Adhesion Info: Abdominal Adhesions

Adhesion Info: Abdominal Adhesions

Teenager speaks out over medical condition that leaves her looking nine months pregnant every time she eats

Hey, wait a minute! 
RACHEL Harley, 19, had to turn down a place at University in London because of her health after developing a bizarre condition that makes her stomach swell so much after eating that people think she's expecting.
http://www.dailyrecord.co.uk/news/real-life/teenager-speaks-out-over-medical-2880437
Teenager speaks out over medical condition that leaves her looking nine months pregnant every time she eats

The inpatient burden of abdominal and gynecological adhesiolysis in the US w Thanks to NIH

BMC Surg. 2011; 11: 13.

Published online 2011 June 9. doi:  10.1186/1471-2482-11-13

PMCID: PMC3141363

The inpatient burden of abdominal and gynecological adhesiolysis in the US

Vanja Sikirica,1 Bela Bapat,2 Sean D Candrilli,2 Keith L Davis,2 Malcolm Wilson,3 and Alan Johns4

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This article has been cited by other articles in PMC.

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Abstract

Background

Adhesions are fibrous bands of scar tissue, often a result of surgery, that form between internal organs and tissues, joining them together abnormally. Postoperative adhesions frequently occur following abdominal surgery, and are associated with a large economic burden. This study examines the inpatient burden of adhesiolysis in the United States (i.e., number and rate of events, cost, length of stay [LOS]).

Methods

Hospital discharge data for patients with primary and secondary adhesiolysis were analyzed using the 2005 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Procedures were aggregated by body system.

Results

We identified 351,777 adhesiolysis-related hospitalizations: 23.2% for primary and 76.8% for secondary adhesiolysis. The average LOS was 7.8 days for primary adhesiolysis. We found that 967,332 days of care were attributed to adhesiolysis-related procedures, with inpatient expenditures totaling $2.3 billion ($1.4 billion for primary adhesiolysis; $926 million for secondary adhesiolysis). Hospitalizations for adhesiolysis increased steadily by age and were higher for women. Of secondary adhesiolysis procedures, 46.3% involved the female reproductive tract, resulting in 57,005 additional days of care and $220 million in attributable costs.

Conclusions

Adhesiolysis remain an important surgical problem in the United States. Hospitalization for this condition leads to high direct surgical costs, which should be of interest to providers and payers.

Keywords: Adhesions, adhesiolysis, abdominal, gynecological, burden of illness, hospitalizations

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Background

Adhesions are fibrous bands of scar tissue, often result of surgery, that form between internal organs and tissues, joining them together abnormally [1]. Postoperative adhesions frequently occur following abdominal surgery and are a leading cause of intestinal obstruction. It has been estimated that more than 90% of patients who undergo abdominal operations will develop postoperative adhesions [2].

The most severe complication of postoperative adhesions is small bowel obstruction (SBO), which has a 10% risk of mortality [3,4]. Recent research has demonstrated that readmission episodes averaged 2.7 per patient for SBO or nonspecific abdominal pain (when adhesions were considered likely). Inpatient readmissions accounted for 87% of episodes; 47% of those required repeat surgery [5]. Additionally, in the large retrospective study Surgical and Clinical Adhesions Research, surgical procedures performed on the bowel or the female reproductive system were associated with an increased chance of adhesion development, termed adhesiolysis [6-8]. Ray and colleagues found that 47% of adhesiolysis-related inpatient hospitalizations were for procedures involving the female reproductive tract [2]. Postoperative adhesiolysis-related SBO occurred in 2.8% of patients undergoing hysterectomy for benign conditions and in 5% of those undergoing radical hysterectomy [4,9].

A number of studies have shown that the economic burden of adhesiolysis is significant [2,5,10]. It was estimated that adhesiolysis procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient care, and nearly $1.3 billion in health care expenditures in the United States (US) in 1994 [2]. This cost has decreased when compared with similar data from 1988,[10] due in part to laparoscopic surgery. Despite the decrease in costs associated with laparoscopic surgery, increased use of such techniques did not lead to a decreased rate of overall hospitalizations [2].

