Prof DR Andi Asadul Islam SPBS-K (Post-Surgical Adhesion A Clinical Burden)

Post-Surgical Adhesions: A
Clinical Burden
Prof. DR. Dr. Andi Asadul Islam, SpBS(K)
For Healthcare Professionals Only
Disclaimer & disclosures

• Views expressed are my own and do not necessarily reflect the Policy or
position of Mundipharma.
• Any previously unreported adverse event disclosed/discussed during the
event must be reported to Mundipharma via the following link:
https://mundipharma.com/report-an-adverse-event/
• This Event is sponsored by Mundipharma, which includes fair market
compensation to the healthcare professional presenters and facilitators.
Post-surgical adhesion
 Adhesion formation is the most common cause of long-term
complications after abdominal surgery.
 Adhesion formation places patients at lifelong risk for various clinical
disorders:
o small bowel obstruction
o female infertility
o difficulties during reoperations
o chronic pain
 The incidence of adhesion-related complications is frequently
underestimated.
 Adhesion prevention is not widely practiced  due to a lack of
awareness regarding the burden adhesions place on patients and society.
Adhesion-related costs in open surgery
• Post-surgical
adhesions are
common in almost all
surgical areas and are
associated with
increased healthcare
costs, especially when
a patient requires
repeat operative
interventions. (1)
The direct health care costs for treatment of adhesion-

related complications after open surgery were: (2)
• $2350 in all patients, and
• $3200 in fertile-age female patients
Economical, clinical, and social burden from
post-surgical adhesions
• The treatment of post- EXCLUDING Social cost
operative adhesions costs
of early
x
the US healthcare system mortality
over USD 2.5 billion Imaging
annually
• Complications related to
post-surgical adhesions Lab tests
results in nearly one million Diagnostic
additional days of inpatient
Mental
care annually
health
Fatehi Hassanabad A, Zarzycki AN, Jeon K, Deniset JF, Fedak PWM. Post-Operative Adhesions: A Comprehensive Review of implications
Mechanisms. Biomedicines. 2021 Jul 22;9(8):867. doi: 10.3390/biomedicines9080867. PMID: 34440071; PMCID: PMC8389678.
Mechanisms of Post-Surgical Adhesion Formation
• 3 core processes:
(A) inhibition of the fibrinolytic and extracellular matrix degradation systems,
(B) the induction of an inflammatory response involving the production of
cytokines and transforming growth factor- (TGF-)
(C) induction of tissue hypoxia, leading to increased expression of vascular
endothelial growth factor (VEGF)
• It is highly likely that post-operative adhesions have a multifactorial
pathophysiology.
Understanding how cells and factors contribute to the formation of

adhesions is key for developing successful preventative strategies
Fatehi Hassanabad A, Zarzycki AN, Jeon K, Deniset JF, Fedak PWM. Post-Operative Adhesions: A Comprehensive Review of
Mechanisms. Biomedicines. 2021 Jul 22;9(8):867. doi: 10.3390/biomedicines9080867. PMID: 34440071; PMCID: PMC8389678.
Prevention of post-operative adhesions
 Given our poor understanding of the
pathophysiology of post-surgical adhesion
formation, there is an unmet clinical need for the
development of safe and effective therapeutic
options that can be used to mitigate them.
 Different pharmacological strategies have been

employed to reduce adhesion formation, severity,
and chronicity
 Biomaterials have also been designed to act as

tissue barriers that can physically isolate wounds
and have been shown to prevent the formation of
adhesions to varying degrees of success
Adhesive small bowel obstruction
• 8 days of hospitalization on average
• In-hospital mortality rate of 3% per episode
• One in ten patient develops at least 1 episode of SBO within 3 years
after colectomy
• Recurrence of SBO:
– 12% of conservatively treated patients are re-admitted within 1 year, rising to
20% after 5 years.
– The risk of recurrence is slightly lower after operative treatment, at 8% after 1
year and 16% after 5 years
ten Broek RP, Bakkum EA, Laarhoven CJ, van Goor H. Epidemiology and Prevention of Postsurgical Adhesions Revisited. Ann Surg. 2016 Jan;263(1):12-9. doi: 10.1097/SLA.0000000000001286. PMID:
26135678.
Adhesiolysis and Related Complications
• Adhesiolysis requires a median of 20 minutes of operative time and is associated with a 10% risk
of iatrogenic bowel injury
• Well-known operative complications of adhesiolysis:

 bleeding
 trocar injury
 conversion from laparoscopy to laparotomy
 damage to peritoneal organs such as the bowel, liver, spleen, bladder, and ureter
• Sequelae of bowel injury:

