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Background: Small bowel obstruction (SBO) is a common surgical emergency, causing high morbidity and healthcare costs. The majority of SBOs are caused by adhesions that result from previous surgeries. Bowel obstruction, however, also occurs in patients without previous operation or known pathology, a so called virgin abdomen. It is unknown if small bowel obstruction in the virgin abdomen (SBO-VA) can be managed according to the same principles as other cases of small bowel obstruction. The aim of this position paper is to evaluate the available evidence on etiology and management of small bowel obstruction in the virgin abdomen. Methods: This is a narrative review with scoping aspects. Clinical topics covered in this review include epidemiology and etiology of SBO-VA, diagnosis and imaging, initial assessment, the role of surgical management in SBO-VA, and the role of non-operative management in SBO-VA. Results: Our scoping search revealed seven original studies reporting original patient data related to SBO-VA. All the included studies are retrospective cohorts, with populations ranging between 44 and 103 patients with SBO-VA. Adhesions were found to be the cause of the obstruction in approximately half of the reported cases of SBO-VA. A relatively high number of cases of SBO-VA were managed surgically with studies reporting 39–83%. However, in cases where a trial of non-operative management was started, this was generally successful. Conclusion: The data available suggest that etiology and treatment results for patients with SBO-VA are largely comparable to the results in patients with SBO after previous abdominal surgery. We therefore propose that patients with a virgin abdomen could be treated according to existing guidelines for SBO and adhesive small bowel obstruction. [ABSTRACT FROM AUTHOR]

The growing incidence of cancer poses a diagnostic and therapeutic challenge for modern medicine. Surgical treatment remains the standard of care in gynecology, particularly in cancer patients. Proper selection of surgical technique is of key importance for optimal therapeutic outcomes with the lowest risk of postoperative complications. Thorough knowledge of these complications will enable not only proper treatment, but also providing patients with complete, reliable information on possible complications, pain or distant consequences of the chosen procedure. Age and comorbidities are well-known primary factors modifying the postoperative risk. The paper discusses prevention and interdisciplinary treatment of the most important and most common complications after major gynecologic surgeries. Due to the common location of the gastrointestinal, urinary and genital tracts in the abdominal cavity, the treatment of complications after extensive gynecologic surgeries often requires cooperation with a surgeon and an urologist. Proper pre-anesthetic assessment, hydration of the patient, assessment of preoperative nutritional status and an early onset of postoperative nutrition may reduce complications resulting from the clinical condition of the patient. It should be also noted that the proportions of different procedures have changed in recent years, with a gradual replacement of conventional laparotomies and transvaginal surgeries with increasingly popular endoscopic techniques. The paper discusses the most important postoperative complications, their symptoms and treatment strategies based on a literature review. [ABSTRACT FROM AUTHOR]

Background: postoperative peritoneal adhesions are common and frequent complication following abdominal and Pelvic Surgery. Adhesions can lead to bowel obstructions and infertility in women (when they develop around the reproductive organs), chronic pain which consequently results in reducing the quality of life for patients, level of energy, productivity, and increase the risk, complexity and chance of complications in subsequent surgeries. Main objective of this review is to study the implication of using the 'good surgical techniques' in the prevention of postoperative adhesions. Methods: the present review included randomized controlled trials (RCTs) that investigated the different surgical technique impact on adhesion-related outcomes were identified through search in Pubmed, CENTRAL and Embase. Identified endpoints were: clinical outcomes and incidence of adhesions. The primary Identification of papers and data extraction were performed by independent researchers. Results: out of 1709 studies, there were only 21 papers eligible for a systematic review and included in the meta-analysis and qualitative assessment. None of the techniques that were compared significantly reduced the incidence of adhesive small bowel obstruction. In a small low-quality trial, the pregnancy rate increased after subserous fixation of suture knots. However, the incidence of adhesions was lower after laparoscopic compared with open surgery [relative risk (RR) 0.14; 95% confidence interval (CI): 0.03-0.61] and when the peritoneum was not closed (RR 0.36; 95% CI: 0.21-0.63). Conclusion: None of the specific techniques that were compared reduced the two main adhesion-related clinical outcomes, small bowel obstruction and infertility. The meta-analysis provides some evidence for the surgical principle that using less invasive techniques, introducing less foreign bodies or causing less ischemia reduces the extent and severity of adhesions. [ABSTRACT FROM AUTHOR]

