Page 166 - Postoperative Intra-Abdominal Adhesions- New insights in prevention and consequences

Chapter 10
development of Cine MRI protocols allowing non-invasive mapping of adhesions is interesting [21]. Normally, the abdominal viscera move freely in the abdomen, but in the presence of adhesions this movement is limited. This phenomenon is called ‘visceral slide’ and can be demonstrated by Cine MRI, a dynamic imaging technique [9]. In Chapters 7 and 8, it was concluded that our data did not support the hypothesis of a causative role for adhesions with regard to chronic abdominal complaints, although other data contradict our results [14, 22]. Regardless, there is very little evidence for the long-term efficacy of adhesiolysis on chronic abdominal pain [23, 24]. Recently, van den Beukel et al. set out to investigate a novel diagnostic and therapeutic approach for pain associated with adhesions [25]. They scored postoperative adhesions using Cine MRI in 106 patients; additionally, pain scores were evaluated by questionnaires. Adhesions were seen in 79 patients and the option of adhesiolysis and additional use of antiadhesive barriers was discussed, resulting in operation on 45 patients. Of these patients, 80% reported improvement of pain. Interestingly, 42.5% of the patients with adhesions but without operation reported less pain as well. Why the pain reduction in the operated group is higher cannot be extracted from these data. It is possible that adhesiolysis with an antiadhesive barrier is indicated in a selected group of patients, but a placebo effect at this moment cannot be excluded and further research should focus on this aspect. When we look into the 42.5% of patients with a reduction in pain without operation, one can only speculate about the rationale. However, reassurance seems to play an important role in the treatment of chronic abdominal pain as it may have in the randomized controlled trial performed by Swank et al [24]. It might be suggested that in these days of centralisation of care patients with postoperative chronic abdominal pain should be referred to a specialized centre, when other causes are excluded. A team for example consisting of a surgeon, gastroenterologist, anaesthesiologist and a psychologist should treat these patients using, among other things, Cine MRI. This might result in the successful treatment of patients with chronic postoperative abdominal pain, without operation and the concomitant risk of complications following adhesiolysis.
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