Adhesions (6) – Does surgery help?

An almost inescapable result of abdominal surgery such as I had as a baby for pyloric stenosis is the formation of adhesions – tough bands of fibrous scar-like tissue formed as part of the healing process and linking and sometimes strangling internal organs and causing pain and sometimes disfigurement.

In this post I want to pass on in full a WebMD Health News 10 April 2003 article that explains why adhesions are very hard to treat and in many cases best left alone.  The points made in this article match what I have learnt from everything I have read about treating adhesions, and what I have observed in my life-work of caring for people, including some with this troublesome condition.

A new study shows that a common surgery for chronic abdominal pain doesn’t actually seem to relieve the pain.  Scar tissue in the abdomen is thought to be a common cause of chronic abdominal pain.  But researchers say that doctors shouldn’t recommend this surgery because the risks outweigh the benefits.

In the study, researchers looked at people with chronic abdominal pain who were found to have abdominal scar tissue (adhesions) during laparoscopic surgery — a procedure in which a scope is inserted through several small holes in the abdomen.  Half of these people then went on to have laparoscopic surgery to remove the scar tissue.

But the scar removal surgery appeared to have no effect on relieving chronic abdominal pain.  The group that had only the original surgery — without scar tissue removal — had the same degree of pain relief.

The problem, says laparoscopic surgeon Dingeman Swank, MD, is that the rate of serious complications is relatively high with the scar removal surgery, and the patients who have it appear to fare no better than those who have diagnostic laparoscopy without removal of abdominal adhesions.

“We are not saying that diagnostic surgery should not be done, because in 5% to 7% of patients, causes for pain other than adhesions can be found and successfully treated,” Swank tells WebMD.  “But removing adhesions offers no benefits for patients.”

Adhesions can form without an obvious cause, but usually result from damage to tissue and organs caused by surgery, such as those shown in this diagram – caused by an appendectomy.

Chronic abdominal pain is often difficult to diagnose and treat.  And people with this condition often undergo many tests without a cause being found.  Bands of scar tissue that attach to organs and other tissue can result from previous abdominal surgery, past infections, or endometriosis.  Adhesions are believed to be a common cause of chronic abdominal pain, although many experts question this association.

Surgery to remove abdominal scar tissue is often the treatment of choice for chronic abdominal pain with no other known cause.  But Swank says he began questioning the surgery’s value after performing the procedure on some 200 patients.

“In this group of people with longstanding abdominal pain we had two deaths and a 10% incidence of serious complications, mostly bowel perforations,” he says.

In this study, Swank and colleagues from the Groene Hart Hospital in the Netherlands, recruited 100 patients (87 women and 13 men) who had undergone prior surgeries for chronic abdominal pain.  Half got the scar removal surgery and the other half had diagnostic laparoscopy without removal of adhesions.

The patients were followed for the next year, during which time pain was assessed through a variety of methods.  Both groups reported substantial improvement in their chronic abdominal pain and improved quality of life a year after surgery.  The degree of pain relief was similar for both groups.  Swank attributes the pain relief in both groups to the placebo effect.  The findings are published April 12, 2003 in the journal The Lancet.

Reproductive endocrinologist and adhesion specialist Michael P. Diamond, MD, tells WebMD the main downside to scar removal surgery is not that it doesn’t work, but that it doesn’t work for very long.  In his own studies, adhesions recurred in more than 95% of patients who have the surgery.

“The literature suggests that 70% to 80% of patients will experience a reduction in pain with this surgery, but these studies don’t follow patients very long,” says Diamond, who directs the division of reproductive endocrinology and infertility at Detroit Medical Center and Wayne State University.  “The truth is that our ability to help patients with longstanding pain who have had multiple surgeries is not at all what we would like it to be.”

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2 thoughts on “Adhesions (6) – Does surgery help?

  1. Wendy

    Hmmm, I urge you to find other doctors’ opinions. Are there doctors who’ve had more success reducing the pain of adhesions? Why does Dr. Swank think that the pain relief after surgery was due to the placebo effect? Also, when Dr. Diamond states that “scar removal surgery . . . doesn’t work for very long,” what exactly is he talking about? 10 years? 5? Depending on this number, the surgery could be well worth it for folks who experience significant abdominal pain. What is true is that any surgery involves risk and one has to weigh the potential benefits vs the potential downsides very carefully. I am so lucky that I haven’t had complications from PS surgery.

    Reply
  2. Fred Vanderbom Post author

    Thank you for your thoughtful questions and comments, Wendy.
    My reading tells me that
    (1) most doctors don’t want to know about adhesions, even ignoring the fact of past surgery and the symptoms of adhesions; after the stonewalling that is so common it seems many patients give up and just bear with the pain and discomfort which are usually not life-threatening;
    (2) the effectiveness of adhesion removal is rarely permanent but its duration varies greatly: you are right that many patients want relief even if it may not be lifelong;
    (3) the article I included above is very much a “one-of” but worth considering since it seems there is so little discussion of this subject.

    Reply

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