Pathogenesis of adhesions is still unclear and does not give a clear response whether the morphopathogenetic mechanisms of congenital and acquired adhesions in children are different or not. Thus, we searched for the appearance and distribution of growth factors, their receptors and chromogranins in adhesions of children in the ontogenetic aspect. Tissues were obtained from 17 children of group 1 (1 day to 3 years old) and 10 children of group 2 (10 to 16 years old). Visibly intact peritoneum was obtained from teenagers of group 2 and used as control tissue. Routine staining and immunohistochemistry for insulin-like growth factor 1 (IGF1), insulin-like growth factor 1 receptor (IGF IR), transforming growth factor beta (TGF-β), hepatocyte growth factor (HGF), chromogranin A (CgA) was applied. Statistical analysis included semi-quantitative evaluation of immunopositive structures, Wilcoxon signed-rank test and Wilcoxon rank sum test for comparison of data. The results showed patchy fibrosis with round-shaped fibroblasts, neoangiogenesis and inflammation. Adhesions in group 1 demonstrated various appearance of IGF, IGF IR, few to moderate number of TGF-β-, HGF- and moderate number of CgA-containing cells. In both groups, fibroblasts predominated among actively expressing cells. Group 2 showed moderate to numerous IGFI and HGF positive cells, while IGF IR- and TGF-β-containing cells were numerous. Intact peritoneum showed variable TGF-β, CgA, and few to moderate HGF, IGFI, IGF IR cells. In conclusion, an increase in IGFI, IGF IR, TGF-β and HGF characterises the acquired ("aged") adhesions. Fibroblasts are most active in adhesion formation with the increase of cellular activity during the aging of children and adhesions. Fibroblasts with changes in shape stimulate further development of disease via intensive CgA expression. [ABSTRACT FROM AUTHOR]

Abstract: This paper is the second of a two-part publication. The initial paper provided a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. There is rising evidence that surgeons can take important steps to reduce the burden of adhesions. In this second paper, we review the various strategies to reduce the impact of adhesions, improve surgical outcomes and provide some practical proposals for action on adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be considered for use particularly in high-risk surgery and in patients with adhesiogenic conditions. Further research into new strategies to prevent adhesions more effectively through an improved surgical environment, new and combination devices and pharmacological agents should be encouraged. Formal recommendations would ensure better prioritisation of adhesion-reduction within the French health system. Patients should also be better informed of the risks of adhesions. [Copyright &y& Elsevier]

Abstract: Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice. [Copyright &y& Elsevier]

Mounting evidence highlights that adhesions are now the most frequent complication of abdominopelvic surgery, yet many surgeons are still not aware of the extent of the problem and its serious consequences. While many patients go through life without apparent problems, adhesions are the major cause of small bowel obstruction and a leading cause of infertility and chronic pelvic pain in women. Moreover, adhesions complicate future abdominal surgery with important associated morbidity and expense and a considerable risk of mortality. Studies have shown that despite advances in surgical techniques in recent years, the burden of adhesion-related complications has not changed. Adhesiolysis remains the main treatment even though adhesions reform in most patients. Recent developments in adhesion-reduction strategies and new anti-adhesion agents do, however, offer a realistic possibility of reducing the risk of adhesions forming and potentially improving the clinical outcomes for patients and reducing the associated onward burden to healthcare systems. This paper provides a synopsis of the impact and extent of the problem of adhesions with reference to the wider literature and also consideration of the key note papers presented in this special supplement to Colorectal Disease. It considers the evidence of the risk of adhesions in colorectal surgery and the opportunities and strategies for improvement. The paper acts as a ‘call for action’ to colorectal surgeons to make prevention of adhesions more of a priority and importantly to inform patients of the risks associated with adhesion-related complications during the consent process. [ABSTRACT FROM AUTHOR]

