David Wiseman, PhD on "Preventing Post-Surgical Adhesions"
June 23, 1998

Drwiseman "Okay, let's go. Who wants to start the ball rolling?"

Drwiseman "Mary:perhaps you can tell us about your recent surgery?"

Perk "Dr. Wiseman I had a hysterectomy on Nov. 21, 1997. I've had continuous granular tissue buildup ever since. I 'I've gone through many office visits to clear up this problem - excision of the tissue and using silver nitrate. I continue to have a light yellow discharge and bleeding during intercourse. Any answers?"

Hmd "Yes, I would like to hear about Mary's experience."

Drwiseman "Okay, Mary: Stage 4 adhesions - Adhesions aren't staged in that way but endometriosis is."

Maryhalm "I have had many surgeries with the last being at the Endo Care Center in Atlanta. It was a 4+ hour laparoscopy"

Maryhalm "I had endo in the past but none was found with the last pathology"

Drwiseman "It's either ACOG or ASRM (can't remember which) which grades endo based on involvement of organs, the extent of organs and the presence of adhesions. Stage 4 endo is the most severe and it means you will have lots of adhesions (but you knew that already)."

West_sunset "endo=endometriosis?"

Maryhalm "The surgery previous to the last was done at the James Cancer Hospital by a GYN Onc. It was a 3 hour laparotomy."

Drwiseman "West-sunset : yes"

Drwiseman "Mary: It's possible that the last time around they got all the endo, but left you with adhesions. adhesions = pain (sometimes)"

Maryhalm "So if my doc referred to my adhesions as stage 4 he's comparing them to an awful case of endo?"

Drwiseman "Perk: where is the granular build up tissue?"

Perk "Cervical area where I was sewn up."

Maryhalm "Isn't granular from a foreign body?"

Perk "I had a total hysterectomy, abdominal incision."

Maryhalm "Like a left-over suture or something?"

Drwiseman "Okay, so this is outside the peritoneum: not really an adhesion problem as such, but still a problem for you. I am not familiar enough with this problem except that it may be related to the type of overhealing that occurs in keloids and hypertrophic scars since the tissue there is related to the cervical tissue.

Perk "Would this eventually heal on its own?"

Drwiseman "Perk: I'm not sure there is a solution here except what you are doing. Is it getting any better?"

Perk "Absolutely no worse, but no better."

Maryhalm "If adhesions form quickly after surgery, why does pain continue to worsen over years for some people? Is it that the adhesions get tighter (for lack of a better word)?"

Perk "My doctor did say it probably has something to do with the sutures used."

Drwiseman says, "Perk: Heal on its own? My guess is that the Dr. is trying to dampen down the scarring response, rather like a ball which bounces lower and lower each time. There may not be an answer for this except time. I must point out that although I know something about wound healing, this problem is a little different from adhesions and I don't have intimate knowledge of this problem"

Barbaran "David would a Wound Treatment Center like at Presby in Dallas be of any help for Perk?"

Drwiseman "Perk: If it is sutures, then if they are non-absorbable sutures, they should be removed and a new type put in. I can see why he might think it is a reaction to the suture. If so, silver nitrate might not help."

Perk "My concern is that I have something inside of me that hasn't healed and should have way before now."

Drwiseman "Barb: Wound Healing centre? Give it a try. I would suggest that the Dr. take a biopsy to determine whether there are suture fragments there or perhaps some other foreign body. Has s/he done this?"

Maryhalm "Perk - I have learned from painful experience that if you think something is wrong you should pursue it. Maybe a second opinion?"

Hmd "From what I have learned, adhesions tend to mature over time and become tougher to excise...and there is more nerve involvement. Is that right?"

Perk "No, they were not permanent sutures"

Drwiseman "Perk: Not permanent sutures - then they would have degraded by now. If that is the problem then the problem should eventually disappear after cautery at least 6 months after surgery. If not, then may be a biopsy should be taken."

Perk "Maryhalm: Thanks, but this is a second opinion dr. that's treating me now."

Maryhalm "Perk, gotta be really frustrating then."

Drwiseman "Mary: To recapture an earlier question of yours - "If adhesions form quickly after surgery, why does pain continue to worsen over years for some people? Is it that the adhesions get tighter (for lack of a better word)?"

