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Department of Abdominal Surgery, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical College
[Abstract] Objective:To explore a simple, effective and noninvasive method for the assessment and scoring of abdominopelvic adhesions. Methods:Ultrasound combined with screenshots of laparoscopic techniques were used to qualitatively and quantitatively assess the degree of adhesions by image processing. RESULTS:The sensitivity and specificity of ultrasound for qualitative diagnosis of adhesions were above 93%, and there was no significant difference between the quantitative diagnosis of adhesion area and degree compared with laparoscopy. Conclusion:Ultrasound can be used as an effective and non-invasive method to assess the degree of adhesions. Zhang Chengpeng, Department of Minimally Invasive General Surgery, The First Hospital of Guangzhou Medical University, Guangzhou, China
【Key words】 Abdominopelvic adhesions; Ultrasound; Assessment method
Postoperative adhesions have always been a problematic issue for surgeons, and according to a recent study, there are between 2,000 and 14,000 cases of adhesion-related problems in the United Kingdom each year [1], and the cost of treating adhesion-related complications in the United States was as high as $1.3 billion in 1994 [2]. Postoperative adhesions account for about 90% of all abdominopelvic adhesions [3], and a large number of studies have been conducted by domestic and foreign scholars to prevent adhesions, but few quantitative clinical studies on postoperative adhesion prevention and treatment have been reported, mainly because of the lack of appropriate clinical adhesion assessment methods. ct, mri, and ultrasound have been more studied in recent years for noninvasive diagnostic assessment methods, but no mature quantitative diagnostic criteria have been proposed [4 ]. We conducted a comparative study of 23 cases of adhesions by both ultrasound and laparoscopy from October 2004 to March 2006 in an attempt to find a set of adhesion scoring and assessment study methods that could be used clinically. It is reported below.
1 Data and methods
1.1 General data:The inclusion criteria were: ① previous history of abdominal and pelvic surgery with a postoperative period greater than 1 week. (ii) The need for laparoscopic surgery again in the near future. Exclusion criteria: ① those with congenital wall peritoneal lesions affecting ultrasound detection results. (ii) Those with peritoneal tuberculosis or tumor. (iii) Those with incisional hernia. A total of 23 cases with 37 abdominal wall incisions were selected. Among them, 10 cases were male and 13 cases were female; age ranged from 33 to 90 years.
1.2 Study methods:Two methods were used to compare ultrasound assessment and laparoscopic assessment.
1.2.1 Ultrasound diagnostic criteria for adhesions: ① continuity of ultrasound echoes of the peritoneum; ② mobility of the organs at different levels under the abdominal wall; ③ deformation of the adherent organs.
1.2.2 Qualitative diagnosis of adhesions: Before ultrasound diagnosis, we should know whether the patient has diseases that cause respiratory weakness, such as chronic obstructive pulmonary disease and excessive obesity, and observe whether the parallel sliding of subabdominal organs in the normal area of the abdominal wall is less than 1 cm when the patient is breathing calmly. A spontaneous visceral sliding distance of less than 1 cm or visceral sliding mobility of less than 2 cm during deep breathing is positive; angular motion or no motion of organs at different levels is positive; if direct adhesion of liver, uterus or intestine to the abdominal wall is considered or if there is deformation of the visceral sliding when the visceral sliding is observed from different angles, using gravity, is positive. If one of these conditions is present, the non-dense adhesions are established. In the case of dense adhesions, there must be: (1) interruption of peritoneal continuity; (2) spontaneous visceral sliding with less than 1 cm of visceral sliding activity or inactivity during deep breathing, and angular movement of the viscera at different levels.
1.2.3 Quantitative diagnosis of adhesions: including assessment of the area of adhesions as well as the degree of adhesions. Patients who meet the selection criteria undergo ultrasonography one day before laparoscopic surgery, with the ultrasound probe punctuated with merocyanine at approximately 1 cm intervals and the center of the marked point at the edge of the adhesions. Laparoscopic diagnosis was performed by first establishing a good pneumoperitoneum during surgery, placing the laparoscope, first exploring the abdominopelvic cavity and observing the presence or absence of adhesions for qualitative diagnosis, and then marking the extent of adhesions under laparoscopy with a laparoscopic lens near the border of adhesions at the red light source marker visible outside the abdominal wall, with the center of the light source point 0.5 cm outside the center of the original marker point (because the size of the laparoscopic light source point is 1 cm ), and mark the deviation distance inside or outside the original marker boundary, and mark the laparoscopic extent of adhesions with different colors on the basis of the original ultrasound depiction. Photographs were taken and entered into the computer. For the first time, Photoshop software was used to calculate the area of adhesions, i.e., to take full advantage of the ability of Photoshop software itself to read the pixel values within the selected images to derive the area contained within the localized points in the ultrasound and laparoscopic images separately for comparison.
1.2.4 Assessment of the degree of abdominal wall adhesions A scale was developed, as shown in Table 1. The degree of adhesions in the abdominal wall under ultrasound was scored as the percentage of the total area of dense adhesions; the degree of adhesions in the abdominal wall under laparoscopy was scored as the percentage of the area of adhesions requiring sharp separation of the total area of adhesions separated intraoperatively.
2 Results
2.1 Qualitative diagnosis of adhesions by ultrasound: statistical analysis was performed using the paired Chi-Square test. spss statistics showed that p=1.000 for the diagnosis of dense adhesions by ultrasound versus laparoscopy, p=0.688 for the diagnosis of loose adhesions by ultrasound versus laparoscopy, and p=1.000 for the qualitative diagnosis of total adhesions by ultrasound versus laparoscopy. 1.000, indicating that there was no significant difference between the qualitative diagnosis of adhesions by ultrasound and the qualitative diagnosis of adhesions by laparoscopy for either dense or loose adhesions. The overall diagnostic sensitivity of ultrasound for the presence of adhesions was 94.7%, and the overall specificity for excluding the presence of adhesions was 94.1%.
