Adhesiolysis: An underestimated morbidity risk

Major finding: Adhesiolysis was required in 62.9% of patients undergoing elective abdominal operations, and bowel defects were incurred in 10.5% of the adhesiolysis patients.

Data source: A prospective cohort study of 755 directly observed procedures in 715 patients at a surgical center in the Netherlands.

Disclosures: The study was sponsored by Radboud University Nijmegen Medical Center. Dr ten Broek and his colleagues stated that they had no conflicts of interest.



Adhesiolysis, or the removal of adhesions immediately after abdominal surgery, is a risk factor for postoperative surgical complications, longer hospital stays, readmissions, and increased costs, according to findings from a large prospective cohort study.

And yet, to date, "adhesiolysis at repeat surgery has received less attention than bowel obstruction and infertility in reports assessing the clinical and socioeconomic burden of postoperative adhesions," wrote Dr. Richard P. G. ten Broek of Radboud University Nijmegen (the Netherlands) Medical Center and his associates.

He and his colleagues evaluated 755 consecutive elective abdominal procedures at the medical center between June 2008 and June 2010, of which adhesiolysis was deemed necessary and performed in 475. In both groups, most procedures were open rather than laparoscopic. Detailed data on adhesiolysis were gathered with direct observation of the procedures by an unaffiliated observer (Ann. Surg. 2012 Sept. 25 [doi: 10.1097/SLA.0b013e31826f4969]).

Primary outcomes were the incidence of adhesions; adhesiolysis time; and the incidence of bowel defects, seromuscular injury, injuries to other organs and structures, and major surgery-related complications.

In the adhesiolysis group, 111 (23.4%) of procedures had one or more major complications, compared with 50 (17.6%) in the nonadhesiolysis group (P = .047).

Adhesiolysis was associated with a significantly higher risk of sepsis (odds ratio, 5.12; 95% confidence interval, 1.06-24.71), intra-abdominal complications (OR, 3.46; 95% CI, 1.49-8.05), and wound infections (OR, 2.45; 95% CI, 1.01-5.94).

Operative time was a mean 20 minutes longer for the adhesiolysis group, and mean inpatient costs were $18,579 per operation, compared with $14,063 in the nonadhesiolysis group (P less than .001). Readmission within 30 days of discharge was also higher in the adhesiolysis group.

Full-thickness bowel defects, either in the form of inadvertent enterotomy or delayed diagnosed perforation, were seen in 10.5% of procedures with adhesiolysis (and in 40% of operations in which adhesiolysis lasted more than 1 hour). By contrast, no bowel defects were reported for the 280 procedures in which adhesiolysis was not performed.

Bowel defects were associated with an increase in in-hospital mortality, from 1.6% among patients without defects to 8%, along with significantly more surgical interventions and longer hospital stays. Patients with bowel defects incurred mean inpatient costs of $43,784.

The study demonstrated the substantial clinical and socioeconomic burden of adhesiolysis, "particularly when a bowel defect occurs. All physicians treating patients with disorders of the abdominal cavity that might require surgery should be aware of the adverse effects of adhesiolysis," Dr. ten Broek and his colleagues wrote.

To date, they said, few clinicians appear to be taking the risks of adhesiolysis seriously. "Underestimation of the related morbidity and the passiveness of many physicians, who consider adhesiolysis an annoying but unavoidable part of redo surgery, account for the paucity of reports on the consequences of adhesiolysis," they wrote.

The investigators noted as weaknesses of their study the need for adhesiolysis in 60% of procedures in the cohort and the low number of laparoscopies – which, they said, could limit the generalizability of the study results.

The study was sponsored by Radboud University Nijmegen Medical Center. Dr. ten Broek and his associates stated that they had no conflicts of interest.

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