Irrigating fluid absorption during transcervical endometrial resection

Abstract

Abstract: Transcervical resection of the endometrium (TCRE) is a new alternative to hysterectomy in women with menorrhagia. The present thesis describes the incidence, extent and monitoring of absorption of the distention medium in patients undergoing this operation. The thesis also focuses on the prerequisites for absorption by different pathways and on the dangers inherent in the use of different irrigating solutions.The fluid balance, the serum sodium level and the ethanol concentration in the expired breath were measured every 10 min throughout 62 TCREs using glycine 1.5%‐ethanol 1% for irrigation. Absorption occurred in 61 of these patients. Uptake by the extravascular route was almost as common as intravenous absorption. The ethanol concentration in the breath correlated strongly with the fluid absorption, as indicated by the other methods.The usefulness of the breath ethanol measurement to indicate the venous blood‐ethanol concentration was challenged in 10 women. They were given an intravenous infusion of 0.4 g/kg of ethanol over 20 min while they were anaesthetized with isoflurane, as well as when they were awake. The results show that the breath‐ethanol value reflected well the concentration measured in venous blood. However, general anaesthesia promoted higher overall ethanol values. This could be attributed to a decrease in the central distribution volume for ethanol during isoflurane anaesthesia, which can probably be explained by vasodilatation.The absorption of irrigating fluid was also studied in 25 women when uterine surgery was not performed. The uterus was filled with methylene blue‐stained glycine‐ethanol fluid and the pressure was gradually increased. Absorption of small amounts of fluid through the endometrium was detected when the intrauterine pressure exceeded 160 mmHg (n=10), while fluid leakage through the fallopian tubes occurred through the laparoscope at varying pressures, sometimes as low as 40 mmHg, in 14/15 women.The chance of survival after intravenous overhydration with the three most frequently used irrigating solutions was studied in 120 mice. Increasing volumes of glycine 1.5%, mannitol 5% and sorbitol 2%‐mannitol 1% were given. The results demonstrate that mannitol 5% is associated with a better chance of survival within 24 h than the other solutions.The flow of solutes across the peritoneal membrane was studied in 10 women by infusing 1.5 1 of glycine‐ethanol into their abdominal cavity over 20 min. The half‐time for the equilibration of ethanol was the fastest (mean 33 min) while that for sodium required a 3‐fold longer and glycine a 4‐fold longer time. This illustrates that ethanol indicates accumulation of irrigating fluid in the peritoneal cavity before hyponatremia and hyperglycaemia develop in the patient.In conclusion, the present thesis shows that fluid absorption is common during TCRE and that it can be monitored by measuring ethanol in the expired breath, both in awake patients and during isoflurane anaesthesia. Mannitol solution should probably be used for irrigation to minimize the risk of death if a large‐sized absorption occurs.