"Ask Dr. Cook" is a series of questions and answers regarding endometriosis. The current subject and answer can be found on Current Ask Dr. Cook web page. The questions may represent a summary of questions I have been asked by several different patients. I hope you find this information helpful. If you have a question you would like answered, please Submit A Question.

How are Adhesions Treated?

Question:
My doctor tells me I have extensive adhesions of my pelvic organs and my intestine. I am in a lot of pain. I have gone through a couple of surgeries to get rid of the adhesion, but it seems to keep coming back and if anything the pain is getting worse. Is there anything that can be done to help me out?

Answer:
Yes, fortunately your situation can be helped. There are recent medical advances that make it more likely that you can permanently get rid of your adhesions and pain. To answer your question adequately we need to address several issues. This is part three of a three part series. Also see part 1"What Are Adhesions?" and part 2 "What Causes Adhesions?".

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

Cutting the adhesions is not adequate treatment. This would leave scar tissue that can re-adhere to other tissue. All of the abnormal adhesive tissue should be removed. In addition, endometriosis is present in scar tissue about half the time, in patients with endometriosis elsewhere in the body. The scar tissue is abnormal tissue that should be removed to allow the remaining normal healthy tissue to heal properly. The laser laparoscope is particularly useful in treating thick and/or cohesive adhesions. These instruments help 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 isideal for removing this type of scar tissue. This approach allows removal of the fibrous scar tissue while leaving the normal tissue unharmed. As we discussed last week the single most important factor in preventing adhesion reformation is good surgical technique.

Having said this, even with good surgical technique, once scar tissue has formed there is always a chance it reform after it is removed. Scar tissue forming or re-forming following surgery is 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 may mistakenly think that the two structures are one and 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 used at the completion of surgery. Probably the most common supportive measure currently used is Interceed. This is a white mesh like material which can placed through the laparoscope or at laparotomy. This mesh acts as a temporary barrier in an attempt to prevent the surfaces from sticking together during the healing process and forming adhesions. Eventually this mesh dissolves and is eliminated from the body. Studies have shown a reduction in amount and degree of adhesion formation following surgery, however, real life experience of some surgeons does not agree with this assessment. I was involved with some of the initial studies and question the effectiveness of Interceed. If there is any oozing (minimal bleeding) it seems that Interceed can even increase adhesion formation. This is the general impression of some members of the medical community. While I have used Interceed in the past, I rarely use it presently.

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

Seprafilm is a new product which seems quite effective in preventing adhesion formation. It looks like wax paper, but turns into a gel once inside of the body. It dissolves and is eliminated by the body after about a month. Studies to date have shown Seprafilm to reduce the number and extent of adhesions. The results I have seen with Seprafilm have been amazing. One patient in particular, who had dense cohesive adhesions in spite of multiple surgeries, did not have any after placement of Seprafilm. I'm not saying that it prevents all adhesions, but it does seem to be the first truly effective absorbable adhesion product on the market. The primary disadvantage is that it is virtually impossible to place through the laparoscope. It is also brittle and fairly difficult to place at laparotomy. Genzyme, the makers of Seprafilm, are working on Seprafilm 2. This should be easier to place and hopefully can be placed laparoscopically. A gel form is also under development.

In conclusion, adhesions can be treated effectively with good surgical techniques with supportive adhesion prevention products. In my opinion, Seprafilm is currently the best product available, however, new products are under development which should be easier to apply and thus more effective. There is always a risk of adhesion re-formation and the specific treatment for an individual case should be chosen by that patient's surgeon.

Updatede October 29, 2005