| Objective:Cases related to spontaneous perforation of pyometra(SPP)were studied by meta-analysis,and the clinical features,diagnostic methods,treatment methods and prognostic outcomes of the disease were comprehensively discussed,so as to provide reference for clinical work.Methods:The computer comprehensively searched CNKI,Wanfang Data,Weipu Chinese Journal Database(VIP),Pub Med,EMbase,Web of Science,selected SPP-related literature,strictly screened the collected literature according to the formulated inclusion and exclusion criteria,and finally included the literature for quality evaluation with reference to the MINORS scale entry,and extracted individual case data patient data(IPD)information: such as patient age,associated medical history,clinical features,auxiliary examination methods,treatment methods,and length of hospital stay.The search period was from the establishment of the database to October 2022,and the statistical analysis was carried out using Stata 15.1 software,including the calculation of ratio and 95% confidence interval(CI)for uncontrolled dichotomous count data,the analysis of continuous variables using the nonparametric Mann-Whitney U test,the descriptive statistical method for clinical data,and the comparative analysis of Fisher’s exact test or chi-square test for categorical variables.Results:According to the literature search strategy and screened according to the inclusion and exclusion criteria,a total of 157 relevant articles,including 144 case reports and 13 retrospective clinical case analysis reports reported 262 patients.1.Age distribution characteristics: The age of 262 SPP patients ranged from 34 to 93 years old,the average age was 70.45 years,and the median age was 70 years.According to the age < 50 years old and≥ 50 years old,there were 8 cases < 50 years old,accounting for3.05%,and 2 54 cases ≥ 50 years old,accounting for 96.95%.Patients aged ≥ 50 were grouped according to age 50-59 years,60-69 years old,70-79 years old,80-89 years old,and ≥ 90 years old,including 13 cases in the 50-59 year old group,accounting for 4.96%,102 cases in the 60-69 year old group,accounting for 38.93%,91 cases in the 70-79 year old group,accounting for 34.73%,43 cases in the 80-89 age group,accounting for 16.41%,and 5 cases in the 90-year old group,accounting for 1.91%,≥ 5 cases in the 90-year old group,accounting for 1.91%.It can be seen that spontaneous perforation of empyeoma often occurs in postmenopausal women,with the highest incidence in the 60-69 age group.2.251 SPP patients described clinical features,243 cases of abdominal pain,accounting for about 96.81%,127 cases of fever,accounting for 50.60%,51 cases of vaginal bloody or purulent discharge,accounting for 20.32%,and 97 cases of nausea,vomiting,anorexia and other digestive symptoms.38.65%,29 cases of defecation changes,accounting for 11.55%,and 8 cases of unconsciousness due to shock,accounting for 3.19%.Abdominal pain and fever are the most common manifestations in patients with SPP.3.Of the included cases,75 underwent abdominal ultrasound,of which 54 showed pelvic/peritoneal effusion,24 indicated uterine effusion,and 10 indicated SPP;Chest/abdominal x-ray was performed in97 cases,of which 53 showed ventilating from the diaphragm;67abdominal CT examinations were performed,of which 17 were diagnosed with SPP;Four MRIs were performed,and two showed SPP,which clearly showed focal muscular defects on sagittal enhanced t1-weighted MRI.The sagittal T2-weighted fast spin-echo image showed focal fullthickness defects in the anterior wall of the uterine body,one case suggestive of empyeosis,and one case showed a cystic mass lesion of the right ovary.Fifty patients underwent gynecological examination,mainly manifested as cervical lift pain,rocking pain,full anterior and posterior vaginal vaults,enlarged and soft uterus,bloody/purulent discharge in the vagina,one of which found a cervical mass involving the anterior and left side walls of the vagina,followed by colposcopic cervical biopsy,and the pathological report was cervical malignancy.There were 37 cases of peritoneal fluid puncture and 2 cases of posterior vaginal fornix puncture,all of which were punctured with a yellowish turbid liquid,and the laboratory results were purulent liquid.CT and MRI are of great help in the diagnosis of SPP,and for patients with abdominal pain and inflammation or malignancy of the female reproductive system,CT or MRI should diagnose SPP promptly.4.Preoperative diagnosis: 247 patients were diagnosed,of which42(17.0%)were initially diagnosed with SPP,and misdiagnosis included:130 cases were diagnosed as peritonitis,101 cases were diagnosed