Pelvic adhesions and pelvic pain: opinions on cause and effect relationship and when to surgically intervene

ABSTRACT Objective In the absence of definitive data, we sought to determine the consensus on the contribution of adhesions to pelvic pain. Methods Impressions about the role of adhesion location, extent, and severity of pelvic pain, were surveyed among 13 gynaecological surgeons. They were asked whether adhesions covering specific organs to a varying extent would be likely to cause pain significant enough to require pain medication, or to lead a woman to alter her normal activities, and when they would recommend surgery to reduce pelvic pain. Results Women with dense vascular adhesions covering all of the uterus but not the bowel or adnexal structures were thought to have a 49^9% likelihood of having pelvic pain; this fell to a 34^7% and 18^5% likelihood of pain if 60% or 20%, respectively, of the uterus was involved with adhesions. Similar observations were made for adhesions involving the posterior cul-de-sac and large bowel. However, adhesions involving the anterior cul-de-sac were thought to be less likely to cause pain. Women with total involvement of both tubes and ovaries with dense, vascularadhesionswerethoughttobe60^9%likelytohavepelvicpain;reduction in extent of adhesions to 50% or 25% reduced the prediction of pain to 38^5% and 21^3%, respectively. In contrast, filmy adhesions to both tubes and ovaries, were thought to cause pain in 46^9%, 26^5%, and 13^3% of women, respectively, according to extent. Half the surgeons said they would recommend surgery for patients with pain and dense adhesions involving 15% of both tubes and ovaries; 10 recommended surgery if it was known that adhesions involved 100% of bothovariesandtubes.Surgeonswereonlyslightlylesslikelytorecommendsurgery for pain relief for adhesions involving either both tubes or both ovaries or for pain associated with unilateral tubal and ovarian adhesions. For bilateral tube and ovary adhesions, surgery was equally likely to be recommended for relief of pain when adhesions were cohesive and dense; for adhesions which were filmy, surgery was less likely to be recommended. For dense adhesions involving 20%, 40%, 60%, and 80% of the uterine surface, surgery was recommended by 42%, 58%, 83% and 92% of surgeons, respectively. Posterior cul-de-sac involvement resulted in recommendation of surgery by 50%, 83%, 92%, and 100% of surgeons, respectively; however, for corresponding amounts of anterior cul-de-sac adhesions, surgery was recommended by only 17%, 33%, 67%, and 75% of surgeons. Conclusions (1) Adhesions are frequently considered to be a cause of pelvic pain; (2) the likelihood of discomfort is related to location, extent, and to a lesser degree, the severity of adhesions, and (3) adhesiolysis is thought to provide the potential for pain relief

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

Social change and the family: Comparative perspectives from the west, China, and South Asia

This paper examines the influence of social and economic change on family structure and relationships: How do such economic and social transformations as industrialization, urbanization, demographic change, the expansion of education, and the long-term growth of income influence the family? We take a comparative and historical approach, reviewing the experiences of three major sociocultural regions: the West, China, and South Asia. Many of the changes that have occurred in family life have been remarkably similar in the three settings—the separation of the workplace from the home, increased training of children in nonfamilial institutions, the development of living arrangements outside the family household, increased access of children to financial and other productive resources, and increased participation by children in the selection of a mate. While the similarities of family change in diverse cultural settings are striking, specific aspects of change have varied across settings because of significant pre-existing differences in family structure, residential patterns of marriage, autonomy of children, and the role of marriage within kinship systems.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/45661/1/11206_2005_Article_BF01124383.pd