Scar tissue from previous surgery

[paula]

Hello everyone, for a couple of years now, I've gone to the emergency room several times, with horrible cramps and vomiting that won't stop, until I get intravenous medicine, so finally, a doctor diagnosed scar tissue, and I will probably have to have surgery to repair this. This is sort of the last resort, but after so many times, happening, they think its the right thing to do.

Just wondering if anyone has had this problem before. I had colon cancer about 15 years ago, had surgery, etc, and this is a result of it, as I'm told.

Thank you for your opinions in advance..................paula

[betula]

Hi there

My husband has a colostomy from surgery for rectal cancer in Dec 2016. He has been having repeated bowel blockages which are completely miserable, end up in er/hospital stay. We watch his diet and for the most part keep him to a low residue diet, use miralax to keep things soft, keep him hydrated and do yoga in an attempt to keep things moving.

I get that doctors do not want to do anything invasive but at this point we don't see the harm.

We feel your pain!

[Button]

Paula:
Repeated small bowel obstructions are pure misery. I empathize with your situation as I have a slew of adhesions.

I have had one open laparotomy for lysis of adhesions. The laporotomy did “fixed” the presenting acute small bowel obstruction at that time. This was a small bowel obstructions that did NOT resolve after a week on an NG tube with suction and complete bowel rest.

Surgery begets more scar tissue and adhesions. That is the colundrum that begets all of us with a history of abdominal surgery. Scar tissue/adhesions are a normal healing response. Scar tissue will form with any surgery - even a surgery to remove adhesions.

Adhesions become our nemisis when they tether or attach to a segment of intestine or to the abdominal wall or to an adjacent organ, causing a “kink.” Back-pressure accumulates as the segment of intestine dilates and swells and the flow of digestive material slows or stops.

You can expect that if you have a surgical lysis of adhesions that you may form new adhesions.

Round and around the Merry-Go-Round.

Moving forward, I have employed the following to best manage my adhesions.
1. Daily dosing with MiraLax. I strive to keep my ileostomy ouput very thin and watery so that it can flow through narrowed or restricted areas of intestine.
2. Follow a low fiber diet. Small portion sizes. I graze and nibble more than eat a meal. Key is to not overwhelm the intestinal tract with a large volume of food that needs to be processed down and through.

Ex. I refrain from eating the membranes of citrus fruits, carefully sectioning oranges to remove the sectional membranes. I do not eat pineapple due to its high stringy fiber content. I avoid foods with kidney beans and similar large legumes. Look at it this way: If my kitchen disposal is going to have to work to pulverize a food, I will also assume that my digestive system will have difficulty digesting said food item. To wit: I also avoid asparagus, long stalks of celery, kernelled pop corn, etanamie, large sized nuts (walnut halves, pecans). You get the gist.

3. Yoga
Ah, my favorite. Yoga. There is nothing better than basic, beginners yoga poses and postures to mobilize adhesions and adjacent intestine. Yoga is, quite simply, massage for the intestines. Yoga - especially poses that empahasize rotation between the thoracic and pelvis (twist to right, left) and longitudinally body elongation (arms up above the head, lying supine). You can Google “Basic beginner and reatorative yoga poses” for ideas that might be appropriate for you. If you have a history of cervical disc disease or ACDF surgery then you would want to have a consultation with a physical therapist to determine appropriate poses.

4. Deep tissue massage
Physical therapists have extensive education on the musculoskeletal system and the anatomy of soft connective tissue. Deep abdominal tissue massage has shown clinical benefit in mobilizing and softening adhesions. Think of that deep massage as a “rake” that helps to realign and soften dense tissue fibers.

E. At the first inking of a possible SBO, I revert to clear liquids only. No solid food.

So far, so good. I am managing.
Karen

[paula]

Thank you betula for your reply. Hope your husband feels better soon. Karen, yes, I get that surgery will only add to more scar tissue, but at this point, I started this in 2014, and between then and now, I've gone to the emergency room about 10 times with the same symptoms. They took all kinds of tests, all came out Ok, finally last May, a surgeon saw me and admitted me, I had a tube put in for a couple of days, and she said, if I had any more episodes, as a last resort, they would do the surgery. The other thing she told me, was to do a high fiber diet, not a low one, so a little bit confused there.

I really do only small portions of food and am aware of what to eat. actually, after all this, I'm almost afraid to eat. I do beginner's yoga, myself, but was wondering if it was good for my condition, now that you say you do it, as well, and it helps, I'm going to do it more often. Will try using Miralax. I'm having a consultation with the surgeon on friday, so let's see what she says.

Thank you so much for your replies. It helps to hear from someone who has the same problems.

