空气栓塞——宫腔镜手术的严重并发症

宫腔镜手术作为一项操作简单、直观可靠、安全性高的内窥镜技术,是宫腔内病变的重要诊断和治疗手段。空气栓塞是该手术中罕见的并发症,往往起病突然,发展迅速,常有致命后果,值得引起妇科医师的高度重视。10年来文献报道均为病例报告,现复习文献,综述如下。 1.发病率:自从广泛应用宫腔镜以来,1990年Perry等最早报道出现空气栓塞并发症。以后陆续有文献报告(表1)。早期报道宫腔镜手术中无症状的气体栓塞发生率为10％～50％,德国的Brandner等对此提出质疑,通过统计8年间5139例宫腔镜检查进行,发现仅1例出现严重但未     

羊水栓塞流行病学现状及病理生理学改变

羊水栓塞是一种妊娠期罕见的灾难性并发症。文章结合近十余年来国内外对羊水栓塞临床病例的总结及实验研究,分析其流行病学特征并阐明其发病相关联的病理生理学改变,从而为羊水栓塞的预防及诊治提供理论依据。     

不同方案治疗剖宫产术后子宫瘢痕妊娠28例临床分析

目的:探讨剖宫产术后子宫瘢痕妊娠(CSP)的临床特点与不同治疗方法的疗效。方法:回顾分析2010年1月至2016年10月同济大学附属同济医院妇科收治的28例CSP患者的临床资料。根据不同治疗方案分为8组:腹腔镜下子宫瘢痕妊娠病灶切除术组2例,宫腔镜下子宫瘢痕妊娠病灶切除术组2例,阴式子宫瘢痕妊娠病灶切除术组2例,子宫动脉栓塞+清宫术组11例,子宫动脉栓塞+宫腔镜下子宫瘢痕妊娠病灶切除术组1例,清宫术组5例,单纯药物治疗组2例,经腹子宫瘢痕妊娠病灶切除术组3例,并进行一定的归纳与总结。结果:手术均取得较好疗效,无一例患者因难治性大出血切除子宫。结论:单纯药物治疗、清宫术、宫腔镜手术治疗CSP存在大出血风险,不作为首选治疗方案,联合UAE可降低发生大出血的风险,腹腔镜手术、经腹手术、阴式手术治疗CSP疗效确定,且阴式手术费用相对较低。     

妇科腹腔镜手术并发症及其防治

腹腔镜越来越多地应用于妇科各类良恶性病变的手术中,手术并发症也相应增加,轻者如皮下气肿、腹膜下气肿、大网膜气肿等,重者如纵隔气肿、气体栓塞、大血管损伤、膀胱输尿管损伤以及直肠损伤等,不同程度影响手术质量和患者预后.本文就妇科腹腔镜手术并发症及其防治作一阐述.     

宫腔镜手术的静脉空气栓塞

静脉空气栓塞 (空气栓塞 ,ｖｅｎｏｕｓａｉｒｅｍｂｏｌｉｓｍ ,ＶＡＥ)或静脉气体栓塞 (ｖｅｎｏｕｓｇａｓｅｍｂｏｌｉｓｍ ,ＶＧＥ)是手术中严重、罕见但致命的并发症。在神经外科、泌尿外科及剖宫产种均有发生[1] 。Ｂｒａｎｄｎｅｒ等[2 ] 的研究说明 ,0 5 1%的空气栓塞无临床症状 ,未被发现 ,剖宫产术无症状的空气栓塞多达 5 2 % [3 ] ,多数无症状。近年来 ,随着宫腔镜手术的普遍应用 ,宫腔镜手术包括二氧化碳 (ＣＯ2 )膨宫宫腔镜检查 (ＣＯ2 宫腔镜检查 )和经宫颈切除宫腔内病变 (ｔｒａｎｓｃｅｒｖｉｃａｌｒｅｓｅｃｔｉｏｎ ,…     