 unplanned bowel resections (56%)
 ICU admission (28%)
 a high risk for wound infections (12%)
 pneumonia (26%)
 mortality (8%)
26135678.
Chronic Abdominal Pain
• The relationship between adhesions and pain is complex and has
been the subject of much debate
• Touching and moving adhesions elicited a clear pain sensation which
was most prominent for filmy adhesions connected to mobile organs
• Disruption of painful filmy adhesions by pneumoperitoneum may
explain the long term pain relief
• At present, there is insufficient evidence to advocate nonoperative
management as a viable alternative to laparoscopic adhesiolysis in
achieving long-term pain relief
26135678.
Anti-adhesion Barriers & Chronic Abdominal Pain
• Recent long-term follow-up data from a trial randomizing between an
antiadhesion barrier film and no specific adhesion prevention,
showed a lower overall number of patients with chronic abdominal
complaints (including pain) in the antiadhesion barrier group.
A potential for antiadhesion barriers to

prevent chronic pain
26135678.
Adhesion Prevention:
Surgical Technique
• Purpose: minimization of injury to serosal surfaces and the parietal peritoneum
• Difficult to substantiate ‘‘good surgical technique’’  based primarily on personal
preferences and experiences rather than published data
• Comparison is only laparoscopy vs open surgery:
Metaanalysis of nonrandomized studies  incidence of adhesive small bowel
obstruction after laparoscopic surgery is lower compared with open surgery
(2.7% vs 3.8%)
All peritoneal trauma has the potential to result in adhesion formation
26135678.
Adhesion Prevention:
Antiadhesion Barriers
• Several forms of antiadhesion barriers:
1. Solid membranes
2. Liquids
3. Gels Ideally should be
4. Solutions-gel inert to the human
immune
• The concept: system and be
 Should not actively interfere with inflammation slowly degradable
and wound healing
 Act as a spacer which separates injured surfaces
of the peritoneum, allowing these surfaces to
heal without forming fibrinous attachments
26135678.
(1) Hyaluronic acid (HA)-based barriers
(2) Cellulose-based barriers (3) Chitosan-based barriers
 the most common chitosan-based barriers used is: N,O-

carboxymethyl chitosan  has shown efficacy in the reduction of
adhesions in the peritoneum and pericardium of rats and rabbits as
well in humans undergoinf pelvic laparoscopy
 The anti-adhesive mechanism of chitosan based barrier is unclear, but

it is hypothesized that it inhibits fibroblast activation and interrupts
fibrin matrix formation
Ideal Antiadhesion Barriers
• Should remain in situ for more than 7 days, because:
The time required for regeneration is approximately 7 days as the
entire surface of the peritoneum quickly mesothelizes
Abdominal inflammation and other complications might prolong
peritoneal healing
26135678.
Economic Considerations
• In USA: The direct hospital costs in 2005 of
adhesive small bowel obstruction (SBO) alone
was estimated at $3.45 billion Great
• In UK: Costs associated with the treatment of an
importance to policy
adhesive SBO are estimated to be $3000 per making and
episode with conservative treatment and $9000 development of
with operative treatment guidelines for
• In the Netherlands: The increase in direct adhesion prevention
hospital costs associated with adhesiolysis are
estimated at $4500 per operation, rising to
almost $30,000 if a bowel injury occurs
26135678.
Take home messages
• Post-surgical adhesions pose a great health and financial burden.
• Inflammation and immune mediators have long thought to play a central
role in the development and severity of post-operative adhesions.
• Primary prevention of post-operative adhesions involves careful and
meticulous surgical work causing minimal tissue injury
• There is a potential for antiadhesion barriers to prevent adhesion-related
complications and to reduce the cost of direct and indirect costs associated
with post-surgical adhesions
• It is of great importance to policy making and development of guidelines
for adhesion prevention
PANDUAN PRAKTIK KLINIK:
Pencegahan Perlengketan
Pasca Operasi
IKABI, PERSPEBSI,
PERHERI, IKABDI, PBEI
TERIMA KASIH

Prof DR Andi Asadul Islam SPBS-K (Post-Surgical Adhesion A Clinical Burden)

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Post-Surgical Adhesions: A

Disclaimer & disclosures

The direct health care costs for treatment of adhesion-

Understanding how cells and factors contribute to the formation of

 Different pharmacological strategies have been

 Biomaterials have also been designed to act as

• Well-known operative complications of adhesiolysis:

• Sequelae of bowel injury:

A potential for antiadhesion barriers to

All peritoneal trauma has the potential to result in adhesion formation

(2) Cellulose-based barriers (3) Chitosan-based barriers

 the most common chitosan-based barriers used is: N,O-

 The anti-adhesive mechanism of chitosan based barrier is unclear, but

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