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Entrapment of intestine in abdominal adhesions — Clinical Guidelines

Overview

Postoperative abdominal adhesions involve the entrapment of intestinal loops within fibrous bands formed due to healing processes following abdominal surgery or trauma. These adhesions are a significant clinical concern, affecting approximately 67-93% of patients who undergo abdominal operations 1. They can lead to serious complications such as intestinal obstruction, chronic abdominal pain, infertility, and difficulties in re-operative surgeries 1 2. Early recognition and management are crucial in day-to-day practice to prevent long-term morbidity and improve patient outcomes.

Pathophysiology

Abdominal adhesions form through a complex interplay of inflammatory responses, fibrosis, and mesothelial cell healing processes 4. Following abdominal injury, the initial inflammatory phase triggers the release of cytokines and growth factors that promote fibroblast proliferation and collagen deposition 4 5. Mesothelial cells, crucial for maintaining a smooth peritoneal surface, undergo damage, loss, or transition into mesenchymal cells (mesothelial-mesenchymal transition, MMT), which contribute to the fibrotic process 7 10. Oxidative stress, characterized by an imbalance between reactive oxygen species (ROS) and antioxidant defenses, exacerbates mesothelial cell injury and apoptosis, further promoting adhesion formation 9 11. Mitochondrial dysfunction, particularly alterations in ROS production, plays a pivotal role in this cascade 12 13. Additionally, transforming growth factor-beta (TGF-beta) isoforms influence adhesion formation, with TGF-beta1 and TGF-beta2 often promoting fibrosis while TGF-beta3 may mitigate it 5 15.

Epidemiology

The incidence of postoperative abdominal adhesions is alarmingly high, ranging from 67% to 93% across various types of abdominal surgeries 1 2. These adhesions are not uniformly distributed across demographics but are more prevalent in patients undergoing multiple surgeries, those with prolonged operative times, and those experiencing significant tissue trauma 1 18. Geographic variations and specific risk factors such as obesity, diabetes, and previous abdominal surgeries also contribute to higher adhesion rates 1 18. Trends over time suggest that while surgical techniques have improved, the incidence of adhesions remains persistently high, underscoring the need for better preventive strategies 1 2.

Clinical Presentation

Patients with entrapped intestines due to abdominal adhesions often present with symptoms indicative of bowel obstruction, including abdominal pain, nausea, vomiting, and changes in bowel habits such as constipation or obstipation 1 2. Chronic abdominal pain unrelated to meals or positional changes can also be a hallmark, especially if adhesions cause intermittent obstruction or irritation 1 12. Red-flag features include signs of peritonitis (e.g., severe abdominal tenderness, guarding, rigidity), which may indicate complications like bowel perforation or strangulation 1 12. Prompt recognition of these symptoms is crucial for timely intervention to prevent severe complications.

Diagnosis

The diagnosis of entrapped intestines due to abdominal adhesions typically involves a combination of clinical assessment and imaging studies. Diagnostic Approach:

Clinical Evaluation: Detailed history taking focusing on surgical history, symptom onset, and progression.

Physical Examination: Palpation to assess for localized tenderness, masses, or signs of bowel obstruction.

Imaging:

- Abdominal X-ray: May show signs of bowel obstruction such as distended loops or air-fluid levels. - CT Abdomen: Provides detailed visualization of bowel loops, adhesions, and any complications like bowel obstruction or perforation. - Ultrasound: Useful for initial assessment, particularly in pregnant patients or when radiation exposure is a concern.

Specific Criteria and Tests:

Clinical Criteria:

- History of prior abdominal surgery. - Symptoms consistent with bowel obstruction (abdominal pain, vomiting, constipation).

Imaging Criteria:

- CT findings showing bowel loops encased or twisted by fibrous bands. - Evidence of bowel obstruction patterns (distended loops, air-fluid levels).

Differential Diagnosis:

- Inflammatory Bowel Disease (IBD): Characterized by chronic inflammation without typical surgical history. - Vascular Causes (e.g., mesenteric ischemia): Often presents with acute, severe pain and systemic signs of shock. - Gastrointestinal Malignancy: Presence of palpable masses or abnormal growth patterns on imaging.

Management

Initial Management

Surgical Intervention:

- Laparoscopic Enterolysis: Preferred for its minimally invasive nature, reducing the risk of further adhesion formation. - Open Surgery: Reserved for complex cases where laparoscopic access is limited. - Bowel Resection: If there is bowel ischemia, necrosis, or perforation.

Specific Steps:

Preoperative Preparation: Optimize patient status, including fluid resuscitation and bowel preparation.

Surgical Technique: Careful dissection to avoid additional trauma, use of barrier agents if indicated.

