{"paper_id":"1a4354ff-484d-414b-97b7-7be15a5cba34","body_text":"13\n© 2017 Annals of Medical and Health Sciences Research  \n Original Article Original Article\nHow to Cite this Article: De Wilde RL, et al. Awareness of Post-Surgical \nAdhesions among Gynaecological Surgeons: Focus on the Surgical \nManagement of Endometriosis. Ann Med Health Sci Res. 2017; 7: 13-17\nThis is an open access article distributed under the terms of the Creative Commons \nAttribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, \ntweak, and build upon the work non‑commercially, as long as the author is credited \nand the new creations are licensed under the identical terms.\nIntroduction\nPostoperative adhesions, bands of connective tissue that join two \nnormally separate anatomical structures, have become one of the \ncommonest sequelae of 75% to 93% of gynecological surgeries, \nleading to chronic pain, infertility or bowel obstruction, \n[1-\n3]. Secondary adhesions due to endometriosis could  affect \nfertility and pregnancy rates through anatomical distorsion or \ninternal reproductive organs  \n[4]. or could produce small bowel \nobstruction. [3]. Since 40% to 60% of surgeons were not aware \nof the consequences of adhesion for their clinical practice and \nwomen’s life, \n[5] a first consensus position was published in 2007 \nby the European Society of Gynecological Endoscopy (ESGE) \nwith the aim to provide evidence-based recommendations \nto reduce postsurgical adhesions in gynecological surgery. \nAwareness of Post-Surgical Adhesions among \nGynecological Surgeons: Focus on the Surgical \nManagement of Endometriosis\nRudy Leon De Wilde1, Julio Alvarez2, Hans Brölmann3, Ying Cheong4, Pierre Collinet5, Attilio \nDi Spiezio Sardo6, Philippe Koninckx7, Per Lundorff8, Leszek Pawelczyk9, Luz Angela Torres-de \nla Roche1, Markus Wallwiener10\n1Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, \nMedical Campus University of Oldenburg, Germany, 2Hospital Universitario Infanta Sofía, San Sebastián de Los Reyes, Madrid, \nSpain, 3Department of Obstetrics and Gynecology, VU University Medical Centre, Amsterdam, The Netherlands, 4Human \nDevelopment and Health, Faculty of Medicine, University of Southampton and Complete Fertility Centre, Southampton, United \nKingdom, 5Centre Hospitalier Régional Universitaire de Lille, France, 6Department of Public Health, University “Federico II” of \nNaples, Italy, 7University Hospital Gasthuisberg, Katholieke Universiteit, Leuven, Belgium, 8Clinic of Gynecology, Private Hospital \nMølholm, Vejle, Denmark, 9Division of Infertility and Reproductive Endocrinology, Poznan University of Medical Sciences, \nPoznan, Poland, 10Department of Obstetrics and Gynecology, University Clinic Heidelberg, Germany\nAbstract\nObjective: Postoperative adhesions occur in 80% of cases of gynecological surgery. Therefore \nevidence-based recommendations have been made to improve surgeons´ knowledge of \npostoperative adhesion formation and preventive strategies. The objective of this survey was \nto assess the perceptions and practice of international gynecological surgeons on adhesions \nfollowing endometriosis surgery. Materials and Methods: Data capture was conducted via \nonline survey. The questionnaire was accessible worldwide during 2 weeks through the \nSociety of Endometriosis and Uterine Disorders (SEUD) website. The qualitative variables \nwere described as number and percent of the different response modalities, comparing \nEuropean participants (n= 35) within the whole sample of surgeons (n= 65) vs non-European \nparticipants (n= 30).  Results: 97% of Europeans and 63% of non-European surgeons recognize \nadhesion prevention as useful to reduce chronic postoperative pain and to avoid complications \nrelated to adhesions. To minimize adhesions, good surgical technique was considered relevant \nto almost all responders, also the use of anti-adhesive barriers or solutions (77% Europeans \nvs 57% non-European). 