What are the treatment options for abdominal adhesions?

Treatment Options for Abdominal Adhesions

The primary treatment for symptomatic abdominal adhesions is surgical intervention through adhesiolysis, with laparoscopic approaches preferred in selected stable patients and laparotomy for unstable patients or cases with extensive adhesions. 1

Diagnostic Approach

Before determining treatment, proper diagnosis is essential:

• CT scan with IV contrast is the gold standard for diagnosing adhesive small bowel obstruction (ASBO), confirming the diagnosis, identifying location and cause of obstruction, and detecting signs of bowel compromise 1
• Water-soluble contrast studies serve both diagnostic and therapeutic purposes:
  • Can be administered immediately or after 48 hours of conservative management
  • Predicts successful non-operative management if contrast reaches the colon within 24 hours 1
• Laboratory evaluation should include complete blood count, lactate, electrolytes, CRP, BUN/creatinine, and coagulation profile 1

Treatment Options

1. Non-Operative Management

For patients without signs of strangulation, peritonitis, or severe intestinal impairment:

• Initial conservative approach includes:

  • Fasting (nil per os)
  • Fluid and electrolyte replacement
  • Bowel decompression via nasogastric tube 2
  • Water-soluble contrast agent (WSCA) administration (50-150 ml orally or via NG tube) 1

• Success rates of non-operative management:

  • Higher when WSCA is used (17% failure rate vs 50% without WSCA) 2
  • If contrast reaches colon within 24 hours, high likelihood of resolution 1
  • If contrast doesn't reach colon within 24 hours, surgical intervention is likely needed 1

2. Surgical Management

Indications for surgery include:

• Signs of bowel ischemia or peritonitis
• Failed conservative management
• Complete obstruction

Surgical approaches:

• Laparotomy (open surgery):

  • Traditional approach for unstable patients
  • Preferred when extensive adhesions are expected 1
  • Higher success rate but also higher morbidity (30-day morbidity of 39% in therapeutic explorations) 2

• Laparoscopic adhesiolysis:

  • Suitable for hemodynamically stable patients with simple cases 2, 1
  • Completed laparoscopically in 35% of cases in one study 2
  • Considerable risk for conversion to open laparotomy (60% conversion rate reported) 2
  • Higher rate of negative explorations compared to open surgery 2

• Adhesion barriers:

  • Can reduce recurrence rates in ASBO cases 2
  • Should be considered during surgical treatment 1

3. Medical Management (Adjunctive)

• Octreotide (150-300 mcg SC bid) to reduce secretions 1
• Corticosteroids (dexamethasone up to 60 mg/day) to reduce inflammation 1
• Prokinetic agents like metoclopramide may help in partial obstructions (use with caution in renal impairment) 1

Post-Treatment Care

• Early mobilization
• Progressive diet advancement when appropriate
• Begin oral nutrition if contrast reaches large bowel on follow-up X-ray after 24 hours 1
• Close monitoring for signs of recurrent obstruction or clinical deterioration 1

Special Considerations

Prevention of Recurrence

• Recurrence rates after surgical management: 8% at 1 year, 16% at 5 years 1
• Use of adhesion barriers during surgery can reduce recurrence risk 3

High-Risk Populations

• Pregnant women: High failure rate (94%) of non-operative treatment with 17% risk of fetal loss 2
• Diabetic patients: May require earlier intervention due to higher risk of complications (7.5% acute kidney injury, 4.8% myocardial infarction if operation delayed >24h) 2
• Elderly patients: Consider frailty index as patients with high frailty have prolonged recovery and may not return to previous functional state 2

Pitfalls to Avoid

• Delaying surgical consultation when indicated
• Prolonging conservative management in patients with signs of strangulation
• Inadequate fluid resuscitation
• Overlooking the possibility of closed-loop obstruction 1
• Opioid use can mask symptoms and invalidate tests of small bowel motility 1

Classification System for Open Abdomen (OA) Management

For complex cases requiring open abdomen management, a classification system guides treatment:

• Grade 1: Clean or contaminated OA without adherence between bowel and abdominal wall
• Grade 2: OA developing adherence/fixity
• Grade 3: OA complicated by fistula formation
• Grade 4: Frozen OA with adherent/fixed bowel; unable to close surgically 2

Treatment should aim to prevent progression to higher grades, which require more complex management.