Transcervical endometrial resection syndrome

Abstract

SummaryDuring transcervical endometrial resection the uterine cavity is irrigated under pressure with 1.5% glycine solution. This solution m a y be absorbed, with consequent fluid and electrolyte shijts. Plasma sodium concentration was analysed in 21 women undergoing transcervical endometrial resection and decreased in every case. In jive cases this decrease was > 10mmol.l-'. Hyponatraemia is a potential risk with this procedure.Key words Surgery; transcervical endometrial resection. Complications; hyponatraemia.It has been recognised for many years that the use of hypotonic solutions for the irrigation of the bladder cavity during transurethral resection of the prostate (TURP) can result in absorption of the solution from the exposed prostatic bed and subsequent fluid and electrolyte shifts [I]. In patients with TURP syndrome, symptoms may appear as the plasma sodium concentration decreases to less than 135 mmol.l-'. Most clinical reactions occur when the sodium decreases by 15-20 mmol.1-l and a plasma sodium concentration of 120 mmol.1-l has been regarded as the level distinguishing moderate from severe reactions [2-41. Symptoms of hyponatraemia are related to the speed of its development, acute changes producing more symptoms than chronic [5]. Electrocardiographic changes, characterised by a widening of the QRS complex and ST elevation, may occur when the sodium falls to 115 mmol.1-'. Convulsions and ventricular tachycardia or fibrillation may occur at plasma sodium levels below 100 mmol.1-l [4].Hysteroscopic transcervical endometrial resection (TCER) with the use of diathermy was first reported by DeCherney and Polan in 1983 [6] and is now an alternative to hysterectomy for women with menorrhagia. Advantages of the technique include a shorter operative time and rapid postoperative recovery and discharge. The procedure involves the use of a cutting loop diathermy to resect the endometrium while the uterine cavity is continuously irrigated with a 1.5% glycine solution. As the uterine cavity is less compliant than the bladder, the irrigation pressures used are greater than during TURP. The aim of this study was to measure the changes in plasma sodium associated with TCER to assess whether fluid absorption is clinically significant.Following completion of the study a case of fluid absorption during TCER occurred, which demonstrated the potential hazard. Details of this case are presented to illustrate the problem. MethodsFollowing ethics committee approval and informed consent, 21 women of ASA grade 1 or 2 presenting for endometrial resection were included in the study. All patients received a standard temazepam premedication. Prior to anaesthesia 10 ml of blood was collected from each patient. The anaesthetic technique consisted of fentanyl 2 pg.kg-l, thiopentone 5 mg.kg-I, and vecuronium 0.1 mg.kg-l. Following tracheal intubation, patients were ventilated with nitrous oxide/oxygen and isoflurane 0.5-1 ?LO to an end-tidal carbon dioxide of 4.5-5 kPa.Intravenous fluids were not administered and monitoring cons...

Central pontine myelinolysis: sequele of hyponatremia during transcervical resection of endometrium

“…Absorption of irrigation fluid leading to water intoxication and hyponatremia has been studied extensively in TURP (4). The potential for a similar syndrome exists in TCRE; in fact the chances are higher as the uterine cavity is less compliant than the bladder and the irrigation pressures used are greater than during TURP (5).…”

Sorbitol 2.5% mannitol 0.54% irrigation solution for hysteroscopic endometrial ablation surgery

“…However, plasma osmolality changes or peak glycine concentrations were not reported. 22 Although sorbitol 2.5%/manrfitol 0.54% and glycine 1.5% are equally hypotonic, the former may have some advantages, firstly by avoiding the potential toxicity of glycine per se. 23,24 Also, mannitol remains extracellular, induces an osmotic water diuresis, and has a long halflife.…”

Fluid absorption and the ethanol monitoring method

“…Surgery that makes use of an irrigating solution to distend a body cavity and/or wash away blood and debris from the operating field always carries a risk of fluid being accidentally absorbed into the patient . Such absorption is a well‐known complication in transurethral prostatic and transcervical endometrial surgery but occurs also, although more rarely, during transurethral bladder surgery and percutaneous nephrolithotripsy …”