Utilizing more recent data, we estimated the current burden of inpatient treatment of adhesiolysis in the US. This study examined the number and rate of adhesiolysis-related hospitalizations, days of care attributable to adhesiolysis, and length of stay (LOS) for adhesiolysis-related hospitalizations, with primary and secondary procedures considered separately. Additionally, we assessed total inpatient costs attributable to adhesiolysis.

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Methods

Data Source

Data were taken from the 2005 Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS)[11]. The NIS is the largest all-payer inpatient care database in the US and contains data from approximately 8 million hospital stays in 2005. The database also contains clinical and resource use information, including patient demographics, International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes, diagnosis-related group (DRG) codes, LOS, charges, discharge status, payer source, and hospital-specific characteristics. Using the survey design elements provided with the NIS, data can be weighted to produce nationally representative estimates [12]. All financial information in the NIS database is presented as charges rather than costs. To convert hospital charges to costs, facility-specific cost-to-charge ratios were used. Finally, the medical care component of the Consumer Price Index was applied to inflate all financial data to 2007 US dollars [13].

RTI International's Institutional Review Board determined that this study met all criteria for exemption.

Study Sample

From the NIS, all hospitalizations containing a DRG code of peritoneal adhesiolysis with or without complications (i.e., DRG 150, 151) were defined as primary adhesiolysis-related hospitalizations. Hospitalizations containing a primary or nonprimary ICD-9-CM procedure code for adhesiolysis, but without DRG 150 or 151, were defined as secondary adhesiolysis-related hospitalizations (Table ​(Table1).1). Hospitalizations related to secondary adhesiolysis were stratified by body system, using the following DRG coding:

Table 1

Description of Procedure (ICD-9-CM) Codes Used to Identify Adhesiolysis-Related Surgical Procedures

(1) Digestive system (i.e., DRG 148, 149, 154, or 468),

(2) Hepatobiliary system (i.e., DRG 197, 493, or 494),

(3) Female reproductive system (i.e., DRG 358, 359, 361, or 365),

(4) Pregnancy with evidence of Cesarean section (i.e., DRG 370, 371, or 378).

Study Measures

Study measures included the number of inpatient hospitalizations involving adhesiolysis, adhesiolysis-related hospitalization rates, days of care, and costs attributable to adhesiolysis.

Hospitalization rates per 100,000 persons were assessed using the US Census Bureau's 2005 total US civilian population projection. The total days of care attributable to adhesiolysis were estimated using methods presented by Ray and colleagues that then were adapted for the HCUP NIS [2]. When DRG 150 or 151 (i.e., primary adhesiolysis) was the primary reason for admission, the attributed LOS was simply the mean LOS for this group. For records without a DRG of 150 or 151, excess days attributed to adhesiolysis were calculated as the difference between the mean LOS for those same procedures with adhesiolysis and those procedures without adhesiolysis within each DRG. The total number of adhesiolysis-related days then was estimated as the product of the attributed LOS for the group and the number of adhesiolysis-related hospitalizations within the group.

This study utilized the methodology from Ray and colleagues to estimate the per-day cost attributable to adhesiolysis [2]. Cost per day was estimated by dividing the total cost of adhesiolysis-related hospitalizations divided by the total number of adhesiolysis-related inpatient days. The total inpatient expenditures attributable to adhesiolysis were estimated by multiplying the estimated cost per day attributable to adhesiolysis by the number of days attributed to adhesiolysis.

Average expenditures for surgeon's services were estimated using the Resource-Based Relative Value Scale (RBRVS). The RBRVS value was estimated for Current Procedural Terminology codes related to adhesiolysis (Table ​(Table2)2) and then multiplied by a fixed conversion factor to determine the average surgeon expenditures for each specific procedure. These figures then were inflated to 2007 dollars using the medical care component of the Consumer Price Index.

Table 2

Description of Procedure (CPT) Codes Used to Identify Adhesiolysis-Related Surgical Procedures to Estimate Expenditures for Surgeons' Servicesa

Total inpatient costs attributable to adhesiolysis consisted of inpatient costs and costs for the surgeon's services. Estimates were made separately for primary and secondary adhesiolysis. These also were examined by body system and then aggregated to estimate a total cost. Additionally, inpatient expenditures were summarized to compare Cesarean section deliveries with and without adhesiolysis.