药物预处理与子宫动脉栓塞术对宫腔镜下清宫术治疗剖宫产瘢痕妊娠疗效的影响

目的：探究药物预处理与子宫动脉栓塞术对宫腔镜下清宫术治疗剖宫产瘢痕妊娠（CSP）疗效的影响。方法：回顾性收集2016年1月-2017年11月河南省信阳市中心医院妇科收治的120例CSP患者的临床资料,根据治疗方法不同分为研究组72例、对照组48例,分别给予米非司酮+甲氨蝶呤（MTX）药物预处理（研究组）、子宫动脉栓塞术干预（对照组）,而后实施宫腔镜下清宫术。观察和统计所有患者手术完成情况、术后恢复进度及并发症发生情况。结果：2组患者的二次清宫、大出血、中转开腹、子宫切除发生率比较,差异无统计学意义（P＞0.05）。2组患者手术耗时、术中出血量比较,差异无统计学意义（P＞0.05）,但研究组术后住院时间、阴道出血时间、月经恢复时间及血人绒毛膜促性腺激素β亚单位（β-hCG）恢复时间较对照组缩短（P＜0.05）。研究组患者并发症以胃肠道反应为主,发生率为22.22%,高于对照组的7.14%（P＜0.05）;对照组并发症以发热、疼痛为主,发生率分别为18.75%、33.33%,高于研究组的2.78%、8.33%（P＜0.05）;此外,2组感染、肝功能受损、宫腔粘连、子宫穿孔发生率比较,差异无统计学意义（P＞0.05）。结论：宫腔镜下清宫术前给予米非司酮+MTX药物预处理有助于改善CSP患者的临床疗效,术后恢复快,并发症少,但仍应注意胃肠道反应等并发症的防治。     

胎盘植入患者血管栓塞治疗

胎盘植入是严重威胁母胎健康的疾病,其治疗手段尚未统一,目前血管栓塞治疗为治疗手段之一。胎盘植入患者预防与治疗产后出血的血管栓塞方法包括：术前预防性血管球囊闭塞术、术中及术后血管栓塞术。血管栓塞的优势为减少手术失血量与输血量,术后并发症及住院时间等。但同时也存在发生一定并发症的风险,包括盆腔内感染、器官缺血、发热、白细胞升高、组织神经疼痛、血管栓塞等。血管栓塞的应用还有待临床大样本的研究进一步评价。     

子宫肌瘤和子宫腺肌病动脉栓塞治疗手术质量控制北大核心CSCD

子宫肌瘤及子宫腺肌病动脉栓塞治疗手术质量涉及术前诊断、临床症状评估、手术适应证和禁忌证掌控、手术操作过程技巧、术后疗效评估、并发症管理、术后随访等诸多环节,各个环节需要有明确的质量控制标准且能符合普遍适用原则,由此,才可能建立动脉栓塞治疗标准临床路径的精细化管理制度。     

提高对妇科内镜手术并发症的再认识

进入21世纪,人们对手术治疗的理念与认识已经基本达成共识,微创手术以其对脏器干扰小、出血少和术后恢复快等优势,已经成为妇科疾病治疗的首选模式。宫腔镜与腹腔镜手术作为现代妇科微创手术的典型代表,在实施手术中具有直视清晰的手术环境、微小创伤和较低的并发症率,在妇科临床上正得到日益普及和广泛应用,并且成为当今妇科医师必备的手术技能。作为一种新兴的微创医疗技术,近年来,学者们对妇科微创手术及其并发症问题做了极具创新意义的深入研究和探索,并取得了许多颇有价值的研究成果,     

宫腔镜术后稀释性低钠血症

唐良萏(主持人,妇产科教授):稀释性低钠血症(1FURP综合征)是宫腔镜手术的严重并发症,处理不及时或不恰当可能给患者带来灾难性后果,甚至危及患者生命.今天,我们请来内分泌科、神经内科的专家们参加妇科1例宫腔镜术后TURP综合征的病例讨论,希望通过回顾性分析,进一步加深对本病的认识,提高预防及正确处理该并发症的水平.首先请住院医师汇报病史.     

