Advances, Retreats and Challenges in Adhesion Research
The purpose of this paper is to review the progress being made to tackle adhesions, both in terms of advances and «retreats» and to list some of the challenges for the future. 1.1 Are adhesions still an extensive and costly problem? Advances: Several pharmacoeconomic analyses highlight the cost and burden of adhesions. While certain adhesion barriers reduce adhesion formation, there is evidence that adhesion barriers may improve other surgical outcomes only in some reports. Retreats: The cost of in-patient procedures for adhesions in the USA outpaced that of other inpatient hospital services by 27% from 1997 to 2013. Challenges: There were over 350,000 in-patient procedures related to abdominopelvic adhesions in 2013 (USA) with aggregate direct costs between $6.2 and $12 billion, equivalent to 20%-40% of the entire budget of the US National Institutes of Health (NIH). These costs do not include outpatient care, work losses, family disruptions, pain management or adhesion-related infertility. While we have achieved some success, the adhesions «community» must emulate the success that groups advocating for other medical conditions have achieved by educating the public that adhesion related complications can happen to anyone undergoing surgery. We still lack reliable data that address whether adhesion barriers improve surgical outcomes. Much of the data on the cost and burden of adhesions comes from the USA and also Europe. More data are needed to assess the extent of the problem around the world. 1.2 Is adhesion-related bowel obstruction still a problem? Advances: Recently issued professional guidelines for the management of obstruction may reflect an increased awareness about adhesions and willingness and ability to tackle them. Mortality associated with adhesion-related bowel obstruction has declined in the USA from a high of 2421 in 2000 to 1545 in 2013. There is some evidence that adhesion barriers may influence SBO-related measures, but more data are required. Retreats: Although adhesions research in general has declined, research related to adhesive bowel obstruction is scant. Challenges: Adhesion related bowel obstruction remains a significant and costly problem with 97,945 (all) and 76,805 (principal) discharges in the US in 2013. These accounted for 95% of the costs of all abdominopelvic adhesions discharges. We must develop better prevention strategies for patients most at risk of obstruction and for those who have already obstructed. 1.3 Is adhesion-related infertility still a problem? Advances: We are beginning to understand the economic impact of treating adhesionrelated infertility secondary to other procedures. Retreats: Because of advances in assisted reproductive technologies, little progress has been made in improving adhesion-dependent fertility outcomes after surgery. Challenges: Due to cost and ethical issues of assisted reproductive technologies, adnexal adhesiolysis may be making a resurgence in popularity. 1.4 Is adhesion-related pain still a problem? Advances: We are now clarifying the relationship between adhesions and pain. There is enough of an association between adhesions and pain to justify their prevention initially, but due to central sensitization, neural cross-talk and the development of CAPPS (Complex Abdomino-Pelvic and Pain Syndrome), adhesiolysis may not be as successful as would be expected if the only reason for pain was a direct, local irritant effect of adhesions. Wearable therapeutic ultrasound appears helpful for pain in adhesions patients. Retreats: Lack of good quality data and misinterpretation of some existing data has added to the confusion about the use of adhesiolysis for pain. Challenges: We must understand better the complex relationship between adhesions and pain. Non-surgical approaches should certainly be used before resorting to surgery but since the therapeutic effect of laparoscopy combined with adhesiolysis may be great enough to justify its performance, adhesiolysis s