14 January 2020

Adhesions after abdominal surgery cause too many re-admissions. Although keyhole surgery reduces the number of adhesions and the complications associated with them, the total disease burden remains high, as reported in The Lancet by researchers from Radboud university medical center. Following abdominal surgery, 4.7% of all patients are still re-admitted for complications due to adhesions. Measures to achieve further reductions in the disease burden—including for abdominal surgery—are urgently needed.

Internal scar tissue emerges relatively frequently following abdominal surgery. Such ‘adhesions’ can have far-reaching consequences. In a 2013 article in British Medical Journal, the surgical resident Richard ten Broek presented an overview of the most important complications (e.g., acute ileus, chronic pain, intestinal injuries from repeat surgeries, and decreased fertility). Adhesions thus constitute a serious medical problem.

The first large-scale study on adhesions (the SCAR study) was conducted in 1999, in which all patients in Scotland who had undergone abdominal surgery were followed. Of these patients, 5% were re-admitted in subsequent years due to complications that were definitely caused by adhesions. In addition, one third of all patients were re-admitted for complaints that were possibly consistent with complications from adhesions.
Fewer adhesions due to keyhole surgery
“The SCAR study was a catalyst for anti-adhesion drugs,” notes ten Broek from Radboudumc, “but most of these drugs were suitable for open surgery, which involves actually opening up the abdomen. At the time that these drugs were introduced, surgeons were increasingly shifting to laparoscopy—to minimally invasive keyhole operations.”

Although it was assumed that keyhole operations would result in fewer adhesions, it would be a long time before we could know the exact reduction in the number of adhesions or whether such techniques also led to other complications. Ten Broek: “In a recent publication, the ten Broek/van Goor research group demonstrates that, following open surgery, adhesions occur in nearly 90% of all patients. After laparoscopy, the number is about 70%. In addition, the adhesions occurring with open surgery are often more extensive, particularly in the direction of the abdominal wall.”
Fewer, but still too many
To improve the comparability of figures, ten Broek and his colleagues re-used the data from the Scottish databank to investigate re-admissions. This SCAR update, which was published in The Lancet, indicates that keyhole surgery reduces the risk of re-admissions due to adhesions. This reduction was 30% for re-admissions that were definitely due to adhesions, and 10% for complications that might have been associated with adhesions.

This seems to be good news. “Absolutely”, states ten Broek, “any decrease in the number of adhesions is more than welcome. Nevertheless, the total disease burden is still high. Too high. Of all patients who have had surgery, 4.7% are still re-admitted for complications due to adhesions, and about 30% are re-admitted for complications that might be associated with adhesions. In 1999, the total disease burden was virtually the same (re-admission rates of 5% and more than 30%, respectively). The risk of complications within certain groups (e.g., surgery on the large intestine or gynecological procedures) also remains high, even for keyhole operations. Although keyhole surgery has reduced the risk of adhesions, the disease burden for adhesions is still too high, even for laparoscopy. We must continue working to reduce these risks even further, while increasing the use of anti-adhesion drugs.”

Publicatie in The Lancet 
Adhesion-related readmissions after open and laparoscopic surgery: a retrospective cohort study (SCAR update) - Pepijn Krielen, Martijn W J Stommel, Pille Pargmae, Nicole D Bouvy, Erica A Bakkum, Harold Ellis, Michael C Parker, Ewen A Griffiths, Harry van Goor, Richard P G ten Broek
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