Statistical Analyses

Descriptive analyses were conducted to display the mean, standard deviation, median, and range of continuous variables, as well as the frequency distribution of categorical variables. All data management and analyses were conducted with SAS and SUDAAN statistical software packages [14,15].

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Results and Discussion

Table ​Table33 illustrates that there were 351,777 adhesiolysis-related hospitalizations in the US in 2005, representing 119 adhesiolysis hospitalizations per 100,000 persons. There were 898 adhesiolysis hospitalizations per 100,000 hospitalizations and 3,549 per 100,000 surgical hospitalizations of any kind (3.5%). Primary adhesiolysis (i.e., DRG 150 or 151) was found in 23.2% of these hospitalizations, while the remaining 76.8% were classified as secondary adhesiolysis (i.e., evidence of the procedure but with a DRG other than 150 or 151).

Table 3

Rate of Adhesiolysis-Related Hospitalizations

Table ​Table44 presents background characteristics for the study sample. For primary adhesiolysis, the number of hospitalizations increased steadily by age; for secondary adhesiolysis, the number increased for most age categories. The lowest rate was in patients who were younger than 25 years (5.2 per 100,000 persons for primary adhesiolysis; 13.8 per 100,000 persons for secondary adhesiolysis), and the highest rate was in patients who were older than 65 years (88.4 per 100,000 persons for primary adhesiolysis; 176.7 per 100,000 persons for secondary adhesiolysis). Women had a higher hospitalization rate than men (34.9 vs. 19.7 per 100,000 persons for primary adhesiolysis; 153.1 vs. 13.4 per 100,000 persons for secondary adhesiolysis). Among primary adhesiolysis hospitalizations, almost half (48%) of the patients were admitted via the emergency department, whereas only 20.5% of the secondary adhesiolysis hospitalizations were via the emergency department. Primary adhesiolysis-related hospitalizations were evenly distributed between private insurance and governmental coverage, i.e., Medicaid and Medicare (44% and 48%, respectively), whereas more than half (56%) of the patients with secondary adhesiolysis hospitalizations had private insurance and 37.4% had government-sponsored health care coverage.

Table 4

Demographics and Other Patient- and Facility-Specific Characteristics of Interest Among Adhesiolysis-Related Hospitalizations (i.e., DRG 150 or 151) in the US in 2005

A total of 967,332 inpatient days of care were attributed to primary and secondary adhesiolysis (Table ​(Table5).5). There were 81,532 hospitalizations and an average LOS of 7.8 days per stay, totaling 632,688 inpatient days of care for primary adhesiolysis. An estimated 334,644 days of care were attributed to secondary adhesiolysis. For hospitalizations in which adhesiolysis was a secondary procedure, we compared the LOS between adhesiolysis and nonadhesiolysis procedures to estimate the LOS attributable to adhesiolysis by each DRG. The majority of DRGs showed an increase in LOS for adhesiolysis hospitalizations versus nonadhesiolysis hospitalizations. On average, hospitalizations related to secondary adhesiolysis resulted in an additional 1.24 hospitalized days compared with nonadhesiolysis-related hospitalizations.

Table 5

Inpatient Care Attributable to Abdominal Adhesiolysis by Surgical Procedure in the US in 2005

The difference in mean LOS was greatest for extensive operation room procedures unrelated to principal diagnosis (i.e., DRG 468), with 4.9 days attributable to adhesiolysis. For stomach, esophageal, and duodenal procedures with complications of comorbid conditions (i.e., DRG 154), 4.6 days were attributable to adhesiolysis. Almost half (46.3%) of all secondary adhesiolysis procedures (125,069) were female reproductive tract related, resulting in 57,005 days of care. Thus, 0.46 day of additional stay were attributable to adhesiolysis. The longest LOS for female reproductive system procedures was for DRG 358 (uterine and adnexa procedures for nonmalignancy), which resulted in an additional day of inpatient stay (0.90 day).

