Visceral mobilization can lyse and prevent peritoneal

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2 G M Bove S L Chapelle, Introduction are no clinical or basic science investigations related to the. efficacy or possible mechanisms of such treatments. Peritoneal adhesions have been reported as an adverse side We designed the current study to evaluate the hypoth. effect of surgery for more than a century Hertzler 1919 esis that visceral mobilization currently in clinical use by. and occur in 90e100 of cases following surgery Menzies one of the authors SLC and applied to a well character. and Ellis 1990 Stanciu and Menzies 2007 They are ized rat model Ar Rajab et al 1991 Irkorucu et al 2009. a leading cause of bowel obstruction infertility pelvic can lyse established adhesions and can prevent peritoneal. pain and repeated surgeries Almeida and Val Gallas 1997 adhesions from forming In this initial report we show that. Attard and MacLean 2007 Beck et al 1999 Menzies and it is possible to identify treat and prevent experimentally. Ellis 1990 Parker et al 2007 Stanciu and Menzies induced visceral adhesions These observations open a line. 2007 Adhesions are pathological bands of fibrous of investigation with the potential to benefit those who. connective tissue that occur between abdominal or pelvic suffer adverse effects due to peritoneal adhesions. organs and other structures including viscera and the. abdominal wall One report indicated that 5 of all Methods. hospital readmissions following abdominal or pelvic surgery. are due to adhesions Ellis et al 1999 The most recent Animals and surgery. estimate of the economic burden of morbidity associated. with abdominal adhesions is 5 billion in the United States. All procedures were consistent with the Guide for the Care. alone Wiseman 2008 Post surgical peritoneal adhesions. and Use of Laboratory Animals National Research Council. are a significant public health concern, USA and were approved by the University of New England. Adhesions form following a number of injuries to the. Institutional Animal Care and Use Committee Thirty adult. peritoneum including mechanical trauma drying blood. male Long Evans rats were obtained from Charles River. clotting and foreign object implantation Ryan et al. Laboratories USA and weighed 300 g when used The,1971 The inflammation caused by peritoneal trauma. methods were designed following previously published. from any etiology leads to a disruption of the balance. reports Ar Rajab et al 1991 Irkorucu et al 2009 Rats. between the fibrin forming and fibrin dissolving capacities. were anesthetized with isoflurane in pure oxygen 4 for. of the peritoneum favoring the deposition of a fibrin rich. exudate on the damaged area diZerega and Campeau induction 1 8e2 for maintenance and their abdominal. walls were shaved and scrubbed with betadine and 70. 2001 Reed et al 2008 If the fibrin is not resolved by. isopropanol The surgical field was draped and a 2 cm. the fibrinolytic system within days adhesions form. Holmdahl 1997 Persistent adhesions can prevent the vertical incision was made 3e4 mm lateral and to the right. of the linea alba approximately 1 3 below and 2 3 above. normal sliding of the viscera during peristalsis and move. the umbilicus The cecum was identified exteriorized using. ments of the body such as respiration Adhesions become. atraumatic forceps and grasped with gloved fingers A. both innervated and vascularized Herrick et al 2000. sterile toothbrush with a 13 mm circular head Braun USA. Sulaiman et al 2000, Adhesiolysis surgical lysis of persistent and symptomatic was stroked 10e12 times across the anterior and posterior. peritoneal adhesions is a common procedure Szomstein cecal surfaces causing multiple petechial hemorrhages. et al 2006 but often leads to reformation and new over a combined area of approximately 7 cm3 The cecum. adhesions Diamond et al 1987 Diamond and DeCherney was placed back in the abdominal cavity The toothbrush. 1987 Gutt et al 2004 Milingos et al 2000 Prevention is was then inserted into the abdominal cavity and the ante. a far more desirable goal Gomel et al 1996 Mettler rior parietal peritoneum was abraded using 5 back and forth. 2003 Scott Coombes et al 1993 and much effort has strokes per side The incision was closed in layers using 3. been expended on adhesion prevention using various sutures for the abdominal wall and 3 sutures for the skin. chemical compounds and barriers Corrales et al 2008 4 0 Monoweb Webster Veterinary USA and the rat was. Guo et al 2009 Ilbay et al 2004 Kutlay et al 2004 allowed to recover. Mettler et al 2003 Oncel et al 2004 Systematic, reviews of these treatments have reported that none Experimental design.
