A reader asks whether I think adhesions cause postoperative abdominal pain and if so, how should they be treated?
I have always been skeptical (no surprise) about blaming adhesions for pain.
If adhesions cause abdominal or pelvic pain, what is the mechanism? We know that the intestine can be handled, cut, and cauterized without causing pain. What about tugging or pulling on the bowel? Would that cause pain? I doubt it. How much tugging or pulling can take place within the confines of the peritoneal cavity anyway? A literature search did not turn up any studies on the mechanism of adhesions causing pain.
UpToDate, the online medical textbook, has a section on this topic. It doesn't address how adhesions cause pain but does discuss the evidence that reoperating on patients with adhesions is not worthwhile.
Although some observational studies claim that lysis of adhesions can decrease chronic pelvic or abdominal pain, at least three randomized controlled trials found little value in performing adhesiolysis except possibly in patients with vascularized adhesions, which would be difficult to diagnose preoperatively.
There are significant risks in performing laparotomy and lysis of adhesions including injury to bowel and the high likelihood of creating more adhesions.
Prevention of adhesions with potions or sheets of difficult-to-handle materials is the Holy Grail of abdominal surgery. As far as I know, none of the many products purported to prevent adhesions has reliably done so.
While investigating this topic, I found a blog post touting a polyethylene glycol solution called SprayShield for adhesion prevention when used before closing the abdomen. A couple of anecdotes were cited.
Two research papers are widely quoted as evidence supporting the use of SprayShield. The first was in an online journal called Wideochir Inne Tech Maloinwazyjne [Polish for "Videosurgery and Other Mini-invasive Techniques”]. It was a randomized, controlled, single-blind trial of eight patients undergoing diverting ileostomy who received SprayShield and three who did not. Adhesions were assessed at the time of ileostomy reversal.
The results were as follows: "In patients who received SprayShield the time required to mobilize the ileal loop at the ileostomy closure was slightly shorter and the incidence and severity of adhesions were somewhat lower vs. control subjects (NS)" meaning not significant.
The second, from Germany and published in Archives of Gynecology and Obstetrics, was a randomized trial of patients undergoing gynecologic surgery—nine received SprayShield and six did not. For the main outcomes—incidence, severity, and extent of uterine adhesions—"no significant differences were found between the two study groups."
A observational study in France involved 20 patients who were having gastric band removal and application of SprayShield with gastric sleeve resection or bypass planned at a later date. It was registered at ClinicalTrials.gov and apparently completed at the end of 2014, but a PubMed search using the name of the principal investigator was fruitless. The study has apparently not been published.
The first generation predecessor of SprayShield, Confluent SprayGel, was blamed for causing painful internal scarring due to an ingredient—methylene blue. One account says that at reoperation the reproductive organs of some women appeared "super-glued together." Covidien, maker of both products, changed the name and formula, and SprayShield contains a vegetable dye instead of methylene blue.
The evidence for SprayShield in preventing adhesions is not strong. The product was never FDA approved for use in the United States and probably never will be.
The first scientist who discovers a safe and effective way to prevent the formation of adhesions after abdominal or pelvic surgery should be awarded a Nobel Prize.