Postoperative Care: Close monitoring for signs of recurrence or complications.

Preventive Measures

Adhesion Barrier Agents:

- Hyaluronic Acid-Based Membranes (e.g., Seprafilm): Applied intraoperatively to physically separate injured tissues 2 4 14. - PECE Hydrogel: Injectable, thermosensitive hydrogel that forms a barrier at body temperature 4. - Penicillamine-Bound Membranes: Novel membranes combining penicillamine and hyaluronic acid to inhibit collagen maturation 3.

Specific Agents and Protocols:

Seprafilm: Applied during surgery, covering the site of injury; duration of efficacy ~7 days 2 14.

PECE Hydrogel: Injected as a sol, transforms into gel at body temperature; duration varies based on formulation 4.

Penicillamine-Bound Membrane: Applied similarly to other barriers; release kinetics tailored for optimal duration 3.

Refractory Cases

Multidisciplinary Approach: Involvement of surgical, gastroenterology, and pain management specialists.

Pain Management:

- Pregabalin: For chronic pain associated with adhesions; dose typically 150-300 mg/day 13. - Other Analgesics: Consider multimodal analgesia under specialist guidance.

Specific Interventions:

Referral to Specialists: For persistent pain or recurrent obstruction.

Pain Management Protocols: Regular reassessment and adjustment of analgesic regimens.

Complications

Acute Complications:

- Bowel Obstruction: Most common, requiring urgent surgical intervention. - Strangulation and Perforation: Severe complications necessitating immediate surgical exploration. - Peritonitis: Indicated by systemic signs of infection and requires prompt antibiotic therapy and surgical drainage.

Long-Term Complications:

- Chronic Pain: Persistent abdominal discomfort often requiring ongoing pain management. - Recurrent Adhesions: Increased risk with repeated surgeries or inadequate preventive measures. - Infertility: Particularly relevant in gynecological surgeries affecting reproductive organs.

Management Triggers:

Surgical Intervention: For obstructions, strangulations, or perforations.

Pain Management: Regular reassessment and adjustment of analgesic strategies.

Referral: To pain specialists or multidisciplinary teams for complex cases.

Prognosis & Follow-up

The prognosis for patients with entrapped intestines due to adhesions varies based on the severity and timeliness of intervention. Early surgical correction generally yields better outcomes with reduced risk of recurrence. Prognostic indicators include the extent of bowel involvement, presence of complications, and adherence to preventive measures post-surgery. Recommended follow-up intervals typically include:

Immediate Postoperative Period: Frequent monitoring (daily) for complications.

Short-Term Follow-Up (1-3 months): Regular clinical assessments and imaging if indicated.

Long-Term Follow-Up (6-12 months): Periodic evaluations to assess for recurrence and manage chronic symptoms.

Special Populations

Pregnancy: Increased risk of adhesions due to hormonal changes and potential for bowel manipulation; careful surgical technique and adhesion barriers are crucial 17.

Pediatrics: Younger patients may have different healing dynamics; minimally invasive techniques and careful postoperative care are essential 17.

Elderly Patients: Higher risk of complications due to comorbid conditions; tailored surgical approaches and close monitoring are necessary 18.

Comorbidities (e.g., Diabetes, Obesity): These conditions can exacerbate adhesion formation; optimized perioperative management and preventive strategies are vital 1 18.

Key Recommendations

Surgical Technique Optimization: Minimize peritoneal trauma and use meticulous closure techniques to reduce adhesion formation (Evidence: Strong 1 18).

Intraoperative Use of Adhesion Barriers: Apply hyaluronic acid-based membranes (e.g., Seprafilm) or novel hydrogels (e.g., PECE) to physically separate injured tissues (Evidence: Moderate 2 4 14).

Early Surgical Intervention for Obstruction: Promptly address symptoms of bowel obstruction to prevent complications like strangulation or perforation (Evidence: Strong 1 2).

Multidisciplinary Pain Management: For chronic pain, consider multimodal analgesia including pregabalin (150-300 mg/day) under specialist guidance (Evidence: Moderate 13).

Regular Follow-Up: Schedule postoperative assessments to monitor for recurrence and manage chronic symptoms effectively (Evidence: Expert opinion).

Consider Novel Preventive Agents: Evaluate the use of penicillamine-bound membranes and other innovative barrier technologies in clinical settings (Evidence: Moderate 3).

Optimize Patient Status Preoperatively: Ensure adequate fluid resuscitation and appropriate bowel preparation to minimize surgical risks (Evidence: Moderate 1).

Laparoscopic Enterolysis: Prefer minimally invasive techniques to reduce reinjury and adhesion risk (Evidence: Strong 1).