consistently prevent adhesion formation Kumar et al. 2009 Metwally et al 2006 Identifying an effective Rats were assigned to 1 of 3 groups Control Lysis or. preventive measure or a treatment that avoids recurrence Preventive All underwent the cecal abrasion surgery. has the potential to avoid much morbidity and economic described above Control and Lysis rats were allowed to. burden survive 7 days during which time no procedures were. Textbooks have been written describing techniques of performed Control rats were killed on postoperative day 7. visceral manipulation and include the treatment of post without performing any other treatment using an overdose. operative scar tissue and adhesions Barral 2007 Finet of sodium pentobarbital 200 mg kg i p and their adhe. 2000 Clinicians from various backgrounds who practice sions evaluated see below Lysis rats were palpated and. these methods anecdotally report the ability to palpate and treated by one of the authors SLC on postoperative day 7. lyse adhesions and that pain and other symptoms as described below Following this treatment the rats were. including amenorrhea infertility and digestive problems killed and their adhesions were immediately evaluated. are resolved following treatment Such claims have never Preventive group rats were palpated and treated each day. been systematically investigated Other than a case series following surgery after which they were killed and their. and editorial from 1899 Coe 1899 Haberlin 1899 there adhesions were evaluated. Please cite this article in press as Bove G M Chapelle S L Visceral mobilization can lyse and prevent peritoneal adhesions in a rat. model Journal of Bodywork Movement Therapies 2011 doi 10 1016 j jbmt 2011 02 004. Visceral mobilization and peritoneal adhesions 3, prevent the formation of adhesions by maintaining normal. movements With these rats the examiner lifted the, abdominal wall from the underlying organs and felt for. restriction of movement The viscera were palpated and. the quality of movement assessed The cecum was gently. mobilized medially to laterally as well as anterior to. posterior The inferior portion of the cecum was stabilized. while stretching the upper portion away The small intes. tine was gently mobilized Rats in the Lysis group were. examined and treated once for approximately 5 min When. adhesions were perceived using the methods described. above attempts were made to lyse them Lytic treatments. were extensions of the methods that were used in the. Figure 1 Representative image of palpation and treatment Preventive rats For cecal to abdominal wall adhesions the. method in an unsedated rat The anterior abdominal wall is abdominal wall was pinched into a fold over the adhesion. being lifted and light pressure is being applied to the cecum forcing the cecum away from the abdominal wall When. Note that the limbs appear relaxed such an adhesion was released the cecum dropped inferior. in the abdomen and was no longer palpable If a restriction. Palpation and treatment was partially released it was difficult to stabilize the. cecum in order to release the remaining restriction In. All treatments were performed on unsedated and unre these cases it was easily determined by subsequent. strained rats Rats in the Lysis and Preventive groups were palpation that the restriction was not completely lysed For. placed on their side Figure 1 and their abdomens other adhesions one part of the cecum was stabilized or. palpated using scaled down methods that are practiced anchored and surrounding structures pushed away from this. upon humans As in humans treatments were tailored to stabilized point Following treatment the abdominal. the palpation findings When the examiner perceived contents were mobilized as detailed above. adhesions between the cecum and another structure one. side of the palpated adhesion was stabilized using one Adhesion evaluation. finger while the other side was mobilized away from the. restriction using a finger from the other hand feeling for Deeply anesthetized rats were perfused transcardially with. reduction in stiffness Each evaluation and treatment buffered saline The abdominal cavities were opened using. session lasted 5e10 min per rat Rats in the Preventive wide inverted U incisions that extended from the lower. group were examined and treated daily starting with the margin of the thorax to the inguinal ligaments The. first postoperative day The treatment was designed to abdominal walls were slowly retracted inferiorly under. Figure 2 Representative images of the 4 types of adhesions arrows A Cecumececum B Cecumeabdominal wall C. Fatececum 4 Fateabdominal wall Width of metal probe in all images Z 2 mm. Please cite this article in press as Bove G M Chapelle S L Visceral mobilization can lyse and prevent peritoneal adhesions in a rat. model Journal of Bodywork Movement Therapies 2011 doi 10 1016 j jbmt 2011 02 004. 