Drwiseman "Mary: Adhesions do form quickly, but they mature with time. what happens is that the adhesion may get more fibrous with time. Also organs may twist around an adhesion many years after surgery and cause a problem that was not there until then . This may happen 50+ years later."

Perk "Biopsy looking for what?"

Drwiseman "Perk: Biopsy to look for another cause of what might be irritation that is causing the granular response"

Maryhalm "For people who continue to suffer with adhesions despite everything being tried, is there hope in the future with Intergel?"

Barbaran "Biopsy can be for many things like infection not just for cancer."

Perk "Is granular tissue synonymous here with suture? I'm a little confused."

Drwiseman "Mary: Does that answer your tightening question? Also Barb - good comment on biopsy."

Maryhalm "Yes, answers the tightening question - thanks."

Hmd "Mary raised a question about Integel. I believe that last chat that you said that Intergel has been approved for use in Europe. Why does Europe tend to be so accepting of new products compared to the FDA in the USA?"

Drwiseman "Re: INTERGEL. First of all, it has only just been released in Europe and may not be available here for another 18-24 months. Second of all, on the limited data that I have seen clinically (I know the animal data very well because my group did most of it when I worked at Ethicon), given the limited clinical data to date it looks as though adhesions will not be prevented 100%. What INTERGEL seems to do, and I stress this is based on limited clinical data available, is work about the same as INTERCEED and Seprafilm, except that it can be used laparoscopically and it can coat many areas at once."

Maryhalm "So essentially it's not gonna be the cure-all. Will there ever be a cure-all do you think?"

Drwiseman "Europe vs. FDA: The requirements for medical device approval in Europe are more stringent than here, in as much as Europe will approve products with animal data and limited clinical data. FDA needs more extensive clinical data which takes time. Also the approval process, once a submission is made, is longer in the US."

West_sunset "How can I get involved in the human study part?"

Hmd "Thanks for answering my question, Drwiseman!"

Drwiseman "Mary: No, I don't think it will be the cure all, and to be fair to Ethicon, I don't think they are saying it is. Will there ever be one? I hope so, but it is not yet on the horizon."

Drwiseman "West_Sunset: do you mean as a patient volunteer? If so email me afterwards and I will tell you who to contact : synechion@aol.com"

Barbaran "Dr. Wiseman, why does one person get adhesions and another does not?"

Drwiseman "Actually it seems that most people get adhesions, but some have problems form them and some don't."

West_sunset "Thank you, yes as a volunteer."

Perk "Drwiseman, please expand on the input about infection vs. cancer in regard to doing a biopsy"

Drwiseman "West: email me afterwards."

Drwiseman "Hi Dr. Bradley"

Drbradley "Good evening, all."

West_sunset "At the address you gave?"

Drbradley "Dr.Wiseman... any comments on fibrin sealant and adhesion reduction?"

Beeswax "Good evening."

Drwiseman "Perk: Biopsy - I realize from Barbara's comment that biopsy is a scary word because many people associate the word with cancer. All it means is that the doctor takes a minute amount of tissue (in your case the granular tissue) and sends it to the lab who will take a look at it through a microscope. If the doctor suspects that there are pieces of suture left behind or some other foreign object (e.g.a piece of lint from a cotton swab, or perhaps a minute tampon fragment"

Hmd "I would like to know how some of you are dealing with chronic pain medically speaking. I am seeing a psychiatrist who is helping me manage my pain with 600 mg carbamazepine daily... and 100mg amitriptyline."

Maryhalm "Hmd - What is carbamazepine?"

Hmd "Carbamazepine is the generic of Tegretol, Mary."

Drwiseman "Dr B: Fibrin glue - I noticed from the transcript of your chat last week that you mentioned this. I don't know of anyone who has published a descent RCT on the subject. The animal data looks quite promising and my feeling is that is should certainly help as far as hemostatsis is concerned and will also help facilitate the action of INTERCEED."

Drbradley "I have used it on occasion when I have anticipated a large peritoneal defect in the pelvic after laparoscopic surgery."

Maryhalm "For the 2 years previous to my last surgery I was on Ultram and low dose Zoloft."

West_sunset "Psychologist, M.D., lortabs, naprosyn, low,low dose amitryptyline, relaxation, deep breathing, journaling, shots of morphine or Demerol=pain management."

Beeswax "Could somebody answer some questions for me about chronic pelvic pain after having nine surgeries in the last two years?"

Drbradley "Hmd... have you tried medical hypnosis??"