20% of all responders do not provide their patients with information \nabout the risks of adhesion formation, related long-term complications or preventive \ntreatment options. Conclusion: Despite a substantial awareness, disparities in daily practice of \ngynecological surgeons around the world facing the problem of adhesion formation in surgical \nendometriosis management exist. In order to improve adherence to anti-adhesion strategies in \nendometriosis surgery, more scientific evidence is needed. National and international scientific \nsocieties can play an important role to initiate research; also it might be helpful to call for more \ncommunication in this field.\nKeywords: Surgery-induced adhesions; Gynecological surgery; Awareness; Prevention; \nEndometriosis\nCorresponding author:  \nRudy Leon De Wilde, Clinic \nof Gynecology, Obstetrics and \nGynecological Oncology, University \nHospital for Gynecology, Pius-\nHospital, Medical Campus University \nof Oldenburg, Georgstrasse 12, 26121 \nOldenburg, Germany,  \nTel: +4904412291524 - 2291506;  \nE-mail: rudy-leon.dewilde@pius-\nhospital.de\n[3] which allowed an improvement in the European surgeons’ \nknowledge and antiadhesion strategies, as demonstrated in a \nsubsequent survey performed in 2014. [6]. In that survey 70% of  \nrespondents thought that endometriosis surgery, myomectomy, \nadhesiolysis, and adnexal surgery are the most likely to be \nassociated with adhesions, but only 60% reported to know the \nsurgical techniques recommended for adhesion prevention; \n\n14Annals of  Medical and Health Sciences Research | October 2017 | Vol 7 | Special Issue 2 |\nDe Wilde RL, et al.: Post-endometriosis surgery Adhesions\nand few (38.4%) used antiadhesion agents regularly, because \nthey did not consider these agents as an important measure in \nadhesion prevention. \n[6]. Based on this findings, the Society of \nEndometriosis and Uterine Disorders (SEUD), an international \nscientific network of experts in women’s and reproductive \nhealth,  performed the present survey with the aim to assess the \nperceptions and practice of international gynecological surgeons \non adhesions following endometriosis surgery.\nMaterial and Methods\nThis was an international online survey conducted among \ngynecological surgeons, who were recruited through the SEUD \nwebsite (http://seud.org/about-the-society-of-endometriosis-\nand-uterine-disorders/). This web-site is a platform of \ninformation to promote medical education about disease \nawareness, pathogenesis, risk factors, diagnosis and treatments \nof diseases that negatively affect women’s health and fertility. \nThe survey was accessible during 2 weeks, from 5\nth to 22 nd \nApril 2014, to surgeons who voluntarily filled up a 12-items \nquestionnaire (Appendix 1). Questions were related to the \nimpact of adhesions on endometriosis and its management, \nfactors associated with adhesion prevention in endometriosis \nsurgery, information of patients and patients consent, prevention \nof adhesions during surgical management of endometriosis, and \nthe role of the anti-adhesion agents during laparoscopic surgery \nof endometriosis.\nIt was an anonymous survey; surgeons all around the world, \nboth members and non-members of the SEUD were allowed to \naccess it, and there was no financial incentive for participants.\nQuestionnaires were provided with a qualitative 4-point-scale \nto answer each question: strongly applicable, undetermined, \nand slightly or not applicable. Every participant was allowed \nto answer the questionnaire only once. Data were analyzed \nusing SAS software version 9.4. The qualitative variables were \ndescribed as number and percent of the different response \nmodalities, comparing European surgeons (ES) within the \nwhole sample of surgeons (WSS) vs. Non-European Surgeons \n(NES). The numbers of missing data were also included.