4 G M Bove S L Chapelle, observation with a surgical microscope to prevent avulsing view the adhesion Figure 4A which appeared similar to. adhesions Adhesions were isolated and then photographed a previously published image of a post myomectomy adhe. through the microscope using a digital camera Nikon USA sion Lau and Tulandi 2000 The abdomen was deflated and. Adhesion severity was graded on a scale of 0 no the fingers were then used from outside the abdomen to lyse. adhesions to 4 established adhesions following pub the adhesion Figure 4B shows the impact of the first. lished protocols Ar Rajab et al 1991 Irkorucu et al attempt which left two small filmy adhesions On the. 2009 Mazuji and Fadhli 1965 Images were randomly second attempt these were lysed and the cecum dropped. assigned a number by an assistant not otherwise partici below the colon and out of sight of the camera. pating in the study to blind the group assignments Analysis of variance of the adhesion scores revealed. Grading was performed by 2 investigators who were a significant treatment affect p 0 01 Table 1 Post hoc. familiarized with the grading scheme using images taken tests Tukey s HSD showed that the largest difference was. from a group of rats not included in this study The eval between the Prevention group mean Z 0 6 0 97 SD. uating investigators viewed the images together discussed and the Lysis group mean Z 1 9 1 84 p 0 01. their impressions until a consensus was reached and Petechial hemorrhages induced by the surgical inter. assigned a single score vention remained after 1 week in all groups While not. quantified there were fewer remaining lesions on the ceca. in the Preventive group such as in Figure 2B There was. Results better overall healing of the parietal peritoneal incision. site in this group, All 30 rats recovered from the surgery with no complica The palpation and treatment skills used on humans were. tions The 20 rats in the Lysis and Preventive groups toler readily transferrable to the rats The ceca were easily. ated the palpation and treatment procedures well identified using palpation through the abdominal wall and. Figure 1 These rats readily relaxed their overall move restricted cecumececum and cecumeabdominal wall. ments and abdominal walls facilitating the investigator to adhesions could be appreciated In rats with adhesions the. perform deep palpation evaluation and treatment of the abdominal contents felt more viscous than in rats with no. abdominal contents adhesions where the abdomen felt fluid and mobile Where. During the post mortem dissection 4 types of adhesions the cecum was attached to the abdominal wall there was. were found cecumececum cecumeabdominal wall a distinctly abnormal resistance to movement end feel. cecumefat and fateabdominal wall Figure 2 and Table 1 that indicated the presence of an adhesion Adhesions. fat refers to testicular fat pad The number of rats with involving fat were difficult to palpate and this was thought. adhesions did not differ by group Fisher s Exact Test The to be because they caused no appreciable restriction in. number of adhesions was significantly lower in the Preven mobility In the Lysis group identified cecumececum and. tive group p 0 05 Fisher s Exact Test In the Lysis group cecumeabdominal wall adhesions offered resistance to. there was clear evidence of 6 broken adhesions Figure 3 and initial lysis but were easily torn once started The force of. Table 1 In the Preventive group there was evidence of 4 the treatments did not evoke escape behavior flinching. adhesions that had been disrupted and healed The one biting Lysing an adhesion took between 15 s and 2 min. cecumececum adhesion in this group showed no overt depending on the position and perceived severity In the. evidence of inflammation and this adhesion was very easily Preventive group there was noticeably decreased overall. disrupted with the fingers In this group adhesion remnants mobility of the viscera after 1 day of surgery compared to. Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model Geoffrey M Bove DC PhDa Susan L visceral manipulation and include the treatment of post operative 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

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