Maryhalm "I was so desperate for pain relief at times that would have let my dog cut on me - seriously!"

Hmd "Tegretol is a seizure medication which has pain-relieving abilities."

Drwiseman "Dr B: Are you using cryo or one of the commercial formulations? I think results will vary greatly on the formulation (e.g. +/- aprotinin). Also, I think it's very important to make sure the glue has set (e.g. wait 2-5 minutes before replacing organs)."

West_sunset "I was told I have virtually no peritoneal tissue left? Is that not a good thing?"

Maryhalm "Beeswax, sounds like we have alot in common as far as #s of ops."

Maryhalm "West_sunset - I think peritoneal tissue grows back, doc?"

Drwiseman "West: I'm not sure what you mean by "not having any peritoneal tissue left" Perhaps Dr. B. can hazard a guess?"

Hmd "Dr. B, no I haven't. I don't even know if it is available in the area where I live."

West_sunset "Nothing left to cover the organs or so they said..."

Beeswax "the pain is unbearable and because we are in the military and stationed overseas there is not much that the doctors can or want to do to help me !!"

Drbradley "I use cryoprecipitate from the patient, with bovine fibrin. It sets up in 1-3 minutes depending on the mixture. I watch until the "sealant" is totally set up. IMHO, "fibrin GLUE" is a misnomer as it is simply a clot without red cells."

Maryhalm "Isn't it omentum that covers organs some?"

Drwiseman "Peritoneal tissue does regenerate, but if you have had EXTENSIVE dissection it will take a long time with a great risk of adhesion formation."

Maryhalm "Beeswax, I have heard awful things about the military and pain relief."

West_sunset "Severe dense adhesions....can't do laparoscopic surgery...severe pain...extensive dissection...12 surgeries and have to have (not by choice) one more."

Maryhalm "Beeswax, what were your surgeries for?"

Beeswax "This has been my worst nightmare ever. It is hard to believe that I never had any medical problems until the birth of my son two years ago. After his delivery, I had six hemorrhages, and it has gone downhill from there. I am only 31."

Drwiseman "DrB: "A clot without red cells" is a good description of what you have. I don't think that too many GYNs have used fibrin "glue" because they make the equation fibrin = adhesions. But the way you are using it can only serve to promote meticulous hemostasis and help to reduce adhesions. I would be interested if you think it reduces adhesions on its own or do you use something else such as INTERCEED. If so, do you think the INTERCEED works better when you have used the cryo?"

Drbradley "That is the precise reason that early (7 day) re-laparoscopy is so important (IMHO): one can knock down whatever adhesions have formed allowing normal reperitonealization to occur."

Beeswax "To try and stop me hemorrhaging after my c-section. Then hysterectomy, right oophorectomy, ovarian remnant syndrome, and then a left oophorectomy."

Maryhalm "West_sunset, I was told by more doctors than I can count that I couldn't have a laparoscopy but I found a doctor that could do it. Since the chance of adhesion formation is greater with a laparotomy, I really wanted to have a laparoscopy."

West_sunset "C-section, three (can you believe this?) oophorectomies, 9 and 10 cm cysts (double cysts), 18 cm hematoma with peritonitis sat in abdomen for two weeks before anyone would help, perforated bowel and purulent peritonitis, etc. etc."

Maryhalm "Yikes."

Beeswax "I am wondering if it would be worth one more surgery to try and get rid of some of these adhesions or would it make it worse ?"

Drbradley "I recently referred a severe adhesion patient in NY to Harry Reich. MD, perhaps the most talented laparoscopic surgeon in the world!! 5 hours of surgery, she is at last pain free!!"

Beeswax "I am even prepared to go home to New Zealand and be seen by an gyn-oncologist if that is what it takes !!"

Maryhalm "I was told after my surgery (one previous to the last) that I should never have surgery again. I had to try it one last time and I'm so thankful I did. It's given me my life back."

Maryhalm "I've heard great things about Dr. Reich."

West_sunset "May I contact this doc? I have ptsd surrounding laparoscopic surgery...long story..."

Drbradley "Don't assume that your oncologist, however talented, is an adhesion expert!"

Beeswax "Would seeing a gyn-oncologist be better than dealing with military gynecologists?"

Barbaran "Beeswax where do you live now?"

Maryhalm "I was told something about Gyn Oncs. They're in the mindset of saving lives not adhesion prevention."