\nResults\nSixty-five gynecological surgeons participated [Table 1], most \nof them Europeans (35/65); mainly working in university \nhospitals (63%), with a median of 42 beds in their departments. \nThe main countries represented were France (16.9%), Spain \n(13.8%), Brazil (7.7%), Russia (6.2%) and South Korea (4.6%). \nDuring the 6 months prior to the survey, comparable numbers \nof laparoscopies and laparotomies were performed by each \nsurgeon. The mean numbers of interventions for endometriosis \nreported during the previous 5 years were 307 for WSS (mean \n61/year), mostly by ES, indicting participants had an appropriate \nlevel of expertise in the endometriosis field.\nRegarding the impact of adhesions on endometriosis and its \nmanagement [Table 2], few NES (20%) think that adhesions \ncan trigger ovarian endometrioma, but 57% of them recognize \nadhesions as a risk factor for endometrioma recurrence, while \n43% of ES agree with both statements.  About the negative \nconsequences of endometriosis on fertility, most of participants \nrecognize this effect, but only 63% of NES recognize adhesion \nprevention as useful to reduce chronic pain and to avoid \ncomplications related to adhesions. This medium-low level \nof knowledge in the pathogenesis of long-term complications \nrelated to endometriosis and peritoneal adhesion could affect \nthe surgeon´s pre and intra-operative decision-making process \nregarding adhesion prevention when facing patients with \nendometrioma.\nTable 1: Survey respondents by country of residency.\nCountry Total Country Total\nn % n %\nEurope Asia\nBelgium 2 3.1 Japan 1 1.5\nSouth Korea 3 4.6\nFrance 11 16.9 Other Countries\nAlgeria 1 1.5\nGermany 2 3.1 Israel 1 1.5\nKenya 1 1.5\nGreece 1 1.5 Lebanon 1 1.5\nRussia 4 6.2\nItaly 3 4.6 South Africa 2 3.1\nTurkey 1 1.5\nPortugal 3 4.6\nUkraine 1 1.5\nUnited Arab \nEmirates 1 1.5\nSpain 9 13.8 Uzbekistan 1 1.5\nUSA 4 6.2\nSweden 1 1.5 Central and South America\nArgentina 1 1.5\nNetherlands 1 1.5 Brazil 5 7.7\nChile 1 1.5\nUnited Kingdom 2 3.1 Mexico 1 1.5\nTotal 35 0.538 Total 30 0.461\nWhen asked about their experience with endometriosis patients, \nand patient counselling [Table 3], it was found that patients with \nendometriosis and adhesions are an important part of their daily \nwork, both medically (87% NES vs 74% ES), and surgically (90% \nNES vs. 74% ES). During the patient counselling process, most \nsurgeons provide information regarding adhesion formation, \nbut the majority did not discuss long-term complications of \nadhesions (73% NES vs. 74% ES), or provide information about \nprevention options to patients with endometriosis undergoing \npelvic surgery (67% NES vs 74% ES). As mentioned before, \nthe lack of up-dated information about the consequences of \nadhesions between surgeons could also impact the quality of \ninformation and care that patients receive by their physicians.\nWhen asked about the factors associated with adhesion \nprevention during surgical management of endometriosis [Table \n4], the large majority of respondents have well defined surgical \nstrategies to prevent adhesions, and also consider adhesiolysis \nas an important preliminary step in the surgical procedures for \nendometriosis. To minimize adhesions, good surgical technique \nwas considered as relevant for both groups, more than the use \nof anti-adhesive barriers or solutions (57% NES vs. 77% ES). \nHere, 60% of NE and 57% of ES reported to use these agents \nregularly as an adhesion prevention strategy. These results \nsuggest that surgeons relay adhesion prevention on surgical \ntechnique more than in anti-adhesion substances, reflecting \nwhat ESGE and other international guidelines emphasize, but \n\n15Annals of  Medical and Health Sciences Research | October 2017 | Vol 7 | Special Issue 2 |\nDe Wilde RL, et al.: Post-endometriosis surgery Adhesions\nalso could be related with a low availability of the substances \nin some settings.