Table ​Table66 shows that total inpatient expenditures for adhesiolysis-related hospitalizations were $2.25 billion: of this amount, primary adhesiolysis-related hospitalizations accounted for $1.35 billion and secondary adhesiolysis-related hospitalizations accounted for $902 million. Of the total secondary adhesiolysis expenditures, $622 million (69%) were related to procedures for the digestive system and $220 million (24.3%) were related to procedures for the female reproductive system. Adhesiolysis related to the hepatobiliary system and pancreas and Cesarean sections accounted for $41 million and $18 million, respectively.

Table 6

Inpatient Expenditures Attributable to Abdominal Adhesiolysis in the US in 2005

The rate of adhesiolysis-related hospitalizations in the US has remained fairly constant from 1998 to 2005: from 115.5 in 1988 [10] to 117.3 in 1994 [2] and ultimately 118.6 per 100,000 persons in 2005. In these same time periods, the average LOS for primary adhesiolysis-related hospitalizations has steadily decreased from 11.2 days to 9.7 days and 7.8 days, respectively. The costs for such hospitalizations, when inflated to reflect 2007 dollars, indicated an increase of $112 million between 1988 and 2005, despite the 3.4-day (or 30%) decrease in LOS--this represented a 5% increase in medical care costs. This increase suggested that costs of treating adhesiolysis have increased substantially.

Primary adhesiolysis contributed 23% of all adhesiolysis procedures (81,532) but represented more than half of the total cost burden ($1.3 billion). Secondary adhesiolysis was substantially higher in volume, representing 77% of procedures (270,245) but less half of the total cost burden ($902 million). The greatest number of procedures was to the female reproductive tract (125,069) while procedures to the digestive tract yielded the highest overall costs ($622 million).

Potentially mitigating this growth in the cost of adhesiolysis may be the continuing trend in the US toward minimally invasive and laparoscopic approaches, which may lessen the occurrence of postoperative adhesions [2]. Although laparoscopy reduces surgical trauma, the procedure has not been show to reduce the incidence of adhesion-related readmissions [16].

This study is subject to potential limitations consistent with retrospective database studies. Conditions and events of interest were identified by diagnosis codes. Previous research has suggested that the condition may be underreported [17]. This may mean that the actual cost of adhesiolysis-related disease is greater than the estimate provided by our study. The database used for this study was not specifically designed to assess inpatient burden. Like all administrative billing databases, the data contained in the HCUP NIS are dependent upon the quality of coding, which may be influenced by reimbursement incentives. However, we do not feel it likely that such incentives greatly affected our results since the majority of overall adhesiolysis costs were a part of secondary adhesiolysis procedures and not the more costly primary adhesiolysis. Moreover, even if such incentives exist and are reflected in the data used for this study, these data are indicative of real world practice. Additionally, with such a large sample, the effect of any coding errors or anomalies would likely be minimized.

Furthermore, due to the nature of the database, detailed clinical characteristics could not be ascertained; therefore, the results could not be adjusted for disease severity or other clinical parameters. However, it is unlikely that these factors would have had a large impact on the results, as this study focused on those patients receiving inpatient care. Additionally, since the database contains US data only, the results may not be generalizable to other populations outside of the US. Lastly, because the focus of this study was on direct cost measures, the results do not account for productivity loss for the patient or caregiver and potential future societal contributions that may be lost due to death resulting from or related to adhesiolysis. Because we examined only the direct health care costs associated with inpatient adhesiolysis, we have not examined any adhesiolysis-related surgeries performed at other sites of care, such as ambulatory surgical centers. Further, our study does not capture direct costs relating to but occurring before or after surgery, including pain medications, cost of work-up visits, and procedures related to diagnosis. Similarly, patient work-ups and diagnostic laparoscopic procedures that may have occurred at separate visits and prior to the adhesiolysis surgery were not captured if specific DRG codes were not listed for those hospitalizations [6,7,9]. Hence, this study's estimates of costs are likely to be conservative.

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Conclusions

Adhesions remain an important surgical problem, and hospitalization for adhesiolysis leads to a high direct cost burden in the US. Despite a trend of decreasing LOS for adhesiolysis-related hospitalizations from 2001 to 2005, adhesiolysis-related costs continue to rise even while the overall rate of adhesiolysis procedures remains constant. Consistent with previous research, the distribution of inpatient care and costs across the diagnostic categories remained steady from 2001 to 2005, with only a slight increase in primary adhesiolysis procedures over time. From 2001 to 2005, hospitalizations for adhesiolysis related to the digestive system and to the female reproductive tract had the largest number of inpatient days and accounted for the majority of costs related to secondary adhesiolysis procedures.

