指南速递 | ACOG委员会意见:宫腔镜在宫内病变诊断和治疗中的应用(下)
翻译:李文衢
单位:南京医科大学附属妇产医院
审核:王素敏
单位:南京医科大学附属妇产医院
接上文:指南速递 | ACOG委员会意见:宫腔镜在宫内病变诊断和治疗中的应用(上)
患者沟通与选择
门诊宫腔镜在异常子宫出血的诊治中的应用已经很成熟了[36]。对于已知宫内病变,选择合适的门诊宫腔镜检查患者选择依赖于:对目标病变的深入的了解和理解,病变大小,病变的侵润深度,患者自愿接受门诊宫腔镜检查,医生的技能和专业知识,评估患者合并症,并提供适当的设备和支持。例如,患者有医疗限制的,比如患有呼吸暂停或心肺疾病,在没有麻醉师在场时,可能不合适门诊静脉麻醉的患者。对于有焦虑症的患者,或者曾经门诊宫腔镜失败,或不能忍受宫腔镜操作的患者,应考虑更换门诊宫腔镜检查场所,如手术室或门诊手术中心。
宫腔镜中的阴道内镜技术
阴道内镜检查指不使用窥阴器和宫颈钳,而直接插入宫腔镜观察阴道,子宫颈,子宫腔,以及所有这些结构。直径较小的刚性或柔性宫腔镜均可用于阴道内镜检查。阴道内镜检查技术包括将宫腔镜温和地引入阴道并使用膨宫介质,如普通生理盐水,用来扩张阴道。与传统的宫腔镜相比,阴道内镜检查已被证实可以减少手术疼痛。此外,与传统宫腔镜技术相比,阴道内镜检查失败率也无明显差异[37-40]。美国妇产科学院(ACOG)和美国妇科腔镜协会(AAGL)一致认定门诊宫腔镜选择行阴道内镜检查能显著减少手术疼痛,且不影响检查效果[41]。
通过按压阴唇使组织内陷缩小阴道从而尽可能减少阴道液体泄漏。宫腔镜直接指向阴道后穹窿,确定宫颈外口。根据子宫前屈或后屈引导宫腔镜进入宫颈管内口,并进入子宫腔。如有必要,可通过在耻骨联合上方直接按压膀胱以减轻子宫前屈,以及通过直肠直接前压减轻子宫后屈的方法改变子宫的轴线位置[42]。
疼痛管理
文献中对于门诊宫腔镜检查镇痛方案包括单一制剂和多种组合制剂,其中包括:局部麻醉剂,非甾体抗炎药,对乙酰氨基酚,苯二氮卓类药物,阿片制剂,使用方法包括宫颈管内使用或宫颈旁阻滞,或两者兼有。根据目前可用的证据,在安全性方面以及在疼痛治疗上,这些方案之间以及和安慰剂对比并没有临床上的显著差异[43]。宫颈旁阻滞可以减少放置宫颈钳时的疼痛和宫腔镜通过宫颈外口和内口时的疼痛[44]。其他研究表明门诊宫腔镜可以忍受无需使用任何镇痛剂,但是原有的疼痛情况如痛经或慢性盆腔痛需使用镇痛剂[45]。然而,没有单一方案或联合用药的临床效果优于安慰剂。
门诊准备
在进行门诊宫腔镜检查时必须优先考虑患者的安全性和舒适性。在门诊宫腔镜检查中获得与住院宫腔镜手术相同的安全性是患者的权力[46]。更多关于有效沟通、医师能力、医疗过失避免,准确跟踪患者机制、麻醉安全和常规流程安全详见ACOG总统特别工作组的报告[46]。流程清单、日志和模拟演练的使用,将有利于形成规范的操作以及便于进行质量审查。
门诊宫腔镜检查应在大小合适,设备齐全,人员配备齐全的治疗室进行。宫腔镜基本设备要求包括:宫腔镜仪器、摄像机和监视器、膨宫设备、清洁和消毒设备。不推荐优先使用特定宫腔镜类型,选择何种宫腔镜应由术者决定[41]。
在消毒或灭菌之前,必须清洗可重复使用的宫腔镜设备。根据所用设备的类型不同,消毒和灭菌方法也有所不同,应遵守制造商的指南并遵循机构、州和联邦法规。
并发症的预防和管理
两个最大的多中心研究13600例诊断及手术宫腔镜以及21676例手术宫腔镜总并发症发生率分别为0.28% 和0.22%[47,48]。与诊断性宫腔镜检查相比,手术宫腔镜术中并发症明显增多(0.95%比0.13%;P<0.01)。更多潜在并发症、发生率以及风险因素详见表2。
【3】Aydeniz B, Gruber IV, Schauf B, Kurek R,Meyer A, Wallwiener D. A multicenter survey of complications associated with21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol2002;104:160–4.