\nSpecifically, anti-adhesion agents during laparoscopic surgery \n[Figure 1] are used on a regular basis by most of all responders \nin case of diagnosis of adhesions during endometriosis \nsurgery. Different agents were mentioned to be used, or to \nbe considered to use, such as oxidized regenerated cellulose  \n(Interceed®) hyaluronic acid (Hyalobarrier gel®)  and 4% \nicodextrin (Adept®); and  20% of surgeons use Ringer´s lactate \nas an adhesion prophylactic agent. In addition, environmental \nperitoneal conditioning technique, which includes the use of \nhumidified CO\n2 and physiologic temperature during laparoscopy, \nwas considered useful in adhesion reduction and prevention by \none third of AS. Here, participants reflect the wide option of \nantiadhesion agents available and used; but in accordance to the \nmedium-frequency of use yet discussed, participants prefer to \nuse them as a secondary prevention measure after adhesiolysis \nof preexisting adhesions.\nTable 2: Impact of adhesions on the endometriosis and its management.\nVariables\nStrongly applicable Undetermined Slightly or\n not applicable\nWSS \nN=65\nNES\nN=30\nES\nN=35\nWSS \nN=65\nNES\nN=30\nES\nN=35\nWSS \nN=65\nNES\nN=30\nES\nN=35\nAdhesions can trigger ovarian \nendometrioma 21(32%) 6 (20%) 15  (43%) 8 (12%) 0 8 (23%) 29 (45%) 17 (45%) 12 (34%)\nPresence of adhesions is a risk factor for \nendometrioma recurrence 32 (49%) 17 (57%) 15 (43%) 9 (14%) 3 (10%) 6 (17%) 24 (36%) 10 (33%) 14 (40%)\nEndometriosis may affect fertility \nby various mechanisms, including \ndisturbance of pelvic anatomy by \nadhesions\n64 (98%) 29 (97%) 35 (100%) 0 0 0 1 (2%) 1 (3%) 0\nAdhesion prevention is very important \nin reducing pain, avoiding complications \nsuch as bowel obstruction, and preserving \nfertility\n53 (81%) 19 (63%) 34 (97%) 2 (3%) 1 (3%) 1 (3%) 0 0 0\nWSS: Whole Sample of Surgeons; NES: Non‑European surgeons; ES: European Surgeons\nTable 3: Information of patients and patients’ consent.\nVariables\nStrongly applicable Undetermined Slightly or not applicable\nWSS N=65 NES\nN=30\nES\nN=35\nWSS \nN=65\nNES\nN=30\nES\nN=35 WSS N=65 NES\nN=30\nES\nN=35\nPatients with endometriosis and \nadhesions are an important part of my \ndaily medical work besides surgery\n52 (80%) 26\n(87%)\n26\n(74%) 7 (11%) 3 (10%) 4 \n(11%)\n6 \n(9%) 1 (3%) 5 (14%)\nPatients with endometriosis and \nadhesions are important part of my daily \nsurgical work\n53 (82%) 27\n(90%)\n26\n(74%) 6 (9%) 3 (10%) 3 \n(9%)\n6 \n(9%) 0 6 \n(17%)\nI provide information on treatment \noptions for adhesions for all patients with \nendometriosis undergoing pelvic surgery\n46 (71%) 20 \n(67%)\n26\n(74%) 8 (12%) 8 (12%) 3\n (9%) 11 (17%) 5\n(17%)\n6 \n(17%)\nI provide information on long‑term \ncomplications of adhesions 48 (74%) 22 \n(73%)\n26 \n(74%) 8 (12%) 4 (13%) 4 \n(11%)\n9 \n(14%) 4 (11%) 5 \n(14%)\nI provide information about adhesion \nformation during the consent process 52 (80%) 22\n(73%)\n30\n(86%) 4 (6%) 4 (13%) 0 9 \n(14%)\n4\n(11%)\n5 \n(14%)\nWSS: Whole Sample of Surgeons; NES: Non‑European Surgeons; ES: European Surgeons\nTable 4: Prevention of adhesions during surgical management of endometriosis.\nVariables\nStrongly -applicable Undetermined Slightly or  not applicable\nWSS\nN=65\nNES\nN=30\nES\nN=35\nWSS \nN=65\nNES\nN=30\nES\nN=35\nWSS \nN=65\nNES\nN=30\nES\nN=35\nAdhesion prevention is one of the goals of \nlaparoscopic surgery for endometriosis 58 (89%) 29 (97%) 29 (83%) 5\n (8%)\n1\n(3%) 4 (11%) 2 \n(3%) 0 2 \n(6%)\nAdhesiolysis is considered an important \npreliminary step in the surgical procedures \nfor endometriosis\n64 (99%) 30\n(100%) 34 (97%) 1 \n(1%) 0 1\n (3%) 0 0 0\nGood surgical technique is important to \nminimizing adhesions 64 (99%) 30\n(100%) 34 (97%) 1 \n(1%) 0 1 \n(3%) 0 0 0\nAnti‑adhesive barriers or solutions are \nimportant in adhesion reduction and \nprevention\n44 (68%) 17 (57%) 27 (77%) 13 (20%) 10 (33%) 3 \n(9%)\n8\n(12%)\n3\n(10%) 5 (14%)\nI regularly (at least two times in the last \nmonth) use agents for adhesion reduction \nand prevention  intra‑operatively\n38 (59%) 18\n(60%) 20 (57%) 10 (15%) 0 10 (33%) 17 (26%) 12 (40%) 5 (14%)\nWSS: Whole Sample of Surgeons; NES: Non‑European Surgeons; ES: European Surgeons\n\n16Annals of  Medical and Health Sciences Research | October 2017 | Vol 7 | Special Issue 2 |\nDe Wilde RL, et al.: Post-endometriosis surgery Adhesions\nFigure 1: Anti‑adhesion agents used during laparoscopic surgery of \nendometriosis, as reported by all respondents (n=65).\nDiscussion\nEndometriosis and its associated adhesions adversely impact \non women’s reproductive health and quality of life, and is a \nsignificant health care burden for patients, clinicians and health \ncare providers. The adverse impact of endometriosis on fertility \nand the optimal surgical options in their treatment are recently \nhighlighted as two of the top ten concerns in endometriosis by \nhealth care practitioners and the public. \n[7]. In addition, there \nis inconclusive evidence about the long-term effectiveness of \nprevention agents. \n[8].\nMany scientific communities involved with women’s health \nare also concerned and they performed surveys to assess the \nawareness of gynecological surgeons regarding postsurgical \nadhesions after surgical management of endometriosis. A \nprevious survey, conducted by ESGE among 253 gynecological \nsurgeons from European countries \n[5], reported that the \nknowledge of recommended surgical techniques and preventive \nmeasures to reduce adhesions were not widely spread; although \nthe responders showed a good knowledge of the risk factors. \nIn the present survey, conducted with the assistance of SEUD, \nit was demonstrated that even in gynecological surgeons with \nexpertise in the field of endometriosis surgery, discrepancies in \nthe respondent’s opinion regarding the impact of adhesions on \nendometriosis and its management exist.\nRegarding the impact of adhesions and endometriosis, the \nassociated impairment of fertility is well recognized by all \nparticipants. In contrast, the role of adhesions in ovarian \nendometrioma occurrence and recurrence is not recognized by \nmore than half of WSS, especially by NES. Different studies \nhave reported that ovarian endometrioma reoccurs in 9.6 to 80% \nof cases after complete laparoscopic resection. \n[9,10]. Presence of \nadhesions, previous pelvic surgery, fulguration, and higher Ca \n125 levels, seem to be risk factors for endometrioma recurrence. \n[10,11]. Interestingly, small endometrioma (< 3 cm) could be \nassociated with a higher degree of pelvic adhesions. [10].\nIn contrast to the 40% of ESGE respondents, we found that \nmost of WSS recognize the importance of adhesion prevention \nto reduce long term complications related to abdominal and \ngynecological surgery. As well, WSS reported to follow the \ninternational recommendations for surgical management \nof endometriosis \n[12,13] that is using laparoscopic approach, \nadhesiolysis and good surgical technique. Thus, patients with \nendometriosis are a high risk for pre and postsurgical adhesions, \nbeing laparotomy more adhesiogenic than laparoscopy (1.23 ± \n0.22, p<0.000; 95% IC 1.02-1.99), \n[14]. and that laparoscopic \nsurgery is associated with higher pregnancy rates (RR 1.44, 95% \nCI: 1.24-1.68, p<0.01), and live birth rates (RR 1.52, 95% CI: \n1.26-1.84, p<0.01). \n[15]. This awareness improvement could be the \nresult of new evidence and educational activities that promotes \nthe application of good surgical technique and complementary \nmeasurements for patients at high risk of adhesions. Therefore \nmore patients will benefit from practices that reduce their own \nrisk of peritoneal adhesions after endometriosis surgery.