Fascia Science and Clinical Applications: Original ResearchVisceral mobilization can lyse and prevent peritoneal adhesions in a rat model
Introduction
Peritoneal adhesions have been reported as an adverse side effect of surgery for more than a century (Hertzler, 1919), and occur in 90–100% of cases following surgery (Menzies and Ellis, 1990, Stanciu and Menzies, 2007). They are a leading cause of bowel obstruction, infertility, pelvic pain, and repeated surgeries (Almeida and Val-Gallas, 1997, Attard and MacLean, 2007, Beck et al., 1999, Menzies and Ellis, 1990, Parker et al., 2007, Stanciu and Menzies, 2007). Adhesions are pathological bands of fibrous connective tissue that occur between abdominal or pelvic organs and other structures, including viscera and the abdominal wall. One report indicated that >5% of all hospital readmissions following abdominal or pelvic surgery are due to adhesions (Ellis et al., 1999). The most recent estimate of the economic burden of morbidity associated with abdominal adhesions is $5 billion, in the United States alone (Wiseman, 2008). Post-surgical peritoneal adhesions are a significant public health concern.
Adhesions form following a number of injuries to the peritoneum, including mechanical trauma, drying, blood clotting, and foreign object implantation (Ryan et al., 1971). The inflammation caused by peritoneal trauma from any etiology leads to a disruption of the balance between the fibrin-forming and fibrin-dissolving capacities of the peritoneum, favoring the deposition of a fibrin-rich exudate on the damaged area (diZerega and Campeau, 2001, Reed et al., 2008). If the fibrin is not resolved by the fibrinolytic system within days, adhesions form (Holmdahl, 1997). Persistent adhesions can prevent the normal sliding of the viscera during peristalsis and movements of the body, such as respiration. Adhesions become both innervated and vascularized (Herrick et al., 2000, Sulaiman et al., 2000).
Adhesiolysis (surgical lysis of persistent and symptomatic peritoneal adhesions) is a common procedure (Szomstein et al., 2006), but often leads to reformation and new adhesions (Diamond et al., 1987, Diamond and DeCherney, 1987, Gutt et al., 2004, Milingos et al., 2000). Prevention is a far more desirable goal (Gomel et al., 1996, Mettler, 2003, Scott-Coombes et al., 1993), and much effort has been expended on adhesion prevention using various chemical compounds and barriers (Corrales et al., 2008, Guo et al., 2009, Ilbay et al., 2004, Kutlay et al., 2004, Mettler et al., 2003, Oncel et al., 2004). Systematic reviews of these treatments have reported that none consistently prevent adhesion formation (Kumar et al., 2009, Metwally et al., 2006). Identifying an effective preventive measure, or a treatment that avoids recurrence, has the potential to avoid much morbidity and economic burden.
Textbooks have been written describing techniques of visceral manipulation and include the treatment of postoperative scar tissue and adhesions (Barral, 2007, Finet, 2000). Clinicians from various backgrounds who practice these methods anecdotally report the ability to palpate and lyse adhesions, and that pain and other symptoms, including amenorrhea, infertility, and digestive problems, are resolved following treatment. Such claims have never been systematically investigated. Other than a case series and editorial from 1899 (Coe, 1899, Haberlin, 1899), there are no clinical or basic science investigations related to the efficacy or possible mechanisms of such treatments.
We designed the current study to evaluate the hypothesis that visceral mobilization, currently in clinical use by one of the authors (SLC) and applied to a well-characterized rat model (Ar’Rajab et al., 1991, Irkorucu et al., 2009), can lyse established adhesions, and can prevent peritoneal adhesions from forming. In this initial report, we show that it is possible to identify, treat, and prevent experimentally induced visceral adhesions. These observations open a line of investigation with the potential to benefit those who suffer adverse effects due to peritoneal adhesions.
Section snippets
Animals and surgery
All procedures were consistent with the Guide for the Care and Use of Laboratory Animals (National Research Council, USA), and were approved by the University of New England Institutional Animal Care and Use Committee. Thirty adult, male Long Evans rats were obtained from Charles River Laboratories (USA), and weighed 300 g when used. The methods were designed following previously published reports (Ar’Rajab et al., 1991, Irkorucu et al., 2009). Rats were anesthetized with isoflurane in pure
Results
All 30 rats recovered from the surgery with no complications. The 20 rats in the Lysis and Preventive groups tolerated the palpation and treatment procedures well (Figure 1). These rats readily relaxed their overall movements and abdominal walls, facilitating the investigator to perform deep palpation, evaluation, and treatment of the abdominal contents.
During the post-mortem dissection, 4 types of adhesions were found: cecum–cecum, cecum–abdominal wall, cecum–fat, and fat–abdominal wall (
Discussion
Movements between organs and the abdominal wall are necessary to accommodate peristalsis and the highly varying volume of the intestines. Following surgery, adhesions form that can limit these movements, causing pain and other pathology. Here we show in a rat model that visceral mobilization designed to promote mobility between the organs can acutely lyse adhesions, and more importantly can prevent adhesions from forming. These findings provide an initial scientific justification for the use of
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