Classifying the structural heterogeneity of peritoneal adhesions by histopathological extracellular matrix characteristics

Background Peritoneal adhesions are a common complication following abdominal surgery and contribute substantially to long-termmorbidity, including bowel obstruction, chronic pain, and infertility. Their diverse clinical presentation, ranging from thin strands todense obstructive bands, suggests multiple underlying pathomechanisms. We propose a histopathological framework for classifyingperitoneal adhesions based on extracellular matrix characteristics, providing a microscopic correlation to clinical heterogeneity andsupporting translational research on adhesion prevention. Methods In this study, adhesions from 77 patients were examined histologically. Masson's Trichrome staining was used to visualize the extracellular matrix, enabling classification into five clusters based on qualitative histological analysis: stringy, dense, loose, fatty, and mixed. Results The "stringy" and "dense" clusters exhibited the highest extracellular matrix fraction and vessel area, whereas the"loose" and "fatty" clusters displayed lower ECM density and vascularity. Immunohistochemical staining for αSMA (myofibroblasts) and PGP9.5 (nerve fibers) further revealed cluster-specific differences in myofibroblast presence and innervation. Cluster distribution was significantly associated with clinical parameters, including adhesion load and prior peritonitis. Conclusions This is the first study to systematically categorize peritoneal adhesions byextracellular matrix characteristics, identifying five distinct histopathological phenotypes. Our findings highlight the structural andcellular diversity of adhesions, offering new insights with potential implications for understanding adhesion pathophysiology andguiding future therapeutic strategies. Validation in larger cohorts will be essential to confirm this framework and establish its clinicalutility.