[Button]

Paula:
Radiation, as you have undergone, does make the difficulties of your adhesions different than mine (my adhesions were likely due to a heightened inflammatory response secondary to sepsis).

Radiation is the gift that keeps on giving. Radiation makes tissue dense, non-elastic, leather-like.

10 ER visits is quite compelling. You have definately been through the wringer.

Most SBOs due to adhesions are the case where a band of scar tissue entraps a segment of small intestine. The small intestine slithers and squirms 24-7 like a snake under the moist fat apron that covers the abdomen (the omentum). This also allows for motility by which a tethered portion of small bowel can then also FREE itself from the clenches of a band of scar tissue, resolving the SBO along with bowel rest and/or NG tube with suction. But food intake and type does play a role. Large meals, high fiber foods, dense food choices slowly become backed-up and less able to maneuver through an area that may be slightly restricted, triggering a more full-blown SBO.

I do not think that I had any real option other than surgery for the recalcitrant small bowel obstruction. 8 days with an NG tube and nasal irrigation with gastrograffin to no avail. It was not a long recovery. The offending scar tissue was readily seen and snipped away. The surgeon did some other scar tissue snipping and placed septa-film between folds/loops of small bowel to minimize recurrence. Overall, a best case scenario.

Each person’s situation is unique. Talk with your surgeon. And then follow your intuition.

I still have episodes of small bowel obstructions. Two hospitalizations last year with an NG tube. So my open laboratory with lysis of adhesions was not a cure-all. I am on Palliative Care and have made the personal choice that I will undergo no further surgical care of any manner. Your situation may be well relieved by some surgical snipping.

Certainly, do talk with the surgeon as to whether he will be using any Septa-film (or similar) to help reduce the likelihood of sprouting additional adhesions. That you are no longer undergoing radiation therapy is a BIG plus in your favor. Your current adhesions are likely related to iriradiated tissue. With radiation now out of the contributing equation, you may have the fortune of low/no additional adhesions.

But certainly, use of Miralax or other similar agent to thin the consistency of your fecal output is worth considering. The goal is to thin the fecal consistency so that it flow unimpeded theough narrowed intestinal passageways or strictures.

The role of a low fiber food choices also Dove-Tails the rational for a thinner consistency of fecal material. Picture a wad of
coconut macaroon cookie getting “stuck” because it cannot squeeze through. High fiber foods (specifically, insoluble fiber) will tend to coagulate and cause mischief.

Yoga will be your friend. With the proposed surgery to snip away your accumulated scar tissue or without. Yoga kneeds and massages the intestines and organs. Yoga helps stretch and mobilize adhesions that are present, keeping them more supple. Adhesions that become thick, dense, and leathery are adhesions that are problematic.

A small bowel obstruction really is the manifestation of a perfect storm. Consisting of: 1. An intermittent “kink” or stricture; 2. Back-pressure from slowly accumulating digested food material that is not flowing through with ease.

Best wishes in meeting with your surgeon. Information is power.
Karen

[paula]

Again, thank you, Karen, for this wealth of information. Yes, I did have chemo and radiation 15 years ago. With this information, I will have more questions than I already had for my doctor. One being the high fiber, which she advised, and until the last episode seemed to be working. She advised me to eat green vegetables soup at lunch and dinner, and integral rice, cereal, etc. So, have to double check that.

Can't wait to see her on Friday, and see what's going to happen next. Thank you again.

paula

[cdogtom]

high fiber -----should be only soluble fiber only not insoluble.... when i begin to slow i take milk of mag. with plenty of water .a trick Button showed us was to drink plain apple juice ....hope all goes well

[Button]

Paula:
Your MDs recommendation for “high fiber” and the specific foods that you mentioned (rice, oatmeal, cooked/steamed vegetables) are all A-OK. These have higher soluble fiber but low insoluble fiber.

You can safely eat soluble fiber (fiber that is able to be easily broken down by mechanical chewing and metabolically broken down by digestive enzymes in the gut). Examples of Soluble fiber: basic balsamic rice; diced, fleshy pulp of an apple, without the skin; cooked Quaker oatmeal; banana without its peel; watermelon, cantaloupe (without outer rind);

You want to avoid/limit insoluble fiber (that is fiber that is NOT easily broken down by mechanical chewing nor broken down by digestive enzymes in the gut). Examples of Insoluble fiber: celery stalks; kerneled pop corn; coconut flakes; asparagus; skin of an apple; membranes of oranges, grapefruits; steel cut oatmeal; wild rice; artichoke leaves.

Your MDs comment to eat “high fiber” needs a qualifier. The qualifying statement: Eat soluble fiber. Limit/avoid insoluble fiber.

