Intra-abdominal adhesions in ultrasound. Parts I and II.

Abstract

The peritoneal adhesions and their clinical consequences, such as bowel obstruction, infertility in women and increased risk of extrauterine pregnancy, still remain an unsolved problem in contemporary intra-abdominal surgery. The frequency of occurrence of adhesions following laparotomies is estimated to reach 67–97%(1, 2). The most common causes encompass a physical trauma (including surgical or thermal one, e.g. electrocoagulation), infection, ischemia and the presence of a foreign body (stitches, talc, gauze, intestinal contents). Peritoneal adhesions are the most common cause of intestinal obstruction. The presence of adhesions increases the risk of each surgery and extends its duration, in particular, the stage of opening the abdominal cavity. Adhesions increase the probability of damaging the intestine while opening the abdominal cavity by 20%(3–5). Adhesive obstruction of the bowels may occur in 5% of patients who underwent a surgery(6). The adhesions which cause intestinal obstruction most frequently form after surgeries involving the large intestine as well as urologic and gynecological procedures. After laparoscopic procedures, adhesions appear more rarely and their preparation is easier(7–9). The methods that help decrease the risk of intra-abdominal adhesions include: non-traumatic surgeries, minimally invasive surgery, usage of gloves without talc, removal of drains and remains of dead tissues from the peritoneal cavity, restraining from suturing the defects in the peritoneum as well as administering pharmacological agents such as non-steroidal anti-inflammatory drugs, anticoagulants, vitamin E, statin, medicines with topical anesthetizing effect, dextran derivatives (Adept – 4% icodextrin solution) and Seprafilm (a biological barrier that prevents adhesions; composed of two polysaccharides: hyaluronic acid, carboxymethylcellulose). Seprafilm is very hydrophilic and does not require suturing. The differentiation between simple mechanical obstruction and strangulation obstruction constitutes a difficult clinical problem. Strangulation and necrosis of the bowel are the cause of a high perioperative mortality rate which in these cases equals 8–28%(7, 10). When diagnosing adhesive obstruction, the most valuable methods comprise: repeated physical examinations, plain abdominal x-ray, computed tomography and bowel passage with water soluble contrast agent (gastrografin). Gastrografin is a hyperosmolar agent (1900 mOsm/L) which increases the amount of water in the bowel and stimulates its peristalsis. The bowel passage of gastrografin is then both a diagnostic and therapeutic method(11–13). To prevent adhesive obstruction, it is proposed to perform internal intestinal splinting for the period of 7–14 days(14). The relevant literature relatively seldom mentions the value of ultrasound examination (US) in assessing the number and localization of intra-abdominal adhesions. It is a shame since there are more and more specialists in clinical sonography who use more and more advanced US equipment. Therefore, abdominal examinations performed to assess adhesive disease of the peritoneal cavity should be encouraged. In 1994, Duffy and diZerega proposed the application of abdominal US examination prior to laparoscopic management of adhesive obstruction in order to localize the first trocar(15). I know Professor Andrzej Smereczynski personally. I have always admired him for his stubbornness in research, consistent actions, enthusiasm and motivation. The Professor has vast experience in clinical sonography. He constantly verifies his studies and findings in the operation theatre. He checks himself and his actions. This is a rare and exceptional feature among diagnosticians. I have read both papers with huge interest(16, 17). Despite my limited, not to say, scarce knowledge and experience in the field of sonography, I recognize the diagnostic significance and value of the examination that is performed well and properly. I can think of numerous clinical situations in which sonographic assessment of adhesions would be of enormous significance, namely: The selection of the best site to perform a surgical cut or insert the first trocar in the patients with the history of surgeries (laparotomies). Such a procedure would surely reduce the risk of damaging the bowel when opening the abdomen. The help to differentiate between simple intestinal obstruction and strangulation of the mesentery that may cause bowel necrosis and requires urgent surgical intervention. Diagnosis of so-called aggressive fibromatosis of the peritoneum in the course of multiple, familial polyposis of the large intestine. The more common application of US examination in intra-abdominal adhesions would reduce the number of computed tomography examinations which are expensive and burden the patient with a high dosage of radiation. I can imagine that learning sonographic diagnosis of intraabdominal adhesions requires a long training. Nonetheless, with such a distinguished center, where Professor Smereczynski works, we might hope that more and more radiologists and other specialists, necessarily including surgeons, will take an interest in this diagnostic method. With all my heart, I wish you all the best and many successes in developing intra-abdominal adhesion sonography.