Beeswax "Okinawa, Japan"

Barbaran "N Z Military or US?"

Hmd "From what I hear about all of the surgeries that some of you have gone through, I guess maybe I should be thankful that doctors wouldn't believe that my chronic pain was real? Dr. B. what is IMHO? I read your recent article about adhesions which I found to be very good. Thank you!"

Beeswax "U.S Military. My husband is in the Navy"

Maryhalm "West_sunset - Your mean post-traumatic stress?"

Drbradley "In My Humble Opinion"

Drwiseman "Beeswax: Dr. B. raises a good point. An early (7 day) laparoscopy after an initial procedure may allow the Dr to get the adhesions while they are still filmy. S/he should use an adhesion barrier. Also see someone who knows adhesions. Dr. B. has made a good suggestion, I can give you others. There are some Japanese doctors who have done some amount of work on adhesions. If you email me later I will give you a reference for you to do some hunting in Japan."

West_sunset "I had repeat surgery exactly seven days and the surgeon threw up his hands and said it would take something short of a miracle...he was a professor and supposed to be and expert...My other professor doc said the same as well as my obgyn!"

Drwiseman "Oh boy."

Hmd "What state does Dr. Reich practice in?"

Drbradley "Unfortunately, there is no 100%solution"

West_sunset "Yes ptsd"

Drbradley "Columbia Presbyterian Hospital, New York"

Beeswax "Thanks Dr Wiseman. I just printed off 13 pages from your adhesion site. Shame it has taken me this long to find it. I have been reading through it all morning."

Maryhalm "West_sunset - email me, Barbaran, can I give my email on here?"

Beeswax "Dr Wiseman, how do I get your email address"

Barbaran "Beeswax, the best solution for you at this time might be to see if you can get a consult from a private physician in Japan...per Dr. Wiseman's referral. It's worth a try."

West_sunset "I told the doc not to do it laparoscopically because he would perforate my bowel...he told me I was basically dumb to think it...I almost died...he wouldn't even let me go to the ER till Ii begged him, by this time I looked nine months pregnant and could not walk."

Iglooanne "Hi everybody!"

Beeswax "I think that will be my next step"

Barbaran "All emails can be exchanged from one to another."

Drbradley "Sadly, egos sometimes preclude good judgement!!"

West_sunset "I'm now terrified of surgery."

West_sunset "I also have strange symptoms my doc needs help with."

Barbaran "Okay ladies, I have to tell you I Love Doctors....my son in law is my breast cancer surgeon so lets ask the good doctors some good questions about adhesions. Okay?"

West_sunset "I have nothing against doctors."

Barbaran "Great!"

Drbradley "Thank you for allowing me to participate tonight. I have not been able to coordinate the time until now."

Beeswax "Doctors here have told me if they were to go in and try and remove the adhesions, it would only make it worse by creating more adhesions. Is this right ?"

Maryhalm "Beeswax - that's true if they aren't qualified - in my opinion"

Barbaran "OK docs please tell the good ladies How to find a qualified gyn"

Drwiseman "DrB: thanks for dropping in. Your comments are certainly most welcome. What else do you use for adhesions?"

Hmd "Drwiseman, I have started communicating with some people on the Internet who are suffering from chronic pain from adhesions...and I have been passing on the URLs for all the sites that you are involved with. Dr. B. I am doing the same with your recent article. Hope that you don't mind. If any of you would like to receive a copy, send an e-mail to olddad66@runestone.net"

Barbaran "to treat repeat adhesions"

Drbradley "I think you have to accept that if a patient has very symptomatic adhesion problems, she only has 2 choices: live with them, or try to find a gyn with experience who might be able to help."

Iglooanne "Okay here goes,Last C-section I had major infection at the scar site, and tons of adhesions accompanied by lots of pain, basically I was rotting away inside...."

Maryhalm "I think Drwiseman's idea of a support group is great and it would be an excellent way to get a recommended doctor list started"

Iglooanne "So had two laps and lasered away, got prego just had the baby, repeat c-section ..."

Iglooanne "What are my chances of getting the adhesions again? and could the same thing happen without the pain? could I rot away without knowing it?"

Drbradley "I use INTERCEED when ever I can, but as you so well know, adhesions can still occur. All the special irrigation solutions, NSAID. steroids are just voodoo"

Hmd "Dr.B. Have your patients had really good luck with hypnosis? If so, for how long?"