Repair of a transected flexor tendon will, despite careful technique and early rehabilitation, usually result in a restricted range of movement. This is mainly because adhesions form between the tendon and the surrounding structures. Our aim was to establish an experimental model in rabbits for future studies on new techniques to reduce the formation of adhesions after zone II repair of flexor tendons. In rabbits' hind paws the metatarsal bones II, IV, and V were removed and the flexor tendon was freed to the metatarsophalangeal (MTP) joint. The digits were secured in a specifically-designed biomechanical testing device comprising a servo-hydraulic actuator that was designed to apply controlled force or displacement. The tests were videotaped with a digital force-monitor behind the tested digit. Paper printouts from the recordings were obtained for 0, 0.5, 1, 2, 3, 4, and 5 Newton (N) and metatarsophalangeal, proximal interphalangeal, and distal interphalangeal, angles and distances between metatarsophalangeal joints and claws were measured. The tensile strength of the tendon was evaluated by a load-to-failure test. The continuous data obtained from the experiments were used to calculate functional stiffness at the selected forces. The model allows for unique continuous recordings of mobility of toes, thereby indirectly quantifying the presence of adhesions and the assessment of tensile strength. The data are reproducible, and there is little variation between the digits tested. The model is primarily intended to compare data among treated and non-treated digits of methods to limit the formation of adhesions after tendons have been repaired. [ABSTRACT FROM AUTHOR]

Abstract: Many gynaecologists do not currently close the peritoneum after caesarean section (CS). Recently, several studies examining adhesion formation after repeat CS appear to favour closure of the peritoneum after caesarean section. We performed a systematic review of the current available evidence with regard to the long-term outcome, mainly in terms of adhesion formation after closure versus non-closure of peritoneum during CS. We undertook a literature search between January 1995 and February 2008 using MEDLINE, Pubmed, EMBASE, Cochrane central controlled trials register and Cochrane pregnancy and childbirth group trials register. We also had searched all the references cited in the relevant studies. Both English and non-English language papers were included. Prospective studies which compared peritoneal closure versus non-closure during CS in terms of adhesion formation were included. Studies were included if they had a primary objective to examine adhesion formation in a repeat caesarean section, had a clear study design, had an adhesion scoring system, excluded patients who had adhesions in the primary caesarean section or interim surgeries after the primary caesarean section, and had no usage of anti-adhesion agents in the primary caesarean section. Retrospective studies which were performed by case-notes review alone, were excluded. Eleven studies were identified via our search strategy. Five were retrospective and six were prospective. Out of the eleven studies, three satisfied the inclusion criteria and were included (n =249); two studies were follow-ups of RCTs and one was not randomised. Out of 249 women included in the analysis, 110 had peritoneal closure during CS whereas the other 139 did not have peritoneal closure. Meta-analysis was performed using the two randomised studies plus (i) the unadjusted estimate from the non-randomised study and (ii) the reported adjusted estimate, adjusted for baseline differences in the groups. Non-closure of the peritoneum during CS resulted in a significantly increased likelihood of adhesion formation in both meta-analyses—OR (95% CI): (i) 2.60 (1.48–4.56) and (ii) 4.23 (2.06–8.69). This systematic review has demonstrated that according to current data in the literature, there is some evidence to suggest that non-closure of the peritoneum after caesarean section is associated with more adhesion formation compared to closure. [Copyright &y& Elsevier]

The objective of this review is to present a current opinion on the management of small-bowel obstruction. The topic is limited to small-bowel obstruction secondary to postoperative adhesions. Other causes of small-bowel obstruction are not addressed. We attempt to give readers a concise insight into the evidence available in the English language literature. This paper does not offer a comprehensive review of the topic; rather it highlights some relevant issues and then outlines what role, if any, laparoscopic surgery should play in the management of adhesive small-bowel obstruction. [ABSTRACT FROM AUTHOR]

When Helicobacter pylori arrives in the human stomach, it may penetrate the mucin layer and adhere to the gastric epithelial cells or it may pass through the stomach without colonizing the mucosa. In this paper, the colonization process and the ensuing immunological response will be briefly described. Urease production is necessary for H. pylori to establish a pH-neutral microenvironment around the bacteria. The flagella enable the bacteria to move and the shape of H. pylori makes it possible to penetrate the mucin layer where it comes into contact with the gastric epithelial cells. H. pylori contains several adhesins that enable it to adhere to the epithelial cells. This adherence activates IL-8 which, together with bacterial antigens, attracts polymorphs and monocytes and causes acute gastritis. Antigen-presenting cells activate lymphocytes and other mononuclear cells that are attracted to the inflamed mucosa, causing chronic superficial gastritis and initiating a cytotoxic or an antigen-producing Th response. The infection is established within a few weeks after the primary exposure to H. pylori. After this initial colonization, many chemical, biochemical, and immunologic reactions take place that are of importance in the progress of the infection and the development of disease. [ABSTRACT FROM AUTHOR]