Embolism of air and gas in hysteroscopic procedures: pathophysiology and implication for daily practice

Hysteroscopic surgery has gained in popularity and has become the method of choice for diagnostic and therapeutic interventions of intrauterine pathology. Advantages consist of short operating time, rapid postoperative recovery, and low morbidity. However, there are concerns about the potential serious complications that can occur, such as venous air and gas embolism. These are rare but hazardous complications, which can occur in all surgical procedures. In hysteroscopic surgery, large uterine veins may be exposed and are, therefore, a point of entry for gas or air. A number of fatal and nonfatal cases have been described as case reports. Although awareness for air and gas embolism is raised this way, proper guidelines as to how to reduce the risk of venous gas or air embolism are lacking. The pathophysiologic difference between gas and air embolism is described herein because composition of the gases differs as does their physiologic effects. A gas embolism is likely to be derived from electrosurgical vapors whereas air embolism seems to arise from improper purging of lines or reinsertion of hysteroscopic instruments. Treatment regimens must, therefore, be designed to address the specific gases involved. Signs and symptoms of these different embolisms are described, as early detection and intervention are crucial for survival. Furthermore, we provide guidelines for operating department personnel, surgeons, and anesthesiologists to reduce the risk of venous gas or air embolism during hysteroscopic procedures. Potential complications of these procedures may be prevented this way.     

宫腔镜术中严重气体栓塞相关因素研究

目的 探讨宫腔镜手术中发生循环气体栓塞（气栓）的相关因素及症状出现的原因。方法 观察郑州大学人民医院2010-08-04至2010-12-31收治的34例宫腔镜手术患者,采用超声多普勒监测循环中气栓的情况,并进行分级;分析不同级别气栓、手术时间、灌注量、单双极电切与临床症状或体征出现的关系。结果 34例患者中发现循环气栓20例,出现症状6例,无气栓者无症状出现;Ⅱ级气栓5例,出现症状2例,Ⅲ级气栓6例,出现症状4例,症状出现与气栓级别呈正相关;手术时间＞30 min者26例,气栓18例,出现症状6例,气栓级别及临床症状率均显著增加;灌注量＞3000 mL 20例,气栓15例,出现症状4例,随灌注量增多,气栓及临床症状出现例数明显增多,差异有统计学意义;单极电切20例,发现气栓12例,出现症状5例;双极14例,发现气栓8例,出现症状1例,发现气栓及出现症状差异无统计学意义。结论 宫腔镜手术临床症状与气栓关系密切,低级别气栓对机体无严重损伤。气栓分级可以预测严重并发症的出现,气栓的等级与临床症状的出现有相关性。     

Bubbles in the brain veins as a complication of daily management of a scalp vein catheter

Recently, it has been suspected that venous dural sinus air embolisms could occur as a result of scalp vein infusion. The possible mechanism for this complication has not been documented to date, and procedures to avoid venous dural sinus air embolism have not been presented. We report a preterm neonate who demonstrated venous dural sinus air embolism following daily management of a scalp vein catheter. The air embolism disappeared in a few days without complications. Clinicians should avoid injecting air into a scalp vein catheter and leaving it open to air. Following careful examination and review of the infant's case, we were able to conclude that positioning the infant in either supine or Trendelenburg position during daily management of scalp venous infusions and using an air-occlusive dressing once the catheter is removed could limit the risk of venous dural sinus air embolisms caused by scalp vein infusions.     

做一位优秀的宫腔镜医生

宫腔镜是当代微创外科的主流技术之一,已逐步成为许多妇科疾病诊断的金标准和手术治疗的新模式。因整复性宫腔镜手术具有不可修复性,宫腔镜空气栓塞并发症可致猝死。为避免不良事件发生,从事宫腔镜的医生必须经过专业培训,熟悉超声介入、膨宫灌流、麻醉监护、视频效果、设备和器械的性能与操作要求,同时掌握腹腔镜技术,重视并实施宫腔镜的术前预处理,警惕和预防宫腔镜手术严重并发症,经过培养和锻炼,成为优秀的宫腔镜医生。     