【4】Jansen FW, Vredevoogd CB, van Ulzen K,Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: aprospective, multicenter study. Obstet Gynecol 2000;96:266–70.
【5】Agostini A, Cravello L, Bretelle F, Shojai R,Roger V, Blanc B. Risk of uterine perforation during hysteroscopic surgery. JAm Assoc Gynecol Laparosc 2002;9:264–7.
【6】Brandner P, Neis KJ, Ehmer C. The etiology,frequency, and prevention of gas embolism during CO(2) hysteroscopy. J Am AssocGynecol Laparosc 1999;6:421–8.
【7】Vilos GA, Hutson JR, Singh IS, GiannakopoulosF, Rafea BA, Vilos AG. Venous gas embolism during hysteroscopic endometrialablation: report of 5 cases and review of the literature [published online May14, 2019]. J Minim Invasive Gynecol. DOI: 10.1016/j.jmig.2019.05.003.
【8】Agostini A, Cravello L, Desbriere R,Maisonneuve AS, Roger V, Blanc B. Hemorrhage risk during operativehysteroscopy. Acta Obstet Gynecol Scand 2002;81:878–81.
【9】Agostini A, Bretelle F, Ronda I, Roger V,Cravello L, Blanc B. Risk of vasovagal syndrome during outpatient hysteroscopy.J Am Assoc Gynecol Laparosc 2004;11:245–7.
穿孔
宫腔镜手术最常见的围手术期并发症手术是子宫穿孔[48,49]。已知的子宫穿孔的危险因素见表2。子宫穿孔的处理依赖于子宫穿孔的位置、原因和严重程度。宫腔镜检查的每一步,包括机械宫颈扩张、宫腔探查、宫腔镜插入或使用电外科或组织切除装置,均可能导致子宫肌层受损。尽管缺乏宫腔镜检查期间假道形成的发生率相关数据,但如果子宫进入困难,可能会增加子宫穿孔的风险。在系统回顾性研究中,术前应用米索前列醇并没有降低宫腔镜手术中的子宫穿孔发生率[7]。若有大量出血,怀疑内脏损伤或电外科所致穿孔需要立即手术干预。
感染
宫腔镜检查不建议常规预防性使用抗生素。盆腔炎急性发作期,以及有前驱症状或活动性疱疹感染患者是宫腔镜的禁忌症[50]。感染性的宫腔镜手术并发症不常见于术后感染(例如,子宫内膜炎或子宫肌炎、尿路感染)发生率在0.01%到1.42%[48,51]。对1952例宫腔镜手术的预期观察研究发现,粘连松解术后患子宫内膜炎的风险比子宫粘膜下肌瘤切除术(RR:5.89;CI:1.68–20.69,P=0.0066)和息肉切除术高(RR:6.36;CI:1.3-31.24,P=0.0154)[52]。在随机试验中,预防性使用抗生素并不能减少诊断性宫腔镜术后[53-55]和宫腔镜手术术后感染[55]。
电损伤
在宫腔镜手术中,电极可能造成严重损伤,通常是在子宫穿孔的情况下。如果出现显著的出血或者怀疑内脏受到热损伤需要进行手术探查。下生殖道(如阴道或会阴)也可能有热损伤的危险。潜在的危险因素包括宫颈过度运动,仪器绝缘套缺损或未在保护套内的电极在宫颈管内被激活[56]。