The extent of the problem of adhesions is considerable and poses a significant burden on healthcare systems, the workload of surgeons and the lives of patients. This paper reviews the work undertaken and the associated evidence for the impact of adhesions. It considers the various options and strategies to reduce adhesions alongside the fundamental necessity for good surgical technique. [ABSTRACT FROM AUTHOR]

Several previous studies have shown that Gastrografin can be utilized to triage patients with adhesive small bowel obstruction (ASBO) to an operative or a non-operative course. Previous studies assessing the therapeutic effect of Gastrografin have been confounded by post-administration radiology alerting the physician to the treatment group of the patient. Therefore the aim of the present paper was to test the hypothesis that Gastrografin hastens the non-operative resolution of (ASBO). Patients, diagnosed with ASBO on clinical and radiological grounds, were randomized to receive Gastrografin or placebo in a double-blinded fashion. Patients did not undergo further radiological investigation. If the patient required subsequent radiological intervention or surgical intervention they were excluded from the study. End-points were passage of time to resolution of ASBO (flatus and bowel motion), length of hospital stay and complications. Forty-five patients with ASBO were randomized to receive either Gastrografin or placebo. Two patients were excluded due to protocol violations. Four patients in each group required surgery. Eighteen of the remaining patients received Gastrografin and 17 received placebo. Patients who received Gastrografin had complete resolution of their ASBO significantly earlier than placebo patients (12 vs 21 h, P = 0.009) and this translated into a median of a 1-day saving in time in hospital (3 vs 4 days, P = 0.03). Gastrografin accelerates resolution of ASBO by a specific therapeutic effect. [ABSTRACT FROM AUTHOR]

Introduction. Adhesions occur in more than three fourths of patients after laparotomy following by numerous serious complications. Thus pathogenesis of adhesions still is the research field and the aim of our work was to reveal the growth factors, neuropeptide-containing innervations, cell adhesion molecules, and apoptosis in human intact and fibrous peritoneal tissues of different adhesion sites. Materials and methods. Fibrous adhesions were obtained from eight 10-14 years old patients. Tissues were proceeded for bFGF, FGFR, NGF, NGFR, TGFβ, PGP 9.5, VEGF, VIP, SP, ICAM-1, VCAM-1 immunohistochemically. TUNEL was used for the detection of apoptosis. Results. All the tested areas showed a high expression of FGFR and NGFR, but bFGF and NGF were low or negative. TGFβ-containing structures were richly distributed in the connective tissue of adhesions (except the small intestine area) and in intact peritoneum. Numerous to abundant PGP 9.5-containing nerves were detected only into the adhesions. Occasional SP positive nerves were observed only in all the adhesions, while VIP fibres here were slightly increased. VEGF was richly expressed by endothelial cells in appendix adhesions, notable in small intestine adhesions, but almost negative in large bowel adhesions and intact peritoneum. Numerous to abundant ICAM-1 and VCAM-1 expression was observed regionally in all the materials. Apoptosis affected regionally connective tissue cells, changed in shape mesothelial cells in adhesions and some cells in intact peritoneum. Conclusions. The inhomogeneous appearance of TGFβ and VEGF suggests about the individual variations in expression of these growth factors in adhesions. The abundant expression of ICAM-1 and VCAM-1 in endothelium and mesothelium proves the involvement of these adhesion molecules in functioning of blood vessels and simple squamous epithelium of adhesions. Increased occurrence of neuropeptide-containing nerves and NFGR also indicates the increased role of innervation in adhesions. However, PGP 9.5-containing innervation does not cover the appearance of VIP- and SP-nerves and also seems to include other neuropeptides in the pathogenesis of adhesions. Regional apoptosis is speculated to depend on the local expression of growth factors, inflammatory mediators and tissue degradating enzymes. The distribution of growth factors, neuropeptide-containing innervation and apoptosis do not depend on the adhesion site. [ABSTRACT FROM AUTHOR]