Background
In abdominal and pelvic surgery, adhesion formation must be regarded as the most common postsurgical complication occurring after 60–90% of procedures [
1,
2]. There is a long list of adhesion-related consequences ranging from small bowel obstruction (SBO) to considerable costs for the health care system. In the past, the Surgical and Clinical Adhesions Research studies (SCAR studies) demonstrated that adhesions are an important issue for the patients and a mounting burden on both the health care system and the surgeons who are faced daily with the treatment of adhesion-related complications [
3‐
5].
In view of the importance of adhesions, more and more research has been performed over the last decades, and our understanding of the complexity of adhesion formation has increased considerably. Investigations into the molecular causes of adhesion formation have produced new concepts of adhesion prevention. New anti-adhesion agents have been developed and existing agents have been evaluated in randomised controlled trials or systematic reviews to validate previous data.
In daily routine, it is more important than ever to be familiar with the complications associated with adhesions. The negligence suits against surgeons due to insufficient preoperative patient education are a problem which can affect every surgeon. Hence, in procedures associated with adhesion formation, surgeons should always inform their patients about the risk of adhesion-related complications. Not only as a precaution against negligence suits but also first and foremost to provide best possible care to our patients, we need to be fully aware now of the extent of the problem and adopt anti-adhesion strategies in our daily routine.
Conclusion
Adhesions are an important problem in surgery and have to be seen as an inevitable risk of abdominal and pelvic procedures. Knowing the consequences which come along with adhesions is important for every surgeon. Adhesions are the subject of successful medico-legal claims, mostly due to intraoperative events such as bowel injury. Insufficient preoperative patient education about the risk of adhesion formation and intraoperative complications associated with adhesions is an important reason for successful lawsuits. Thus, every patient who undergoes procedures which can lead to adhesion formation or can be complicated by adhesions should be informed about the associated complications like infertility, small bowel obstruction, chronic pelvic pain and bowel injury [
58].
Recent research into the patient’s awareness in a German women’s university hospital has demonstrated that at present <50% of patients, undergoing procedures with a high risk of adhesion formation, were made aware about this risk prior to surgery. In the UK, the percentage of informed patients was even lower with 27 and 8.5%, respectively. It was assumed that one reason for this difference between the German hospital and the UK hospitals could be the way of getting informed consent. In the UK hospitals, no written form was used for the consent process so the surgeons might forget to mention adhesions more often. Nevertheless, in the German hospital, despite the fact that adhesions were a part of the written informed consent form, the percentage of informed patient was also not adequate. An additional written informed consent form where adhesion formation and their related complications are described could be a more effective way to point out the impact of adhesions. If this additional form would be part of the regular patient educations, neither the surgeons would forget to mention it nor the patients would be unaware of this important issue. The main source of patient information about adhesions is their physicians, therefore, the pre-operation discussion is the most powerful resource for patients education that we can use [
59,
60].
A further remarkable finding of one of the above-mentioned research was that only 8% of the patients (5% in the UK, respectively) were aware of possibilities for prevention and therapy of adhesions. Hence, it is important for every surgeon to adopt anti-adhesion strategies in their daily routine especially when adhesions are expected and could affect future fertility and procedures, so they are able to inform their patients adequate about the different possibilities of adhesion prevention strategies. Another recent research into the awareness of adhesions in German hospitals has demonstrated that surgeons are interested in the topic and are well informed about adhesion formation, but that adhesion prevention strategies are nonetheless not widely used. Uncertainty as to whether an agent is effective or not is an important reason for the reserved use of anti-adhesion agents [
61].
At present the costs for the available anti-adhesion agents are not reimbursed by the health system regularly which might be due to concerns about the efficacy. When considering a possible reimbursment of anti-adhesion agents the cost of an anti-adhesion agent has to be set against the extensive costs associated with adhesion-related complications like, for example, prolongation of operations in further surgeries, readmissions due to complications or diagnosis and treatment of impaired fertility. By sensitising our patients for the important issue of adhesion development and strategies to avoid adhesions, a higher demand for adhesion prophylaxis by patients will arise and this could potentially lead to reimbursment by the health system 1 day.