宫腔镜手术并发症36例临床分析

目的 探讨官腔镜手术并发症发生的原因、处理方法与预防措施。方法 对我院1993年1月至2004年11月10余年间,36例官腔镜手术并发症患者的临床资料进行回顾性分析。结果 36例并发症中,子宫穿孔或不全子宫穿孔11例,均发生在复杂的官腔内手术操作中,除1例中转开腹外,均在腹腔镜下行缝合修补;术中大出血5例,均由于对子宫肌壁破坏过深所致,经官腔放置双腔导管压迫止血或子宫切除治愈;灌流液过量吸收综合征3例,给予利尿及补钠治疗,预后良好;空气栓塞1例,早期发现后积极抢救成功;输卵管绝育一子宫内膜去除术后综合征4例,行子宫切除加单侧或双侧输卵管切除、宫腔扩探及粘连分离,治愈;官腔粘连12例,分别行官腔扩探、粘连分离、排除积血或子宫切除。结论 复杂的官腔内操作、官腔灌流压力过高、子宫肌壁破坏较深以及子宫内膜残留,是发生官腔镜手术并发症的潜在危险因素;术中腹腔镜或B超监护、提高术者处理复杂官腔手术的能力和加强围手术期管理,是降低并发症的必要措施。     

行宫腔镜手术发生严重并发症35例临床分析

目的：探讨行宫腔镜检查和宫腔镜电切术发生严重并发症的早期诊断,治疗及预防。方法：对12921例患者行宫腔镜检查,同时行B超扫描;对2221例患行宫腔镜电切术,同时行B超或腹腔镜监护,结果：发生严重并发症35例,其中出血9例,经宫腔球囊置入、电凝、填塞或子宫体切除治愈;子宫穿孔11例,经保守治疗、腹腔镜或子宫切除治愈,空气栓塞1例,经抢救存活,术后感染4例,经抗生素治疗治愈,尿道电切前列腺（TURP）综合征5例,经利尿及静脉输注盐水治愈,子宫内膜去除－输卵管绝育术后综合征（PASS）4例,经扩宫、排出积血,行宫腔粘连或子宫切除治愈,术后8年发生子宫内膜癌1例,再次手术治疗,结论：行宫腔镜检查,以球囊压迫宫腔可有效控制出血,应注意B超腹腔镜监护不能完全防止子宫穿孔,控制灌流液压和手术时间,可减少TURP综合征的发生。行宫腔镜电切术后应加强随访,早期发现PASS和子宫内膜癌,避免空气栓塞的发生。     

Venous Thromboembolic Events in Minimally Invasive Gynecologic Surgery

The rate of venous thromboembolic events (VTEs) including deep venous thrombosis and pulmonary embolism among women undergoing gynecologic surgery is high, particularly for women with a gynecologic malignancy. Current guidelines recommend VTE thrombopropylaxis in the immediate postoperative period for patients undergoing open surgery. However, the VTE prophylaxis recommendations for women undergoing minimally invasive gynecologic surgery are not as well established. The risk of VTEs in patients undergoing minimally invasive surgery appears to be low based on retrospective analyses. To date, there are no established guidelines that specifically provide a standard of care for patients undergoing minimally invasive gynecologic surgery for benign or malignant disease.     

宫腔镜手术并发症诊治现状及展望

宫腔镜诊治宫腔内病变微创、有效。但子宫穿孔、出血、体液超负荷、低钠血症、空气栓塞及术后妊娠子宫破裂等严重并发症时有发生,文章回顾近年来宫腔镜并发症发生的现状,探讨宫腔镜手术并发症发生原因及预防方法,以提高宫腔镜手术的安全性。     

Thromboembolism in pregnancy

Venous thromboembolism in pregnancy is a clinical emergency that has been associated with significant risk for maternal and fetal morbidity and mortality. The adaptation of the maternal hemostatic system to pregnancy predisposes women to an increased risk of thromboembolism. A timely diagnosis of deep venous thrombosis is crucial because up to 24% of patients with untreated deep venous thrombosis develop a pulmonary embolism. Recent clinical guidelines identify compression venous ultrasound as the best way to diagnose deep venous thrombosis in pregnancy and CT pulmonary angiography as the best way to diagnose pulmonary embolism in pregnancy. Therapy involves supportive care and anticoagulation with unfractionated or low molecular weight heparin, depending on the clinical scenario.