A C TA Obstetricia et Gynecologica Letters to the Editor
Thermal injury to the sigmoideum following hysteroscopic hydrothermal ablation
Sir A 39-year-old woman with a surgical history including laparoscopic enucleation of an endometrioma underwent hydrothermal endometrial ablation because of menorrhagia and severe dysmenorrhea. Clinical findings at abdominal as well as pelvic examination were without remarks. Ultrasound examination showed a normal-sized anteverted uterus, normal in structure. The endometrium thickness was homogeneous. No adnexal abnormalities were found. Hysteroscopy was performed exposing a small polyp with benign appearance, size 5 mm, in the posterior wall of the uterus. The polyp was removed with Versapoint© (www.ethicon.com) according to the guidelines and sent for histopathology. Hydrothermal ablation was started under hysteroscopy guidance and the procedure was carried out without any technical difficulties. After surgery, the woman suffered from an expected degree of abdominal pain, which was sufficiently treated with peroral analgesia. The day after surgery the woman was feeling fairly well and the pain was almost completely gone. In the evening, the day after surgery, she suddenly experienced increasing abdominal pain and diarrhea. During the night she developed fever and in the morning she was immediately admitted to the hospital. She suffered from high fever, diarrhea and general abdominal pain but no peritonitis. The laboratory blood test showed normal hemoglobin concentration and very high level of inflammatory markers. The woman was immediately started on intravenous antibiotics and a CT scan was performed, not revealing any free diaphragmatic air. The woman’s general condition deteriorated resulting in a decision for laparotomy. The intraoperative findings included intra-abdominal fluid, a pathological pale area on the sigmoideum, 1 cm in diameter, suggestive of heat injury, but no perforation. On the posterior wall of the uterus there was an equivalent pale area but no perforation. The rest of the bowel and the intra-abdominal organs were thoroughly inspected and found to be unaffected. Drainage
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was left intra-abdominally and the abdomen was closed. The woman recovered slowly and the drainage was removed 2 days postoperatively. Hydrothermal ablation is a hysteroscopic procedure involving the circulation of heated saline, 90°C, within the uterine cavity. The heated saline is circulated for a period of 10 minutes. When the treatment is completed, the uterine cavity is rinsed with room-temperature normal saline to reduce the temperature of the fluid in the uterus. During the procedure, if more than 10 mL of fluid is lost, the system shuts down. Adverse effects associated with hydrothermal ablation include perforation of the uterus, thermal injury, urinary tract or vaginal infection and hematometra. There are only a few cases reported of bowel injury caused by thermal damage to the bowel as a perioperative complication. A possible explanation for the induced injury to the serosa of the sigmoideum is the removal of the small polyp before the hydrothermal ablation. The removal most probably caused a weakening and thinning of the uterus wall, facilitating heat transmission through the myometrium. The temperature will drop while going through the tissue, which is why damage occurred only to the serosa of the sigmoideum – this time!
Johanna F. Silwer* and Christian Falconer Division of Obstetrics and Gynecology, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden *Corresponding Author: Johanna F. Silwer E-mail: [email protected] DOI: 10.1111/aogs.12274
ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 218–220
Thermal injury to the sigmoideum following hysteroscopic hydrothermal ablation
Sir A 39-year-old woman with a surgical history including laparoscopic enucleation of an endometrioma underwent hydrothermal endometrial ablation because of menorrhagia and severe dysmenorrhea. Clinical findings at abdominal as well as pelvic examination were without remarks. Ultrasound examination showed a normal-sized anteverted uterus, normal in structure. The endometrium thickness was homogeneous. No adnexal abnormalities were found. Hysteroscopy was performed exposing a small polyp with benign appearance, size 5 mm, in the posterior wall of the uterus. The polyp was removed with Versapoint© (www.ethicon.com) according to the guidelines and sent for histopathology. Hydrothermal ablation was started under hysteroscopy guidance and the procedure was carried out without any technical difficulties. After surgery, the woman suffered from an expected degree of abdominal pain, which was sufficiently treated with peroral analgesia. The day after surgery the woman was feeling fairly well and the pain was almost completely gone. In the evening, the day after surgery, she suddenly experienced increasing abdominal pain and diarrhea. During the night she developed fever and in the morning she was immediately admitted to the hospital. She suffered from high fever, diarrhea and general abdominal pain but no peritonitis. The laboratory blood test showed normal hemoglobin concentration and very high level of inflammatory markers. The woman was immediately started on intravenous antibiotics and a CT scan was performed, not revealing any free diaphragmatic air. The woman’s general condition deteriorated resulting in a decision for laparotomy. The intraoperative findings included intra-abdominal fluid, a pathological pale area on the sigmoideum, 1 cm in diameter, suggestive of heat injury, but no perforation. On the posterior wall of the uterus there was an equivalent pale area but no perforation. The rest of the bowel and the intra-abdominal organs were thoroughly inspected and found to be unaffected. Drainage
220
was left intra-abdominally and the abdomen was closed. The woman recovered slowly and the drainage was removed 2 days postoperatively. Hydrothermal ablation is a hysteroscopic procedure involving the circulation of heated saline, 90°C, within the uterine cavity. The heated saline is circulated for a period of 10 minutes. When the treatment is completed, the uterine cavity is rinsed with room-temperature normal saline to reduce the temperature of the fluid in the uterus. During the procedure, if more than 10 mL of fluid is lost, the system shuts down. Adverse effects associated with hydrothermal ablation include perforation of the uterus, thermal injury, urinary tract or vaginal infection and hematometra. There are only a few cases reported of bowel injury caused by thermal damage to the bowel as a perioperative complication. A possible explanation for the induced injury to the serosa of the sigmoideum is the removal of the small polyp before the hydrothermal ablation. The removal most probably caused a weakening and thinning of the uterus wall, facilitating heat transmission through the myometrium. The temperature will drop while going through the tissue, which is why damage occurred only to the serosa of the sigmoideum – this time!
Johanna F. Silwer* and Christian Falconer Division of Obstetrics and Gynecology, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden *Corresponding Author: Johanna F. Silwer E-mail: [email protected] DOI: 10.1111/aogs.12274
ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 218–220