Adhesiolysis remains a substantial economic burden to the US health care system, which should be of interest to providers and commercial and government payers. Further research incorporating detailed clinical data and indirect costs would aid in a greater understanding of the overall burden of adhesiolysis.

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Competing interests

VS was an employee of Ethicon, Inc. at the time that this manuscript was prepared; he is currently an employee of Shire Pharmaceuticals. BB, SDC, and KLD are employees of RTI Health Solutions, the research organization contracted by Ethicon to conduct this study. AJ is an employee of Texas Healthcare; MW is an employee of Christie NHS Foundation Trust.

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Authors' contributions

VS was responsible for developing the study design, interpreting the analysis results, and drafting the manuscript text; he is the primary author of this manuscript. BB, SDC, and KLD were responsible for the acquisition, management, interpretation, and analysis of all study data. BB, SDC, and KLD also assisted with developing the study design, interpreting the analysis results, and drafting the manuscript. AJ and MW contributed clinical expertise and guidance and assisted in interpreting the analysis results and drafting the manuscript text.

All authors confirm that they have read the journal's position on issues involved in ethical publication and affirm that this research report is consistent with those guidelines. Finally, all authors have read and approved the final manuscript.

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Funding

This study and the preparation of this manuscript were funded by Ethicon, Inc. The authors acknowledge that Ethicon, Inc. is the maker of GYNECARE INTERCEED, a product that is marketed to prevent pelvic adhesions.

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Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2482/11/13/prepub

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Acknowledgements

Portions of the study data presented in this paper were previously presented as a podium presentation at the VIIIth PAX Meeting; Clermont-Ferrand, France; September 18-20, 2008, as well as a poster presentation at the 57th Annual Clinical Meeting of the American College of Obstetricians and Gynecologists; Chicago, Illinois; May 2-6, 2009.

The authors wish to thank Ms. Gail Zona of RTI Health Solutions and Ms. Heidi Waters of Ethicon, Inc., for assistance with preparing this manuscript.

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References

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• Ray NF, Denton WG, Thamer M, Henderson SC, Perry S. Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994. J Am Coll Surg. 1998;186(1):1–9. doi: 10.1016/S1072-7515(97)00127-0. [PubMed] [Cross Ref]
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• diZerega GS, Tulandi T. Prevention of intra-abdominal adhesions in gynaecological surgery.Reprod Biomed Online. 2008;17:303–306. doi: 10.1016/S1472-6483(10)60211-8. [PubMed][Cross Ref]
• Tingstedt B, Isaksson J, Andersson R. Long-term follow-up and costs analysis following surgery for small bowel obstruction caused by intra-abdominal adhesions. Br J Surg. 2007;94:743–748. doi: 10.1002/bjs.5634. [PubMed] [Cross Ref]
• Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, Menzies D, McGuire A, Lower AM, Hawthorn RJ, O'Brien F, Buchan S, Crowe AM. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet. 1999;353:1476–1480. doi: 10.1016/S0140-6736(98)09337-4. [PubMed] [Cross Ref]
• Parker MC, Ellis H, Moran BJ, Thompson JN, Wilson MS, Menzies D, McGuire A, Lower AM, Hawthorn RJ, O'Briena F, Buchan S, Crowe AM. Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum. 2001;44:822–829. doi: 10.1007/BF02234701. [PubMed] [Cross Ref]
• Lower AM, Hawthorn RJ, Ellis H, O'Brien F, Buchan S, Crowe AM. The impact of adhesions on hospital readmissions over ten years after 8489 open gynaecological operations: an assessment from the Surgical and Clinical Adhesions Research Study. Br J Obstet Gynaecol.2000;107:855–862. doi: 10.1111/j.1471-0528.2000.tb11083.x. [PubMed] [Cross Ref]
• Meagher AP, Moller C, Hoffmann DC. Non-operative treatment of small bowel obstruction following appendectomy or operation on the ovary or tube. Br J Surg. 1993;80:1310–1311. doi: 10.1002/bjs.1800801030. [PubMed] [Cross Ref]
• Ray NF, Larsen JW, Stillman RJ, Jacobs RJ. Economic impact of hospitalizations for lower abdominal adhesiolysis in the United States in 1988. Surg Gynecol Obstet. 1993;176:271–276.[PubMed]
• HCUP Nationwide Inpatient Sample. Healthcare Cost and Utilization Project (HCUP)http://www.hcup-us.ahrq.gov/nisoverview.jsp
• Steiner C, Elixhauser A, Schnaier J. The Healthcare Cost and Utilization Project: an overview.Eff Clin Pract. 2002;5(3):143–151. [PubMed]
• US Bureau of Labor Statistics. Consumer Price Index for medical services.http://data.bls.gov/PDQ/outside.jsp?survey=cu
• SAS Institute Inc. SAS 9.1.3. Cary, NC: SAS Institute Inc; 2003.
• Research Triangle Institute. SUDAAN (Release 9.0.1) Research Triangle Park, NC: Research Triangle Institute; 2005.
• Gutt CN, Oniu T, Schemmer P, Mehrabi A, Büchler MW. Fewer adhesions induced by laparoscopic surgery? Surg Endosc. 2004;18(6):898–906. doi: 10.1007/s00464-003-9233-3.[PubMed] [Cross Ref]
• Parker MC, Wilson MS, Menzies D, Sunderland G, Clark DN, Knight AD, Crowe AM. Surgical and Clinical Adhesions Research (SCAR) Group. The SCAR-3 study: 5-year adhesion-related readmission risk following lower abdominal surgical procedures. Colorectal Dis. 2005;7:551–558. doi: 10.1111/j.1463-1318.2005.00857.x. [PubMed] [Cross Ref]