\nBased on the safety and reported efficacy compared to no-\ntreatment to reduce surgical adhesions, \n[16]. anti-adhesive \nbarriers and the use of peritoneal conditioning have been \nproposed in the recommendations as complementary measures. \nAntiadhesion agents were reported to be important, or to be \nused in daily practice by our responders in similar way to what \nwas reported by ESGE participants (59%  SEUD vs. 60.5% \nESGE). \n[5]. However, we found a decrease in the frequency of \nuse of peritoneal conditioning compared to ESGE survey (34% \nSEUD vs. 55.3% ESGE). [6]. This limited use of complementary \nand effective measures to prevent postsurgical adhesions could \nbe explained by the non-availability of these technologies \nin low income settings or by their high cost, when available. \nMeanwhile, in some settings the woman reproductive health or \nthe burden of postsurgical adhesions will not be improved, what \nis contrary to the objectives of the clinical guidelines? \nDespite the interest of gynecological surgeons in post-surgical \nadhesions and their preventive measures facing one of the major \nmedical problems in gynecology, The majority of surgeons yet \ndoes not provide their patients with information about the risks \nof adhesion formation, long-term complications related with \nor preventive treatment options (73% NES vs. 80% ES). This \nfrequency is higher than was former reported by surgeons in the \nNetherlands (10% to 41%), and the United Kingdom (23% to \n48%). \n[1]. Incorporating adhesion prevention as a routine in the \npre-operative counselling procedure could thus help to prevent \nmedical malpractice lawsuits when complications occur. \n[1].\nWe recognize that the scope of the present survey was limited by \nthe low number of respondents, especially NES. In consequence, \nthe composition of our groups did not constitute completely \nrepresentative sample of gynecologists that take care of women \nwith endometriosis. But, all together these results reflect again \nthat the knowledge, perceptions and practices of surgeons \nregarding adhesions should be improved in order to increase \nthe benefits of adhesion prevention after endometriosis surgical \nmanagement, especially on women´s reproductive health.\nConclusion\nThe results of this survey highlight the disparity in the \nopinion of gynecological surgeons around the world, on the \nmanagement of adhesions in the context of endometriosis.  It is \nprudent that surgeons remain up to date with evidence in order \nto provide women with adequate information on the impact \nof endometriosis and adhesions on their reproductive health. \nNational and international, scientific and funding bodies should \n\n17Annals of  Medical and Health Sciences Research | October 2017 | Vol 7 | Special Issue 2 |\nDe Wilde RL, et al.: Post-endometriosis surgery Adhesions\nprioritize research in the area of endometriosis, particularly \naround its detrimental impact on women’s reproductive health \nand ways to optimize surgical management with a focus on \nadhesion formation, reformation and prevention.\nAcknowledgements\nThe authors thank all responders of the survey for their important \nopinions, and Laurence Saya, MD, Altius Pharma CS, Paris, \nFrance, for the help in medical writing.\nAuthor Disclosure Statement\nAll members of the ANGEL group received travel reimbursement \nfees to attend the author´s meeting to analyze and discuss the \nsurvey´s results.\nFunding\nNordic Pharma sponsored the survey´s platform and the \ntranscription of the author’s meeting for the preparation of this \nmanuscript.\nAuthorship\nAll named authors meet the International Committee of \nMedical Journal Editors (ICMJE) criteria for authorship for this \nmanuscript, take responsibility for the integrity of the work as \na whole, and have given final approval to the final version to be \npublished.\nReferences\n1. 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