Letter to the Editor

Abstract

I read with great interest the extremely well-written review by Somigliana et al [ 1 Somigliana E. Vigano P. Benaglia L. et al. Adhesion prevention in endometriosis: a neglected critical challenge. J Minim Invasive Gynecol. 2012; 19: 415-421 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar ] about adhesion prevention in endometriosis. In response, we would like to draw attention to Harold Ellis, who studied the pathogenesis and prevention of postoperative adhesions for 47 years. In 1962, Ellis published the results of meticulous experiments on the crucial role of ischemia in the pathogenesis of postoperative adhesions, thesis research to qualify for a Doctor of Medicine degree from Oxford University. Ellis tested his “ischaemic” theory of adhesion formation. He hypothesized that “it is not serosal integrity but tissue ischaemia which is the important factor in the aetiology of fibrous post-operative adhesions, and that these adhesions represent not scar tissue but vascular grafts from adjacent healthy organs into a devascularized substrate.” In a series of tissue crushing and devascularizing experiments on rats, Ellis showed clearly that tissue ischemia was a crucial stimulus for postoperative adhesion formation [ 2 Ellis H. The aetiology of post-operative abdominal adhesions: an experimental study. Br J Surg. 1962; 50: 10-16 Crossref PubMed Scopus (241) Google Scholar ]. In his experiments, omental pedicle grafts rapidly adhered to ischemic segments of intestine, and by 7 days, Ellis was able to demonstrate “large blood vessels…streaming across the omental graph into the underlying bowel and there establishing rich connexions with the intramural arteries” [ 3 Ellis H. The aetiology of post-operative adhesions. Proc R Soc Med. 1962; 55: 599-600 PubMed Google Scholar ]. Adhesion Prevention in Endometriosis: A Neglected Critical ChallengeJournal of Minimally Invasive GynecologyVol. 19Issue 4PreviewPrevention of adhesions, whether de novo or by re-formation, is one of the most important and surprisingly neglected aspect of the treatment of endometriosis. Adhesions may cause infertility, dyspareunia, chronic pelvic pain but also intestinal obstruction and complications at subsequent surgery. They may play a role in the development of some forms of the disease such as ovarian endometriomas and possibly also deep invasive nodules. Three randomized controlled trials have been published documenting some partial success with Interceed, Oxiplex/AP gel or Adept solution in reducing adhesions extent at second look laparoscopy performed a few weeks after initial surgery. Full-Text PDF ReplyJournal of Minimally Invasive GynecologyVol. 19Issue 6PreviewI would like to thank Dr. Batt for his contribution. The role of ischemia was not sufficiently emphasized in our article, and his comment is thus opportune, timely, and greatly appreciated. Ischemia has not received much attention in the pathogenesis of endometriosis-related adhesions. However, it is likely that it may contribute significantly. Moreover, it has to be pointed out that a critical aspect of endometriosis management is postsurgical adhesion formation or re-formation. In this particular context, the role of ischemia may be even more relevant. Full-Text PDF