Your MDs comment to eat soups is also A-OK and wise. Soups have a liquid base that is advantageous to the digestive flow as well as soft/cooked/steamed vegetables that are generally diced/sliced. Soups are generally easy to digest.

Examples of A-OK soups: Creamed/strained soups; broths; chicken noodle soup; tomato soup

Soups to eat with some caution: split pea (due to insoluble fiber): thicken/stew-like minestrone soup; thicken lentil soup.

You can google both terms (insoluble fiber and soluble fiber) to get a fuller listing of specific foods that fall under each category.
Karen

[paula]

Once again, thank you, Karen for the information.

Paula

[paula]

karen, just wanted to update on my visit to the surgeon to decide about the surgery, to repair the scar tissue. Unfortunately, when I started to ask some questions about the surgery, she took it badly, and thought I was doubting her. I told her, that I would always ask these questions, as they pertain to my health and body. Anyway, she recommended me to another doctor, who a friend of mine, who is a nurse, knows, and comes highly recommended, and has a lot more experience, so I think its for the best. Will be seeing him tomorrow, and hopefully, will be able to resolve this.

By the way, been looking at Restorative Yoga Poses, as you suggested, I don't know if I mentioned that I have a colostomy, but I'm thinking this is still ok. I do beginners yoga, and haven't had any problems.

Hope you're feeling well. Again, thank you for all your information.

paula

[betula]

Please keep us posted on your doctor's appointment. My husband is currently in the hospital for another obstruction. We will find out more tomorrow whether they will do surgery or not. On one hand we want it because we feel we have tried a lot regarding, diet, staying hydrated, stretching/yoga but on the hand it is scary.

Good luck tomorrow!

[Ostemy-101]

I am new to this forum and very interested in this topic. My mom has been hospitalized 3 times in the past month for a lower bowel obstruction. She is 75 years old, has lost a very significant amount of weight in the last year (down to 100 pounds), has had so many scans,x rays, etc. The surgeon tells us she is not a surgical candidate (and this occurs because of scar tissue and liasons from her previous surgeries) . They did a motility test which shows her intestines are sluggish. They say small, frequent, meals is the answers. What I dont understand is how to stop this vicious cycle.... shes been in the hospital, this round, for 9 days. Shes on a soft food diet. Today her BP skyrocketed and she spiked a fever. Im.so worried and frustrated does anyone know what other questions I should be asking? What has worked for you folks that get frequent lower bowel obstructions? How do I keep my mom hydrated when she starts to show symptoms because by then, she cant keep anything down. Any input is appreciated.

[paula]

Betula:

I had my appt with the new doctor, who I found much more open to questions, and doubts I might have. So, very happy with the change. He did say, the same thing however, regarding the surgery. After so many episodes, this will be the right step to take. Laparoscopy surgery will be the first thing to try, but, if not working, they will have to do "open" surgery.

I have scheduled pre surgery tests, a catscan to the pelvic abdomen, heart test, blood work and a visit to the doctor who will be doing the anesthesia. Then, if all goes well, I'll be going back to him, to schedule the surgery. Must admit that I am a little apprehensive and scared, but at the same time, can't wait to do it, as this is not a very good quality of life. Afraid to eat, don't know exactly to eat, etc.

So sorry to hear about your husband. Praying that all goes well. Thank you again.

[Button]

Paula:
I am glad that the second surgeon was a better fit for you and offered you a hopeful plan for resolving your recurrent small bowel obstructions.

Make no doubt, your intuitive sense of a surgeon is valid. Our intuition provides a thoughtful inner voice that should not be dismissed. That you had reservations and doubts about the first surgeon is reason enough to have sought another opinion. I am glad that you did.

That your adhesions likely came to form from the effects of radiation therapy in treating your distant cancer gives good reason to hope that surgical lysis/snipping of the bands of scar tissue will resolve your hostile abdomen once and for all. I think you are wise in pursuing the surgery.

A Laparoscopic technique for lysis of abdominal adhesions is not often a first choice or approach. Laproscopic surgery entails using carbon dioxide gas used to inflate the abdomen, providing visualization to the surgeon. Expanding the abdomen with gas separates and frees the abdominal wall from adjacent internal organs as well as frees internal organs from adjacent organs. The internal abdomen becomes expansive in the space it
occupies. The risk: As gas inflates the abdomen and the abdomen expands there is risk that adhered or fixed/frozen connective tissue and tethered scar tissue causes more widespread damage - i.e. riping or avulsion of attached tissue resulting in bleeding or hemorrhage.

Surgery for my lysis of adhesions was open surgery, because of concern for the above.

