What data is used to inform the prognosis of post-operative adhesions?

Data Used for Prognosis of Post-Operative Adhesions

The Peritoneal Adhesion Index (PAI) is the only validated scoring system that provides prognostic information for post-operative adhesion outcomes, specifically predicting convalescence after surgery and risk of injuries during adhesiolysis. 1

Validated Prognostic Scoring Systems

Peritoneal Adhesion Index (PAI)

• Measures adhesion tenacity on a 1-3 scale at 10 predefined anatomical sites to integrate both tenacity and extent of adhesions in a single score 1
• Validated to predict convalescence duration after surgery for adhesive small bowel obstruction (ASBO) 1
• Validated to predict risk of iatrogenic bowel injuries during adhesiolysis 1
• Critical limitation: requires operative assessment, making it only applicable to surgical cases 1
• Not validated for long-term risk of adhesion-related complications or recurrence 1

American Fertility Society (AFS) Score

• Designed specifically for grading pelvic adhesions at four sites: right ovary, right tube, left ovary, and left tube 1
• Scores extent and severity, summing right and left sides separately 1
• Major limitation: relatively low inter-observer reproducibility 1
• A patient with AFS score of 0 can still have adhesions due to scoring methodology that discards one side 1
• Modified AFS versions have gained popularity to address these limitations 1

Risk Stratification for Need for Surgery

Zielinski Score

• Three radiological and clinical predictors: mesenteric edema, absence of small-bowel feces sign, and obstipation 1
• Concordance index of 0.77 in validation study of 100 ASBO cases 1

Baghdadi Score

• More accurate than Zielinski score with area under the curve of 0.80 in validation of 351 cases 1
• Comprises radiological findings, sepsis criteria, and comorbidity index 1
• Limitation: somewhat complex to assess in clinical practice 1

Epidemiological Data for Prognosis

Recurrence Rates

• Non-operative management: 12% readmission within 1 year, rising to 20% after 5 years 1
• Operative management: 8% recurrence after 1 year, 16% after 5 years 1
• Operative treatment shows slightly lower recurrence rates compared to conservative management 1

High-Risk Surgical Populations

• Colorectal surgery: 1 in 10 patients develops at least one episode of small bowel obstruction within 3 years after colectomy 1
• Pediatric surgery: 4.2-12.6% require reoperation for ASBO 1
• Colorectal patients: 3.2% require reoperation for ASBO 1
• Oncologic gynecological surgery also carries highest risk 1

Predisposing Factors That Inform Prognosis

Direct Risk Factors

• Genetic polymorphisms in interleukin-1 receptor antagonist increase adhesion risk 2
• Increased estrogen exposure predisposes to adhesion development 2
• Endometriosis directly increases post-operative adhesion risk 2

Indirect Risk Factors (Through Hypofibrinolytic State)

• Genetic polymorphisms in plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor 2
• Diabetes mellitus, metabolic syndrome, and hyperglycemia 2
• Obesity and depression 2
• Binge alcohol consumption 2
• Anti-Parkinsonian medications and oral hormone therapy 2
• Pregnancy and cancer 2

Surgical Technique Factors

• Laparoscopic approach: 1.4% reoperation rate for ASBO (95% CI 1.0-1.8%) 1
• Open surgery: 3.8% reoperation rate for ASBO (95% CI 3.1-4.4%) 1
• Foreign body reaction (starch-powdered gloves, meshes) significantly increases adhesion formation 1
• Monopolar electrocautery causes more peritoneal injury compared to bipolar or ultrasonic devices 1

Critical Limitations in Current Prognostic Data

None of the existing adhesion scoring systems have been validated to correlate with long-term risk for recurrence of adhesion-related complications 1. This represents a significant gap, as adhesion development after every abdominal operation is highly variable with no predictable patterns regarding density, time interval to symptoms, or clinical presentation 3. There is no available preoperative marker to predict the occurrence, extent, or severity of adhesions 4, making it impossible to identify which patients are more prone to develop problematic adhesions before surgery.