液体超负荷
流体监测指南见方框2。过度吸收膨宫液会导致严重的并发症,包括肺水肿,神经系统并发症,甚至死亡。使用非电解质与低渗膨宫液低渗发生低钠血症和脑水肿的风险更大。充分的围手术期准备,使用液体管理系统和充分评估病变切除范围可以将液体过度灌注引起的并发症降低到最小。液体过度灌注受切除的病变的大小和数量,子宫肌层切开的深度,切开的肌层的数量,以及宫内压力的影响。预防措施包括:限制过多液体吸收、快速发现和处理液体吸收过多、选择一种风险最低的膨宫介质。宫颈注射血管加压素可减少液体灌注量[16]。限制过多液体灌注的最佳方法是密切而频繁地监测液体吸收量。液体过度灌注处理包括终止手术;评估血流动力学,神经、呼吸和心血管状况;血清电解质和渗透压的测定;并考虑利尿剂的使用。新的液体管理系统使得液体监测更加准确;但是,其中一些系统相当昂贵,并非所有设备都可以使用。
空气和气体栓塞
引起空气和气体栓塞的原因有:二氧化碳作为宫腔镜膨宫介质,在器械进出宫颈或子宫时带入室内空气,气态单极或双极手术时产生的气体,或病人头低脚高位时[57]。气体的化学性质影响栓塞的风险。二氧化碳在血液中的溶解度比氧气高;因此,来自室内空气(含氧和氮)的空气栓塞风险大于二氧化碳[58]。空气和气体栓塞的严重并发症包括心肺衰竭或死亡。空气和气体栓塞最常见的症状是呼吸困难和胸痛。但是麻醉患者潮气末二氧化碳分压降低,以及血流动力学状态的改变(低血压、心动过速)会导致临床对栓塞发生的怀疑。典型的体检表现是听诊到搅动或喷射样的呼吸音(“磨轮”样杂音),但是并非所有病例均能检测到。尽管相关文献中空气和气体栓塞的发生率高低不一,但具有严重临床后果的空气和气体栓塞发生率很低[59,60]。
预防宫腔镜空气和气体栓塞方法包括:对管道和仪器充分排气;减少器械反复进出宫颈,以免空气以“活塞式”方式进入子宫;排出宫内气泡;限制宫内压力。急性空气和气体栓塞治疗包括支持治疗以及积极的处理措施,包括迅速终止操作、排出宫腔气体,排出膨宫液体和气体。杜兰特操作,表现为左侧卧位和头低脚高位,可促进空气或气体向右心室的迁移减少右室流出道梗阻[58]。
出血
对于出血的处理,术中可以采用各种止血措施,具体取决于出血的严重程度,性质和位置;然而,关于这些措施有效性的证据不足。例如:出血点的电凝,使用宫腔内球囊(Foley导管),子宫动脉栓塞,注射血管加压素或肾上腺素,氨甲环酸和子宫切除术。
血管迷走神经反应
一旦发现血管迷走神经反应体征(低血压,心动过缓)或症状(恶心,呕吐,发汗,苍白,或意识丧失),应该立即停止操作,并进行患者评估和采用支持治疗措施(生命体征包括脉搏、血压和“ABCs”-气道、呼吸和循环)。大多数血管迷走神经反应的处理采取支持措施,例如抬高患者的双腿或头低脚高位。如果相应症状或心动过缓持续存在,每3至5分钟单剂量静脉注射阿托品0.5mg,总量不得超过3毫克[61]。
专家简介
王素敏
目前专业方向:妇科内镜:宫腔镜、腹腔镜;
社会兼职:
现任南京医科大学附属南京妇幼保健院临床技能培训中心主任
卫生部四级妇科内镜技术培训基地南京市妇幼保健院四级妇科内镜技术培训基地主任
中华医学会妇产科分会内镜学组委员
中国医师协会妇科内镜技术专业委员会宫腔镜学组委员
中国医师协会内镜医师分会妇科内镜专业委员会常务委员
中国妇幼保健协会宫腔镜学组副主任委员
中国亚太内镜领域做出重大贡献的名誉会员
中国中医药研究促进会中西医结合妇科与妇幼保健分会常务委员
海峡两岸医药卫生交流协会海西微无创专家委员会常务委员
华东地区妇科内镜学组委员
江苏省中西医结合学会生殖医学分会任三届副主任委员
江苏省医学会妇科内镜学组副组长
《中国计划生育和妇产科》杂志第二届编辑委员会编委;
THE JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY《微创妇科杂志中国版》编辑委员会第一届编委;《中国微创外科杂志》第五届常务编委;《中国内镜杂志》编辑委员会编委等。
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