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Articles from BMC Surgery are provided here courtesy of BioMed Central

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141363/

Karen Steward in your search for relief from Adhesion's and Adhesion Related Disorder

Have you encountered self proclaimed adhesion activist Karen Steward in your search for relief from Adhesion's and Adhesion Related Disorder?
 

If you stuck by her side have you found yourself feeling very uncomfortable, scared, humiliated, intimidated, browbeaten, cajoled, exploited, bullied????


Karen’s anger comes from her own agenda of being obsessed with Dr Kruschinski and knowing that harvesting patients and controlling them after surgery is the only way “Kru” will get patients and it is the only way she can stay connected to him! 

DO YOU VALIDATE INFORMATION YOU READ ON THE INTERNET??
If NOT, always validate what is said on any board..as it is YOUR LIFE!

Kruschinski found the most vulnerable patient population to exploit that we can think of and in fitting irony he exploits Karen Steward herself. Yup his very willing cash cow.


The truth of Karen Steward and Dr. Kruschinski lies within the archives of the internet.....be safe and go look for it.
Others have noticed dreadful, outrageous, intimidating behaviors besides IHRT bloggers. See what they have to say on other websites or forums. Join one of Karen's facebook groups and see for yourself.

IHRT's advice.....Stay away from the chaos of Kruschinski and Steward.
This is not an option. It is dangerous. It is not your only chance. 
Kruschinski has no published credible studies....zip, bubkus, nada.
Sprayshield is unproven. Most likely as ineffective as Spraygel.

Please do more research and you will find safe, affordable options for you, most likely near you.

If you or a loved one have been effected by this pair of Con's you have a safe place here to speak out with no fear of repercussions. 
You have seen Karen rip adhesion sufferers apart on Facebook....recent post surgical patients who did not fair well under Kruschinski's rusty scalpel are left feeling hopeless and isolated and terrified. You are not alone, it has happened to more folks than on the international patient list. That list that takes the place of actual science and statistics. The list contains the folks who wish to continue to stay on Karen's good side.

Please consider writing your story here where she can't get you. Please consider sparing others your fate.

Just post what you wish anonymously. We promise, the truth will set you free. Your truth will empower you. Don't let Karen take liberties with your life and use you to entice more to her spiders web.

Wishing you all Happy Holidays and we want you to know there is hope and there is help. Consider sharing your gift of truth with other adhesion sufferers.