Maybe your surgeon is ordering the pelvic CT scan to get an feel for the density of pelvic scar tissue. Scar tissue/adhesions are normally opaque to imaging mediums (x-ray, CT, MRI). That is, they are not readily seen or identified. Particularly dense deposits of scar tissue may be “seen” as density produces a more shadowed/darker image.

All to say . . . I would probably lean toward giving your surgeon an open invitation to for him to choose an open incision.

Septa-Film would also be part of my discussion with a surgeon. Placing sheets of Septa-Film between loops of small bowel or areas in the lower pelvis where your surgeon finds and removes radiation-induced scar tissue would potentially mitigate scar
tissue from forming after this lysis surgery. Septa-Film could have a preventative role. Not all surgeons employ the use of Septa-Film. It does not have universal acknowledgement by general surgeons. But it would be worth clarifying with your new surgeon so you have reasonable expectations.

Recovery from the lysis of adhesions surgery was much easier than any of my other abdominal surgeries. There was no other internal “work” done (no rerouting of intestine, no stoma creation or revision, no wash-out, no post-op drains placed). The surgery was a seek and find mission to find and release/snip away offending bands of scar tissue. I was tired overall from the anesthesia, but the recovery process was A-OK with minimal pain and overall moved along faster and was less problematic than prior surgery experiences.

You have my best wishes for a great adhesion free outcome,
Karen

[Button]

Ostemy-101
As a starting point for your mother, I would suggest establishing a daily bowel routine with the intent to make it easier for digested food material to move along and through the digestive
tract, where scar tissue may be causing a stricture, narrowing, or kink. As I was outlining earlier, options include:

A. Daily dosing with Miralax or Milk of Magnesia.
Both are osmotic laxatives that can be used on a long-term basis without risk of lazy colon or dependency. Both are effective by drawing water into the colon, with the intended effect being to make the consistency of fecal matter more more fluid and more liquid. Picture a sizeable wad of firm stool trying to pass through a narrow segment of intestine vs a stream of fecal matter that is the consistency of cream of wheat cereal. You want to achieve the later consistency of cream of wheat.

Magnesium found in both Miralax and Milk of Magnesia provides a requisite motility nudge or motility enhancement that helps with the smooth muscle contractions that propel and move digested food material along. Magnesium is a vital electrolyte involved in muscular contractions. Magnesium helps regulate smooth muscle contractions of the intestine.

B. For those wanting a more holistic approach to intestinal motility, you can use daily dosing with aloe Vera juice (1-2 tablespoons a day). Think of aloe Vera juice as an internal intestinal lubricant. Cod liver oil is another holistic/natural option (1-2 teaspoons a day). Cod liver oil was a home remedy for constipation and regularity in the early 1900’s.

C. Small portion sizes, 1/2 cup or less. Small mini-meals. Grazing. Keep the volume of food material that the body is trying to digest within reason. The key is to avoid/minimize digested food material backing up in the intestine due to slow motility or narrowed areas of intestine.

D. Hydrate, hydrate, hydrate. Generous water intake and hydration truly does help keep food material moving along the length of the digestive tract. It is anoglius to turning up the flow of water from a kitchen faucet. Soups are a good food choice for a mini-meal as they have a liquid base and are easy to
digest (mechanical digestion/chewing and enzymatic breakdown of food).

E. General body movement/exercise
The intestines are a long tube of smooth muscle and are influenced in their motility and contractions by the body’s overall movement and exercise during a given day. To wit: Get up walk; swim; engage in pleasurable sports or activities; practice yoga; simple stretching exercises.

F. Heat/warmth for muscle relaxation
During a partial bowel obstruction, surrounding musculature contracts in a guarding response. Easing muscle contractions and easing muscle tension is helpful in resolving a partial
Obstruction. Take a hot shower or soak in a warm bathtub. Use a rice or buckwheat warming pack, using warmed in a microwave.

There are proactive measures that can employed to help ease the symptoms of an impending small bowel obstructions or to ease the severity of the event.

I always stop all intake of any form of soft or solid food when I experience initial symptoms of a small bowel obstructions. Clear liquids only (grape juice, tea, water).

When to seek medical care/emergency room:
a. Recurrent vomiting, vomiting over-and-over, vomiting that becomes explosive - that is not resolving
b. Severe abdominal pain, pain that literally has you doubled over, waves of abdominal pain - that is not resolving
c. No or sparse ostomy/stoma output, no or sparse release of gas - that is not resolving

The severity of pain and the intensity of experience of a bowel obstructions really is unique and will have your full attention. Once you have experienced an obstruction, you do not easily forget and the experience/memory can be useful in deciding when to access the emergency room.

Hopefully this will be informative and act as a service message in providing awareness for anyone who has had abdominal surgery and who is at some degree of heightened risk for adhesions and a possible small bowel obstruction.
Karen