The ideal anti-adhesion agent needs to be efficient, safe, easy to use and cost effective. Wilson developed a model for the cost effectiveness of an anti-adhesion agent based on the data from the SCAR studies. It is postulated that an agent which costs €130 and could reduce the adhesion-related readmissions about 25% in one year in the UK could save more than €40 million over a 10-year period [
62]. Therefore it is necessary to take anti-adhesion agents and the economic data on their usage into consideration to reduce the burden on the health care system [
40].
There is a growing literature with inconclusive data on the efficacy of anti-adhesion agents. This is an enormous problem for the surgeon. The Cochrane Menstrual Disorders and Subfertility Group reviewed barrier agents as well as fluid and pharmacological agents for adhesion prevention tested in randomised controlled trials. Not all the currently available agents were included in the review and reliable statements regarding efficacy were only possible for agents that have been available for a long time. Of the above-mentioned agents, only Interceed
® and Seprafilm
® have been studied with regard to efficacy. Adept
® and SprayShield
® were not assessable due to the limited data available. Pregnancy rate or pain relief was not used as endpoints in most studies, though it is precisely the evaluation of these clinical outcome parameters that defines the true success of adhesion prevention [
25,
63]. Other recent research directly compared the most common anti-adhesion agents and demonstrated that the reduction in adhesion formation obtained with the most common agents was unsatisfactory. This shows once more that, despite the studies in a rodent model, further research on the available agents is necessary to enable use of these agents without concerns in daily routine [
64].
To date, only a small number of the various available anti-adhesion agents have been studied in randomised controlled trials. In the future, it will be necessary to test more agents in large trials with endpoints such as pregnancy rates or decreasing incidence of adhesive SBO [
63]. A consistent study design is necessary to enable comparison of studies in systematic reviews. Although large-scale blinded randomised controlled trials are difficult to conduct, they are important for validating the efficacy of anti-adhesion agents. At present, it is difficult to determine the extent to which an agent is effective. This could be a challenge for the future. Knowing the real efficacy of an agent will make it easier for surgeons to choose the appropriate agent in their daily routine. Whereas the available agents have been demonstrated to effectively adhesion formation in clinical studies, none of them are able to reduce adhesion formation to a minimum. To achieve this, in combination with good surgical technique, will be the aim in the development of anti-adhesion agents in the future.
Further research will reveal new insights into the pathophysiology of adhesion formation and lead us to fully understand how adhesions form, what processes influence them and which patients will develop them. The possible combination of mechanical barriers and pharmacological agents is another promising field for future research.
The Expert Adhesion Working Party of the European Society of Gynaecological Endoscopy (ESGE) in 2007 published guidelines summarising the actions to reduce adhesions that should be adopted by all surgeons to fulfil their duty of care to their patients (Table
2).
Table 2
Consensus proposals: actions to reduce adhesions, from [
36]
1. Adhesions need to be recognised as the most frequent complication of abdominal surgery |
2. Surgeons, other healthcare workers, budget holders and policy makers need to increase their awareness and understanding of adhesions and the associated healthcare burden and costs and take active steps to reduce this |
3. Patients need to be informed of the risk of adhesions, given that adhesions are now the most frequent complication of abdominal surgery |
4. Surgeons who do not advise of the risk of adhesions may put themselves at risk of claims for medical negligence |
5. Surgeons have a duty of care to protect patients by providing the best possible standards of care—which should include taking steps to reduce adhesion formation |
6. Surgeons should adopt a routine adhesion reduction strategy, at least in surgery associated with a high risk of adhesions, such as: |
• Ovarian surgery |
• Endometriosis surgery |
• Tubal surgery |
• Myomectomy |
• Adhesiolysis |
7. Good surgical technique is fundamental to any adhesion reduction strategy—see Table 1
|
8. Surgeons should consider the use of adhesion-reduction agents as part of their adhesion-reduction strategy, giving special consideration to agents with data to support safety in routine abdominopelvic surgery and efficacy in reducing adhesions. The practicality and ease of use of agents, as well as the cost of any agent, will influence their acceptability in routine practice |
9. Further research to understand the impact that adhesion reduction agents have on clinical outcomes will be important |
10. Research towards more effective preventative agents should be encouraged—including the use of combinations of agents to prevent the formation of de novo adhesions, as well as adhesion reformation |
11. Surgeons need to act now to reduce adhesions and fulfil their duty of care to patients |
Conflict of interest
Rudy Leon De Wilde is a consultant to SHIRE, BAXTER, COVIDIEN, and NORDIC.