are there any diagnostic tests (non-invasive) that can be used to diagnose adhesions, MRI or something of that sort?

<Drwiseman> Sorry, missed Hmd's question: how can you locate a surgeon who used INTERCEED. Two options: call J&J (go to their web site:

http://www.adhesions.com and send email) or contact me.

<Bethp> Hi Dr. Wiseman. I had surgery in Feb during which extensive

adhesions were removed (along with uterus, ovaries, and appendix). I had not had previous surgery and don't know what caused the adhesions. What are the chances of new adhesions forming?

<mary_s> Interesting, Beth. How do you end up with adhesions if you haven't had surgery?

<Drwiseman> Hi Bethp: glad to have you back (I though you were someone else for a moment). The chances of the adhesions reforming are 75% (for each one). As to how you had adhesions without prior surgery, perhaps you had

endometriosis or pelvic inflammatory disease?

<Bethp> No endo was found; no history of PID. Problems started after my 2^nd pregnancy.

<Drwiseman> Back to Beth's q: the chances of adhesions reforming at each site are 75%. If you had no prior endo or PID, there are some patients in whom adhesions form spontaneously, or congenitally, that is they were there from birth.

<Drwiseman> These patients are very few in number. Did you have a c section?

<Bethp> No; two regular deliveries. Used vacuum extraction for my 1st child.

<Herto> PID??

<Drwiseman> I'm stumped what about you Herto?

<mary_s> Are surgeons initially (in med school, residency, etc.) trained to use adhesion barriers?

<Drwiseman> Good question Mary. The answer is probably no. In some centers where use is high, residents going through those programs will use them SOP. But this use is sporadic.

<mary_s> That's unfortunate.

<Drwiseman> The goal of most companies in this field is to make the use of

barriers SOP (standard operating procedure). Obviously they want to sell their product, but more than that perhaps, I think it leads to good overall health care, no matter what product is used.

<Bethp> I guess I could have had a PID and not known it. My dr did find

scarring in at least one tube.

<Drwiseman> I know this lady well: she is a regular correspondent of mine.

<mary_s> Who, Hmd?

<Drwiseman> Yes, Hmd

<Drwiseman> Nice lady

<Drwiseman> Hmd: I have some of your email: do you mind if I cut and paste it into here?

<Hmd> That would be great. Thanks!!

<Bethp> Is there anything I should or shouldn't do to prevent reformation of

adhesions? I'm not sure what, if any, barrier my doctor used; I'll be sure to ask him.

<Drwiseman> Here goes: In 1970 I had a laparotomy done and about 5 days

afterwards developed pain again...which I was told was the result of

adhesions. I have suffered with this pain for 27 years; and finally found a doctor who would listen to me. I had a laparoscopy done by him on August 1, 1997...with an adhesiology being done. I had adhesions the full length(7 inches) of the laparotomy incision which was complicated by a layer of fat 4 inches across. The surgeon used the Kleppinger scissors to free the adhesions from the omentum. For 10 days I felt like a new person!! But then I started developing pain again...and now he won't even see me. I don't really know what the purpose is regarding e-mailing this address; but since I know deep in my heart that I am definitely suffering again from adhesions, I decided to follow your suggestion in your article Synechion. I wish someone had told me that a product such as yours could have spared me all the pain I'm experiencing. Unfortunately the patient is at the mercy of the surgeon.

<Annor> should adhesions be cut only or removed from the site completely?

<Drwiseman> Bethp: there's not much too be done at this point (or not to be done)

<Drwiseman> Annor: I think most surgeons would say remove the entire adhesion if you can.

<Annor> Ok, that was my thinking too.

<Annor> Thanks for your answers Drwiseman, gotta go!

<Drwiseman> Thanks annor.

<Drwiseman> I guess we have a few more minutes: does any one have any more questions?

<Drwiseman> Going back to Hmd's mail: you see that she's coped with the problems of adhesions for 27 years: a long time and something to inspire

others.

<Bethp> Dr. Wiseman -- could I have had a PID and not known it?

<Drwiseman> It's possible.

<mary_s> I have heard many adhesion stories but it would be interesting to hear the surgeons' viewpoints.

<mary_s> I wonder if they are as frustrated as the patients?

<Drwiseman> Perhaps that's how we should write the next article: have the patient story and then the doctor story.

<mary_s> I think that is a very good idea.

<Drwiseman> I think for the most part they are as frustrated as patients, perhaps more so. I know how frustrating it is to give the same answers to patients who email me and I am not even an MD.

<mary_s> I was just about to ask if you were in New Orleans at ACOG and if so...was there anything there for the Drs about adhesion prevention (classes, etc..)?

<Drwiseman> I was at ACOG and I don't remember anything specific about adhesions. May be as part of some other stuff on good technique and also may be a lunch round table, but that it all.

<mary_s> That too, is unfortunate.

<Drwiseman> I have to leave now. Any last questions?

<mary_s> Bye, and thanks. Have a good trip!