Lanciano R, Corn B, Martin E, Schultheiss T, Hogan W M, Rosenblum N
Fox Chase Cancer Center, Philadelphia, PA.
Int J Radiat Oncol Biol Phys. 1994 Jul 30;29(5):969-74. doi: 10.1016/0360-3016(94)90390-5.
To define the incidence and severity of perioperative morbidity and its subsequent management with standard tandem and ovoid insertions and to evaluate pretreatment and treatment factors associated with an increased risk of perioperative morbidity.
Ninety-five tandem and ovoid insertions were performed at the Fox Chase Cancer Center between 1985 and 1992 for cervical (n = 91) and endometrial (n = 4) cancer. Patients were placed on antibiotics in 19%, usually for a positive routine preoperative urine culture, but no patient was given prophylactic antibiotic therapy. Deep-vein thrombosis prophylaxis was practiced for 70% of implants and included subcutaneous heparin (40%), graduated compression elastic stockings (16%), and external pneumatic calf compression (14%). All patients were placed on prophylactic diphenoxylate hydrochloride, with doses ranging from three to eight tablets/day.
Intraoperative complications were seen in 3% of implants and included two perforations and a vaginal laceration in two patients. Twenty-four percent of implants (16 patients) developed temperatures of > 100.5 (range 100.6 to 103), although only one patient required implant removal because of fever. Management of fever included antibiotics in 35% and acetaminophen only in 65%. Five implants (5%) were removed emergently secondary to presumed sepsis (n = 1), exacerbation of chronic obstructive pulmonary disease, hypotension, change in mental status (n = 3), and myocardial infarction/congestive heart failure (n = 1). No patient developed a deep-vein thrombosis, pulmonary embolism, gastrointestinal obstruction, or died of a postoperative complication. Univariate analysis of pretreatment and treatment factors revealed older age (p < 0.005) and spinal/epidural anesthesia (p < 0.02) to be associated with increased perioperative morbidity, and older age (p < 0.05) and higher ASA classification (p < 0.02) to be associated with severe complications requiring removal of implant. Multivariate analysis revealed only older age (p < 0.01) to be significantly related to perioperative morbidity.
Fever of > 100.5 was seen in 24% of implants and can be managed successfully without removal of the implant in 96% of cases. Use of antibiotics preoperatively and intraoperatively did not reduce the risk of perioperative temperature elevation. Use of routine diphenoxylate hydrochloride prophylaxis was tolerated without ileus or gastrointestinal obstruction clinically. Although routine deep-vein thrombosis prophylaxis is reasonable, our data would support a low risk of deep-vein thrombosis for untreated patients. Severe perioperative morbidity necessitated premature implant removal in only 5% of cases and was related to older age in multivariate analysis.
确定标准串联和卵圆形植入术中围手术期发病率及其严重程度，并评估其后续处理措施，同时评估与围手术期发病率增加相关的预处理和治疗因素。
1985年至1992年间，福克斯蔡斯癌症中心对91例宫颈癌和4例子宫内膜癌患者进行了95次串联和卵圆形植入术。19%的患者使用了抗生素，通常是因为术前常规尿培养呈阳性，但没有患者接受预防性抗生素治疗。70%的植入患者采取了深静脉血栓预防措施，包括皮下注射肝素（40%）、使用分级加压弹力袜（16%）和外部气动小腿压迫（14%）。所有患者均接受预防性盐酸地芬诺酯治疗，剂量为每日3至8片。
3%的植入术出现术中并发症，包括2例穿孔和2例患者的阴道撕裂伤。24%的植入患者（16例）体温超过100.5华氏度（范围为100.6至103华氏度），尽管只有1例患者因发热需要取出植入物。发热的处理措施包括35%的患者使用抗生素，65%的患者仅使用对乙酰氨基酚。5例植入物（5%）因疑似败血症（1例）、慢性阻塞性肺疾病加重、低血压、精神状态改变（3例）以及心肌梗死/充血性心力衰竭（1例）而紧急取出。没有患者发生深静脉血栓、肺栓塞、胃肠道梗阻或死于术后并发症。对预处理和治疗因素的单因素分析显示，年龄较大（p < 0.005）和脊髓/硬膜外麻醉（p < 0.02）与围手术期发病率增加相关，年龄较大（p < 0.05）和美国麻醉医师协会（ASA）分级较高（p < 0.02）与需要取出植入物的严重并发症相关。多因素分析显示，只有年龄较大（p < 0.01）与围手术期发病率显著相关。
24%的植入患者体温超过100.5华氏度，96%的病例无需取出植入物即可成功处理。术前和术中使用抗生素并未降低围手术期体温升高的风险。临床耐受性良好，常规使用盐酸地芬诺酯预防未出现肠梗阻或胃肠道梗阻。虽然常规深静脉血栓预防是合理的，但我们的数据表明未治疗患者发生深静脉血栓的风险较低。严重的围手术期发病率仅导致5%的病例需要提前取出植入物，多因素分析显示与年龄较大有关。
