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How Are Adhesions Treated?

Question:

With my recurring adhesions, what are my options for treatment?

Answer:

Once adhesions are present, there are two crucial aspects to getting rid of them. The first is surgical removal of all of the adhesions, and the second is to prevent them from coming back during the healing process. Adhesions form or reform in the first couple of days and weeks after surgery. If they are not present a month after the surgery, they will not reform.

Merely cutting the adhesions is not adequate treatment, as this leaves scar tissue that can re-adhere to other tissue. All of the abnormal adhesive tissue should be completely removed. In addition, about half the time patients who have endometriosis elsewhere in the body also have endometriosis in scar tissue. Scar tissue is abnormal tissue that should be removed, allowing the remaining normal, healthy tissue to heal properly. A laser laparoscope is particularly useful in treating thick and/or cohesive adhesions, helping to minimize trauma to the normal tissue. The leathery type of tissue that squeezes the normal tissue (see discussion in "Ask Dr. Cook" archive – What Are Adhesions?) should be removed as well. Laser laparoscopy is ideal for this process, as it allows for the removal of the fibrous scar tissue while leaving the normal tissue unharmed.

As we described in the "What Causes Adhesions?" section, the single most important factor in preventing adhesion reformation is good surgical technique. But having said this, even with good surgical technique, once scar tissue has formed there is always a chance it may reform – even after it has been removed. Scar tissue forming or re-forming following surgery is simply an error in the healing process. If two structures are touching each other (e.g., the ovary and the bowel) during the healing process, the body – mistakenly thinking that the two structures are one – may heal them as one, forming scar tissue around both of them.

Once all of the scar tissue is removed, how can we keep it from coming back? Currently, several supportive measures are available which can be used at the completion of surgery.

Interceed
At present the most common supportive measure is Interceed. This looks like a white mesh material that turns into a gel and can be placed via the laparoscope, or at laparotomy. Interceed acts as a temporary barrier, hopefully preventing the surfaces from sticking together during the healing process and forming adhesions. Eventually the Interceed dissolves, and is eliminated from the body. Studies in patients who received Interceed following their surgeries have suggested a reduction in the amount and degree of adhesion formation.

I was involved with some of the initial studies of the use of Interceed. If any oozing (minimal bleeding) is present, it appears that Interceed can actually increase the formation of adhesions (this opinion is shared by several members of the medical community).

Seprafilm
Seprafilm is another product used to help prevent adhesion formation. It looks like waxed paper, but turns into a gel once inside of the body. Eventually it dissolves, and is eliminated by the body approximately a month later. Studies to date have shown that Seprafilm reduces the number and extent of adhesions. Seprafilm's primary disadvantage is that it is virtually impossible to place through the laparoscope. Also, it is brittle and fairly difficult to place at laparotomy.

Gortex Soft Tissue Patch
Gortex Soft tissue patch (previously Gortex Surgical Membrane) looks kind of like white plastic paper, and was the next development in adhesion prevention. I was involved in the first gynecologic studies of Gortex Surgical Membrane at Johns Hopkins Hospital with Dr. John Rock, and used it following myomectomy to prevent adhesion formation. It works well, although fairly large pieces are needed, and they must be sutured into place. Also, the primary disadvantage of Gortex is that it is a permanent foreign body, which could increase the risk of an infection.

ADEPT
ADEPT® Adhesion Reduction Solution was approved by the FDA in August 2006. Its use is indicated intraperitoneally as an adjunct to good surgical technique for the reduction of post-surgical adhesions in patients undergoing gynecological laparoscopic adhesiolysis. ADEPT® is the first FDA-cleared device for adhesion reduction in gynecologic laparoscopic surgery.

Intergel
The FDA initially rejected approval of Intergel in the United States in 2000 because of an increased risk of infection in women. The manufacturer appealed this denial and received approval for Intergel in November 2001. A significant number of complications, including post-operative infection and even death, have been reported following the use of Intergel. The manufacturer voluntarily recalled Intergel on March 27, 2003 after receiving a warning letter from the FDA in January 2003.

SprayShield Adhesion Barrier System
The SprayShield™ Adhesion Barrier System was released for use in Europe on October 2, 2008. It offers surgeons a unique synthetic, sprayable hydrogel that provides a strong barrier between tissue and organ planes, helping to reduce the development of post-surgical adhesions. The SprayShield Adhesion Barrier System is indicated for use in both open and laparoscopic abdominopelvic surgical procedures. This product is not currently available in the United States.

Adhibit
Adhibit is also a synthetic hydrogel anti-adhesion product. It is sprayed onto the surgical site as two separate streams of polyethylene glycol-based precursor liquids, which rapidly cross-link on the target tissue to form a flexible, adherent, bioabsorbable gel barrier.

Adhibit is chemically identical to Angiotech's CoSeal® Surgical Compound. I have used this product in a lab. I was impressed with the product, and feel that it holds promise. Vital Health Institute was slated to be one of the studies centers for clinical trials of this product several years ago. The FDA is requiring manufacturers to demonstrate that anti-adhesions products demonstrate a reduction of pain as well as a reduction in adhesion formation.

Currently approved in Europe to prevent or reduce post-surgical adhesion formation in pediatric patients undergoing cardiac surgery, Adhibit is an Angiotech product that is sold and marketed by Baxter Healthcare Corporation worldwide, excluding the U.S. Baxter has an option to license Adhibit in the U.S.; however, Adhibit is not currently approved for sale in the U.S.

In conclusion, adhesions can be treated effectively with good surgical techniques, combined with supportive adhesion prevention products. Adhesion prevention products can be helpful in reducing adhesion reformation. However, more effective products are needed and are in development. Since there is always a risk of adhesion re-formation, the specific treatment for each individual case should be chosen by the patient's surgeon.

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