Drwiseman "Beeswax Q:Doctors here have told me if they were to in and try and remove adhesions, it would only make it worse by creating more adhesions. Is this right ??Doctors here have told me if they were to in and try and remove adhesions, it would only make it worse by creating more adhesions. Is this right ??. It is true that adhesions will reform: about 75% of the time. So the glass is 3/4 empty and 1/4 full. However you may be one of the lucky 25% (this is on an organ by organ basis). If you use INTERCEED, or Seprafilm properly, the numbers become 50% vs. 50%. These odds are probably worth it for many patients"

Barbaran "Doctors are there physicians that specialize in adhesion removal and if so how do we find them?"

Drbradley "Dr.Wiseman, the list suggestion could be very helpful to patients. Unfortunately there is only one harry Reich, Carmen Nezhat etc.Patients sometimes assume that anybody packing up a laparoscope qualifies for this unique company> Not So!!"

Drwiseman "Dr B makes an excellent point regarding irrigating solutions. I have just finished co-writing a paper on this very subject (it will appear in fertility and Sterility in about 4 months). Ringer''s lactate or saline do not appear to reduce adhesions. Make sure you understand your doctor's views on this and ask him/her to consider using INTERCEED or Seprafilm."

West_sunset "Seven docs told me the same thing...surgery makes it worse, for some, but my doc is torn because of the fevers, vomiting nausea, sweats, severe pain etc."

Maryhalm "Gotta mention the doc who did my last surgery, Dr. Robert Albee. He's great at what he does."

Drbradley "Hypnosis is an excellent tool for the suppression of pain."

Drwiseman "DrB you are right, there is only one Harry Reich and Camran Nezhat et al. what I usually do is have patients let me know where they live and then I try to match them with someone I know in the area"

Beeswax "Dr Wiseman, could you answer one more question. Doctors here prescribed me Elavil for pain relief. I realize this is an anti depressant. Dr told me I have to be depressed after all I have been through in two years. I don't believe that I am depressed, just very frustrated with this situation. Does Elavil help with the pain. All it seemed to do for me was make me sleepy"

Maryhalm "I enjoyed this but I have to go now. Thanks everyone."

Drwiseman "Bye Mary H: keep in touch"

Drbradley "Good night all!!"

Maryhalm "I sure will."

Drwiseman "Thanks Dr. B."

Hmd "Elavil does help with relieving pain. I have been using it since 1975."

Drwiseman "Beeswax: I don't think it has any effect on the pain itself. Depression and other nervous states can alter your perception of pain and ability to deal with it because it deal with depression."

Drwiseman "I need to go soon. Any last questions?"

Barbaran "It's an old medication with new usage and works well for some people with severe chronic pain."

Beeswax "Thanks for your time Dr Wiseman."

Drwiseman "You're welcome. Stay in touch."

Hmd "Thanks Drwiseman!"

Barbaran "Very nice group tonight Dr. Wiseman and thank you to you."

West_sunset "Thank you - just referrals."

Iglooanne "What are the probabilities of recurrent adhesions without the patient knowing it and them causing problems?"

Beeswax "Will do. It is nice to know that there are people out there that are interested and want to help."

Iglooanne "i.e., infertility problems"

Drwiseman "Igloo: Adhesions will invariably occur without the patient knowing. Only if they get pain, infertility or obstruction will they find out."

Drwiseman "Good evening Roberta. Wie geht es?"

Beeswax "Thanks again. Bye"

Iglooanne "So its kinda wait and see huh?"

Drwiseman "yup"

Iglooanne "Okay thanks!"

West_sunset "Is there somewhere I can refer my doc for info? He has asked for any info he can get...he feels so helpless."

Drwiseman "West: give him the article that I wrote on adhesions: http://www.obgyn.net/english/pubs/features/wiseman/wiseman_adhesions.htmhttp://www.obgyn.net/english/pubs/features/wiseman/wiseman_adhesions.htm"

West_sunset "Thank you Sir, I will. I really appreciate it."

Barbaran "West, email me at barbara@obgyn.net and I'll send you the URL if you missed it tonight."

Barbaran "David this was an excellent chat tonight."

West_sunset "The site Dr. Wiseman gave me, can I copy it and put it in the address box on my IE?"

Drwiseman "West: That's exactly what you do."