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Sindrom aderenţial postoperator

Aderente postoperatorii

Postoperative adhesions are one of the most important factors determining intestinal obstruction; in fact, they can cause small bowel adhesive obstruction and this may represent a big problem for the frequency of the occlusions that these adhesions may determine, the difficulty in choosing the right treatment, the elevated percentages of associated mortality and morbidity and the high incidence of recidivism.
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Moreover, the presence of an adhesive syndrome cannot be expected and it can also produce the first symptoms also many years after surgery. Considering which and how many complications can derive from their development, an important  purpose for surgeons must be preventions or at least reduction of the formations of surgical adhesions, especially concerning ileum. By this way the principal strategies are two: a best surgical procedure and the use of mechanic barriers. aderente 2


Introduction
Surgical trauma causes a peritoneal reaction and the formation of fibrin coagula which are soon
colonised by monocytes, macrophages and polimorphonucleate leucocytes (inflammatory cells).
Perivascular mesenchyme develops if stimulated by phlogosis and produces fibroblasts.
When the production of fibroblasts ends, the process of laying down collagen fibres starts. These
fibres determine adhesions among bowels or between bowels and the abdominal wall.
The main cause of adhesions is to be found in the fibrinolysis endoperitoneal inhibition due to a
reduction or a lack of production of t-PA by the damaged peritonaeum’s mesotelial cells.
Recent studies have laid the basis of a molecular research including, besides the process of fibrinolysis,
the process of angiogenesis and the involvement of cytokines, chemokine and tissue factors(1).


Adhesions caused by abdominal surgery determine clinical frameworks of different seriousness, such as abdominal pain, sub-obstructive episodes occurring in intestinal obstructions(2,3). Postoperative adhesions are one of the most important factors determining intestinal obstruction; they can determine, for example, small bowel adhesive obstruction and in this case the colorectal surgery plays a very important role(4). In female patients, gynaecological procedures usually determine the formation of adhesions, whereas in male patients colorectal surgery determine more than other small bowel adhesive obstruction(5).
Postoperative adhesions represent a varying report after abdominal surgery. A post mortem examination carried out on 752 corpses pointed out adhesions in 67% of those who had previously undergone a surgical abdominal operation, whereas in 28% no adhesions were found(6). The adoption of an accurate surgical technique is very important to prevent the formation of adhesions. In the same way, an accurate hemostasia plays a very important role in diminishing the formation of endoperitoneal coagula that stimulate the formation of connective tissue.

Clinical studies
This study has been carried out by reviewing the literature on this subject in order to evaluate the interval between the last abdominal operation and the first case of admission to hospital for post-surgical adhesive syndrome. The interval between the last abdominal operation and the first case of admission to hospital for post-surgical adhesive syndrome is different in the studies taken into account: • In the first study 21% of patients presents the first example of obstruction just a month after the operation(7). • In the second study the percentage of patients showing the first example of obstruction just a month after the operation is 5% (8).

Discussion
We have tried to define which treatment is to be used, since one of the most important problems associated with patients affected by small bowel adhesive obstruction concerns the use of conservative methodologies or surgical procedures. Many studies have been carried out on this topic so far, but none of them has provided certain indications which have proved useful to identify symptoms and signs leading to surgery(9,10,11). The condition of womb closed to faeces and gas and the presence of fever in patients that have previously undergone an abdominal operation lead to surg e r y. The choice of surgery should be easier with patients showing strangulated intestinal ansas. The risk of conservative treatments when dealing with strangulated intestinal ansas should always be considered, even if, according to literature data, this circumstance may vary from 6% to 8%(8,12). S u rgery is needed when dealing with acute peritonitis (11). According to some authors, in most cases an immediate surgical treatment is needed (13,14). According to other authors, 50% of patients affected by small bowel adhesive obstruction reacts positively to conservative treatments(15). Conservative treatments are used with patients showing a clinical framework that does not justify an immediate surgical operation.

Conclusions
Abdominal surgery may determine small bowel adhesive obstruction. This happens in presence of the following predisposing factors: • Predisposition to adhesive diathesis; • Typology of intervention (abdominal surgery concerning organs located in the lower part of the abdomen and in the pelvis, colorectal surg e r y, hysterectomy predict the development of small bowel adhesive obstruction); • methods the primitive surgical intervention is carried out (accuracy of hemostasia, quality of suture materials).

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