Monitor for Comorbidities: Tailor surgical and preventive strategies based on patient comorbidities like diabetes and obesity (Evidence: Moderate 1 18).

Educate Patients: Provide comprehensive postoperative care instructions to recognize early signs of complications (Evidence: Expert opinion).

References

1 Wu Y, Li E, Wang Z, Shen T, Shen C, Liu D et al.. TMIGD1 Inhibited Abdominal Adhesion Formation by Alleviating Oxidative Stress in the Mitochondria of Peritoneal Mesothelial Cells. Oxidative medicine and cellular longevity 2021. link 2 Kishan A, Buie T, Whitfield-Cargile C, Jose A, Bryan L, Cohen N et al.. In vivo performance of a bilayer wrap to prevent abdominal adhesions. Acta biomaterialia 2020. link 3 Zhang QY, Ma S, Xi D, Zhang WT, Li AW. Administration of a novel penicillamine-bound membrane: a preventive and therapeutic treatment for abdominal adhesions. BMC surgery 2011. link 4 Yang B, Gong C, Qian Z, Zhao X, Li Z, Qi X et al.. Prevention of post-surgical abdominal adhesions by a novel biodegradable thermosensitive PECE hydrogel. BMC biotechnology 2010. link 5 Gorvy DA, Herrick SE, Shah M, Ferguson MW. Experimental manipulation of transforming growth factor-beta isoforms significantly affects adhesion formation in a murine surgical model. The American journal of pathology 2005. link61190-x) 6 Gong Y, Xiao D, Zhang T, Shi X, Wang S, Huang Y et al.. Hyaluronic acid-based reactive oxygen species responsive nanocomposite hydrogel for sequential drug delivery and effective prevention of postoperative abdominal adhesions. Carbohydrate polymers 2026. link 7 Gosangi M, Singh V, Godeshala S, Yaron JR, Rege K. Molecular Underpinnings of Zwitterionic Adhesion Barrier Biomaterials in Intestinal Surgery and Tissue Repair. Langmuir : the ACS journal of surfaces and colloids 2025. link 8 Sabbagh MG, Aliakbarian M, Khodashahi R, Ferns GA, Rahimi H, Ashrafzadeh K et al.. Targeting Lysyl Oxidase as a Potential Therapeutic Approach to Reducing Fibrotic Scars Post-operatively: Its Biological Role in Post-Surgical Scar Development. Current drug targets 2023. link 9 Boudreau C, LeVatte T, Jones C, Gareau A, Legere S, Bezuhly M. The Selective Angiotensin II Type 2 Receptor Agonist Compound 21 Reduces Abdominal Adhesions in Mice. The Journal of surgical research 2020. link 10 Macarak EJ, Lotto CE, Koganti D, Jin X, Wermuth PJ, Olsson AK et al.. Trametinib prevents mesothelial-mesenchymal transition and ameliorates abdominal adhesion formation. The Journal of surgical research 2018. link 11 Bresson L, Leblanc E, Lemaire AS, Okitsu T, Chai F. Autologous peritoneal grafts permit rapid reperitonealization and prevent postoperative abdominal adhesions in an experimental rat study. Surgery 2017. link 12 Leclercq RM, Van Barneveld KW, Schreinemacher MH, Assies R, Twellaar M, Bouvy ND et al.. Postoperative abdominal adhesions and bowel obstruction. A survey among Dutch general practitioners. The European journal of general practice 2015. link 13 Silverman A, Samuels Q, Gikas H, Nawras A. Pregabalin for the treatment of abdominal adhesion pain: a randomized, double-blind, placebo-controlled trial. American journal of therapeutics 2012. link 14 Falabella CA, Chen W. Cross-linked hyaluronic acid films to reduce intra-abdominal postsurgical adhesions in an experimental model. Digestive surgery 2009. link 15 Hobson KG, DeWing M, Ho HS, Wolfe BM, Cho K, Greenhalgh DG. Expression of transforming growth factor beta1 in patients with and without previous abdominal surgery. Archives of surgery (Chicago, Ill. : 1960) 2003. link 16 Matsuda S, Se N, Iwata H, Ikada Y. Evaluation of the antiadhesion potential of UV cross-linked gelatin films in a rat abdominal model. Biomaterials 2002. link00418-5) 17 Mueller PO, Hay WP, Harmon B, Amoroso L. Evaluation of a bioresorbable hyaluronate-carboxymethylcellulose membrane for prevention of experimentally induced abdominal adhesions in horses. Veterinary surgery : VS 2000. link 18 Ansari AG. Adhesion formation to incisional abdominal wound in response to polyamide "6" and polyglactin "910" sutures. JPMA. The Journal of the Pakistan Medical Association 1992. link

Entrapment of intestine in abdominal adhesions