adhesions Flashcards
what are adhesions?
● Type of “scar tissue ” form between organs and tissue after abdominal surgery
-forms as a result of injury to tissues during surgery
-tissue injury -> inflammatory response-> fibrin deposition-> tissue adhesions
INCIDENCE ADHESIONS
▪ Postoperative Adhesions in horses are commonly associated with surgical diseases of the Small Intestine
▪ Adhesions are the most common cause of recurrent abdominal pain in horses after SI surgery.
-the most common reason for death after surgery is SI adhesions
RISK FACTORS ASSOCIATED WITH ADHESIONS horses
-Small Intestinal Lesions
▪ Prolonged Post-operative Ileus
▪ Repeated Exploratory Celiotomy
▪ Age (Higher Incidence Foals)*
▪ Peritonitis & Abdominal Abscesses
pathogenesis of adhesion formation
The 2 categories of peritoneal injury that predispose to adhesions are:
1. Inflammation (trauma, infection, bacteria)
2. Ischemia (strigulating lesion, vascular compromise)
-leading to increased fibrin deposition
-all we have is fibrinolysis system to stop adhesions which is decreased in horses
-imbalance between fibrin deposition and fibrinolysis within the peritoneal cavity, resulting in excessive or prolong fibrin deposition
Coagulation Cascade
-Peritoneal injury initiates adhesion formation by activating the intrinsic and
extrinsic pathways of coagulation.
-TPA is the KEY REGULATOR OF FIBRINOLYSIS** tissue plasminogen activator which makes plasminogen to plasmin which then degrades fibrinogen and fibrin into fibrin degradation products*
ADHESIONS BECOME CLINICAL PROBLEM when
-imbalance between fibrin deposition and fibrinolysis
-fibrinous adhesions mature with inadequate fibrinolysis -> leads to restrictive fibrous adhesions which are permanent fibrous adhesions -> formed day 7-14 days after surgery (very important post colic)
-these permeant adhesions can compress or distort intestine, and stop normal passage of ingesta–> death
Fibrinous Adhesions
▪ Rarely Cause Clinical Problems
▪ Undergo Fibrinolysis
● Lysis 48-72 hours
Omental Adhesions
-in small animals develop due to increase in vascular supply
▪ Rarely Cause Clinical
Problems
▪ Most Benign Adhesion
▪ May Entrap Small Intestine
Focal fibrous Adhesions
▪ Form Inadequate Fibrinolysis
- Result From Ingrowth
Fibroblasts & Endothelium
▪ Cause Clinical Signs:
▪ Intestine to the mesentery
▪ Intestine to the incision
▪ Intestine to peritoneum
▪ Do NOT cause distortion
or kinking of intestine**
▪ May predispose to obstruction
or stricture in the small intestine
how focal fibrous adhesions cause problems
- Cause distortion of mesentery or intestine–> Sharp convolutions
▪ Impede flow ingesta
▪ Cause obstruction
-intestine to intestine adhesion
-intestinal volvulus
▪ Adhesive Fibrous Bands can form
▪ Between Intestinal Loops or intestine and mesentary
▪ Incarcerate Small Intestine
Massive Fibrous Adhesions
- Most Severe Form
Adhesion
▪ Between Multiple Loops
Small Intestine
prevention of adhesions goals
▪ Minimize Peritoneal & Serosal Inflammation
▪ Maintain or Enhance Fibrinolysis
▪ Mechanically Separate Adhesiogenic Surfaces
▪ Stimulate Intestinal Motility
prevention of adhesions
-preventative therapy should begin at surgery- 3/4 days post op
-Intra-operative Considerations:
Most Important Principle to
Prevent Adhesions**
▪ Meticulous Aseptic
Surgical Technique!!
Intra-operative Considerations to prevent adhesions * Halsted ’s Principles of Surgery
- Halsted ’s Principles of Surgery
- Gentle Handling of Tissues
- Meticulous Hemostasis
- Removal Damaged Tissue
- Minimize Exposure Suture (have to do inverting patterns in large animal to prevent adhesions)
- Minimize Surgical Time
prevention of adhesions intra-op
-starch gloves cause inflammation, rinse with sterile saline
-keep bowl moist, lavage, spray
-Anastomotic Technique (want no leakage and don’t have exposed suture)
-intra-op abdominal lavage, removes blood, firbin and inflammatory mediators
-at the end of surgery lavage with saline to reduce contamination and firbin
-protective tissue coating: mechanical lubricating barrier with viscous solution
-omentectomy
prevention of adhesions post op
-post op abdominal lavage with drain placed, removes peritoneal firbin. 10 liters LRS at 12/24/36 hours.
-Pharmacologic Adhesion Intervention: antibiotics (penicillin), NSAIDS (flunixin), DMSO
-heparin increases fibrinolysis TPA*, acts as anticoagulant
Prevent Post-operative Ileus:
-prokinetic agents lidocaine CRI, erythromycin
treatment of less severe adhesions
▪ Recurrent Colic
▪ Managed Medically: Flunixin meglumine
▪ Low-Residue Diets: Pelleted Rations● Grazin
Severe Restrictive
Adhesions
▪ Intestinal obstruction
▪ Strangulation lesion
-repeat celiotomy
▪ Euthanasia
Surgical Treatment of Adhesions
▪ Removal Devitalized Intestine: Establish Functional Passage of Intestinal Contents
Adhesiolysis: Breakdown of Adhesions,
resection of adhesionogenic tissue and make an intestinal bypass