2.2 Quantitative diagnosis of adhesions by ultrasound-Photoshop software to obtain the area of adhesions: statistical analysis by paired rank sum test. the results of SPSS analysis can be concluded that the theoretical diagnosis of the area of dense adhesions by ultrasound compared with laparoscopic diagnosis P=0.099; the quantitative diagnosis of the area of loose adhesions by ultrasound compared with laparoscopic diagnosis P= 0.079; indicating that there was no statistical difference in the quantitative (area) diagnosis of dense adhesions and loose adhesions by ultrasound compared with laparoscopy.
2.3 Quantitative diagnosis of adhesions by ultrasound – degree assessment: statistical analysis was performed using paired t-test. SPSS analysis comparing ultrasound diagnosis of adhesions score with laparoscopic diagnosis of adhesions score yielded P=1.000, indicating that there was no significant difference in quantitative diagnosis of adhesions score by ultrasound compared with laparoscopy.
3 Discussion
The causes of intra-abdominal adhesions are mainly acquired, except for a very few congenital abnormalities in the abdominal cavity, which are commonly caused by abdominal inflammation, injury, bleeding, intra-abdominal foreign bodies, abdominal radiation and intra-abdominal injection of chemical therapy (chemotherapy). Peritoneal adhesions are a common response to peritoneal trauma and occur mostly after surgical procedures, and despite great advances in modern surgical techniques, postoperative intra-abdominal adhesions are still a common complication after abdominal surgery, with an incidence of up to 90% [3].
The formation of adhesions occurs in the peritoneal layer, and their occurrence is determined by the contact between the two injured plasma surfaces and the inhibition of fibrinolytic activity within 5-7 d after the occurrence of peritoneal injury; adhesion formation and non-adhesive re-epithelialization are the two outcomes after peritoneal injury.
In the past, the diagnosis of intra-abdominal adhesions mainly relied on the patient’s history and clinical manifestations for subjective judgment, or in animal experiments, the method of dissection after execution of the animal was used to study them, which could not be applied in clinical studies. In recent years, the application of laparoscopy has provided a certain basis for the diagnosis of intra-abdominal adhesions, but laparoscopy as an invasive examination obviously cannot be widely used for the diagnosis of intra-abdominal adhesions, but the development of laparoscopic surgery requires high preoperative judgment of the presence of intra-abdominal adhesions to avoid complications such as damage to intra-abdominal organs, intestinal perforation, bleeding, hematoma and peritonitis caused by blind placement of laparoscopy to improve the quality of the procedure.
Three independent indicators were chosen to determine the assessment of intraperitoneal adhesions to improve the sensitivity of the diagnosis.
3.1 Ultrasound continuity of the peritoneum: Borzellino et al. concluded that if no adhesions are present under the abdominal wall, then the mural peritoneal echoes should be continuous, and if there is a break in this continuity or if they become irregular dotted or lamellar, then the change is considered to be due to the presence of adhesions, with a diagnostic sensitivity of 100% in their study.
3.2 Relative motion between the subabdominal viscera and the abdominal wall: under normal circumstances, without the presence of adhesions, the motion of the intra-abdominal viscera at different depths of the plane and the peritoneum of the wall should be a straight and parallel motion. Sigel et al. first proposed the use of ultrasound to diagnose the presence of abdominal wall adhesions by observing the movement between viscera with respiratory motion or artificial probe impact to determine the site of adhesions and to select surgical options, with a sensitivity and specificity of 95% and The sensitivity and specificity are 95% and 100%, respectively. We also measure the distance of visceral sliding by using a relatively stable intra-abdominal structure at different depth levels of marker points, and by using the umbilicus or a wire placed between the probe and the abdominal wall, which produces an acoustic shadow as a reference marker of relative motion.
3.3 Deformation of adherent organs: Zhang Xiaoying et al [5] proposed the idea of ultrasound-guided intra-abdominal direct injection of equilibrium fluid (i.e., abdominal media-enhanced ultrasonography) for ultrasound adhesion detection. Zhu Fu et al [6] reported the use of ultrasound to diagnose the presence of adhesions by exploiting the restricted motion of organs due to adhesions, which deform during motion. We have likewise utilized these principles and have mainly studied organ adhesions such as liver and uterus.
Previously used systems for quantitative assessment of adhesions include the Nair assessment system, the Leach assessment system, and the Oncel adhesion severity scoring system. These assessments have to be performed under the naked eye, i.e., the results are obtained by dissecting the animal after execution and performing gross observation, and these methods are not clinically applicable. In this study, we drew on Leach and Oncel’s adhesion scoring, and the scoring rationale specified a scoring system suitable for both ultrasound and laparoscopic assessment of adhesions.
Ultrasound is a widely used clinical imaging test that is currently simple to perform, inexpensive and noninvasive. By comparing ultrasound and laparoscopy for abdominal adhesions, we concluded that ultrasound can be used for qualitative diagnosis of adhesions and can differentiate between dense and loose adhesions; ultrasound can be used for quantitative diagnosis of adhesions, and there is no significant difference in the diagnosis of adhesion area and adhesion grade compared with laparoscopy. The adhesion scoring system can be combined with the adhesion area (how much) for clinical adhesion control studies. Since this experiment is a comparative assessment in clinical work, there is still a lack of comparison and accumulation of animal experimental model samples, so this study still needs to be further developed.
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