as gastrointestinal perforation,and 33 cases were diagnosed as appendicitis/appendicitis perforation,all of which were confirmed as SPP by laparotology.It can be seen that SPP is most likely to be misdiagnosed with peritonitis and PGIT,and the misdiagnosis rate is as high as 83.0%,which should be paid attention to clinically.5.Location of uterine perforation: Of the 262 patients included,239 described the location,size,and number of uterine pyometroperations.There were 39 cases of anterior uterine wall perforation,including 5 cases with posterior uterine wall rupture,151 cases of fundal perforation,including 4 cases with posterior uterine wall rupture,and 42 cases of posterior uterine wall perforation,which showed that uterine floor perforation was more common in SPP.6.Bacterial culture: 81 patients underwent bacterial culture of intraperitoneal fluid or pus.The most common pathogenic bacteria were Escherichia coli(39 cases,%),of which 6 were associated with Bacteroides fragilis and 2 were combined with Streptococcus insolven.There were 14 cases of the genus Anaerobes,of which 11 were cultured as Bacteroides.Twenty-six cases of other bacterial genera.There were22 cases of mixed bacterial infection.Bacterial cultures were negative in 12 patients,and E.coli was the most common infectious genus.7.The related disease history of 158 patients was obtained,among which hypertension and diabetes were the most common,32 patients with hypertension,accounting for 20.25%,and 33 patients with diabetes,accounting for 20.89%.Combined with preoperative and postoperative pathology,20 patients with SPP had cervical malignant tumors,accounting for 7.63%,which was the most common malignant tumor among patients with SPP.Pelvic examination should be performed to rule out associated malignancy.8.Among the 262 patients included,219(83.59%)underwent open hysterectomy and 169 underwent total hysterectomy,of which 136 underwent bilateral adnexectomy.Forty-three patients(16.41%)did not undergo hysterectomy,21 patients underwent uterine repair with postoperative drainage,including 1 complicated stage ⅢB cervical cancer,postoperative intraluminal brachytherapy ICBT,and 1intraoperative appendectomy.22 patients underwent pelvic irrigation and drainage only,1 case underwent appendectomy at the same time,1case underwent pelvic irrigation drainage through laparoscopy,1patient had cervical squamous cell carcinoma stage ⅡB,pelvic irrigation and drainage was treated with radiotherapy,1 case was postoperatively drained,1 case was unable to perform open surgery due to the patient’s poor general condition,and peritoneal aspiration was performed in the emergency department,and SPP was diagnosed by autopsy.Hysterectomy is the most common treatment for patients with SPP.9.The survival outcomes of 254 patients were obtained,and there was no significant difference in in-hospital mortality between total hysterectomy and conservative management,with a P value of 0.75.Among the patients who underwent hysterectomy,63.63%(112/176)recorded the length of hospital stay,with a mean length of stay of 23.86±19.49 days,and 60.61%(20/33)of patients undergoing conservative treatment recorded the length of hospital stay,with an average length of stay of 18.45±13.96 days,and there was no significant difference in the postoperative hospital stay of patients(P=0.15).10.Among the included cases,there were no significant differences between the patients whose age,uterine perforation site(e.g.,fundus perforation),correct preoperative diagnosis,treatment modality,and type of bacterial infection(E.coli,anaerobic bacteria,mixed flora)were not significantly different between the dead and surviving patients,with P values of 0.43,0.87,0.28,0.70,(0.79,0.12,and0.07),respectively,and in patients with a history of related diseases,only limited mobility(e.g.,bed rest,hemiplegia)affected the survival outcome of patients,with a P value of 0.04.Conclusions:1.SPP occurs in postmenopausal women,more common in the age group of 60-69 years old,the most common symptoms are abdominal pain,fever,patients are easy to misdiagnose peritonitis or gastrointestinal perforation,CT and MRI examination can detect SPP in time than ultrasound.2.At present,most patients with SPP are treated with hysterectomy plus anti-infective therapy,and DCS treatment may become the preferred treatment for patients with SPP.3.There were no significant differences in the prognosis of patients with SPP preoperative diagnosis,uterine perforation site,bacterial species and surgical methods,and patients with limited activity had a poor prognosis(P=0.04). |
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