糖尿病患者盆腔淋巴结清扫术后淋巴囊肿感染致脓毒性休克13例临床分析

The clinical analysis of septic shock caused by lymphocyst infection after lymph node dissection in 13 diabetic patients

目的分析糖尿病患者盆腔淋巴结清扫术后淋巴囔肿感染致脓毒性休克的临床特征和诊疗经过,提高其抢救成功率。方法回顾性研究2015.1-2020.1新诊断膀胱癌、前列腺癌、肾癌、宫颈癌、子宫内膜癌及卵巢癌,入住中山大学孙逸仙纪念医院泌尿外科及妇科的糖尿病患者,均按专科规范行包含盆腔淋巴结清扫术在内的手术治疗,共计462例:148例术后盆腔淋巴囊肿形成,其中89例发生感染,之中的13例发展为脓毒性休克。比较淋巴囊肿感染者中休克和非休克患者的年龄、性别、糖尿病病程、BMI、糖基化血红蛋白、手术切除的淋巴结个数、术后引流管留置时间、淋巴囊肿最大直径及与辅助化疗的相隔时间;分析13例脓毒性休克患者始发症状和发病后首次血象、发病至引流穿刺的时间及最终转归;分析感染的淋巴囊液病原学培养和药敏结果。结果分类变量检验显示休克和非休克患者相比,糖基化血红蛋白(P=0.018)、辅助化疗(P=0.014)和囊肿大小(P<0.001)差异有统计学意义;13例脓毒性休克患者中就诊时11例首发症状仅为轻中度的发热或腹痛;初次血象白细胞总数均在2万以下;从发病至穿刺的时间平均为33 h。13例患者中,有5例发展为多器官功能衰竭,其中1例死亡;有2例病情反复难以控制,经影像学检查证实脓腔和周围脏器连通;12例患者好转后仅1例对残留的淋巴囊肿预处置,其中4例再发囊肿感染1-2次,之中2例进展为脓毒性休克,1例死亡。病原菌以革兰氏阴性菌常见,主要是大肠埃希菌、肺炎克雷伯菌及铜绿假单胞菌,哌拉西林/他唑巴坦、碳青酶烯类及替加环素均为敏感药物,头孢他定、头孢曲松和左氧氟沙星耐药率均为50%以上。结论血糖控制不佳、化疗和较大的淋巴囊肿(d≥5 cm)是糖尿病患者盆腔淋巴结清扫术后发生淋巴囊肿感染致脓毒性休克的高危因素;大多数休克患者始发症状及白细胞总数均没有显著的示警意义,导致从感染发生到穿刺引流时间较长,延误处置;早期诊断、及时穿刺引流和广谱抗生素治疗是救治成功的关键。治疗效果欠佳时脓腔贯通周围脏器感染的可能性要被考虑。糖尿病患者在发生术后淋巴囊肿感染致脓毒性休克后,应积极干预处置较大的残留淋巴囊肿,避免再次发生危及生命的严重感染。

Objective To improve the rate of successful rescue through analyzing the clinical features and treating processes of septic shock caused by lymphocyst infection after lymph node dissection in diabetic patients.Methods A total of 462 cases of diabetic patients with bladder,prostate,renal cancers,cervical,endometrial and ovarian were retrospectively analyzed,all of whom underwent standard surgical treatments including pelvic lymph node dissection,hospitalized in department of urology surgery and gynecology of Sun Yat-sen Memorial Hospital from Jan 2015 to Jan 2020.Lymphocytes were confirmed in 148 cases,of which 89 cases were complicated by infection,and 13 cases developed septic shock.Patients with lymphocyst infection were divided into shock and non-shock groups,and age,sex,duration of diabetes,BMI,glycosylated hemoglobin at admission,number of lymph nodes surgically removed,retention time of drainage tube after operation,maximum diameter of lymphocyst and time between infection and previous chemotherapy were compared.The initial symptoms,blood routine in the first time after the onset of the infection,the time from onset to drainage puncture and catheterization and the final outcomes were analyzed in 13 patients with septic shock.The results of pathogen culture and drug sensitivity of infected lymphocyst fluid were also analyzed.Results Categorical variable test showed that:in diabetic patients with lymphocyst infection,there were significant differences in glycosylated hemoglobin(P=0.018),adjuvant chemotherapy(P=0.014)and lymphocyst size(P<0.001)between shock group and non-shock group.Among the 13 cases of septic shock,11 caseshad mild to moderate fever or abdominal pain.The total leukocyte count of all cases in the first hemogram were less than 20×10^(9)/L.The average time from onset to drainage was 33 hours.Among the 13 patients,5 developed MODS and 1 died.There were 2 patients whose conditions were complex with frequent fluctuations.In the 12 patients who recovered from septic shock,only 1 underwent a residual lymphocyst pretreatment,4 had recurrent cyst infection for 1-2 times,2 had septic shock again,and 1 died.Gram negative bacteria were the most common pathogens,and the main was Escherichia coli,Klebsiella pneumoniae and Pseudomonas aeruginosa.Piperacillin/tazobactam,carbapenems and tigecycline were commonly sensitive,while the drug resistance rates of ceftazidime,ceftriaxone and levofloxacin were more than 50%.Conclusions Poor glycemic control,adjuvant chemotherapy and big lymphocyst size(d≥5 cm)are the high risk factors of septic shock.Most of shock patients'initial symptoms and total white blood cell count have no warning significance,leading to longer time from infection to drainage,and delayed treatment.Early diagnosis,timely drainage and active anti-infection treatment are the key to a successful treatment.The possibility of connection between lymphocyst and surrounding organ should be considered when the treatment effect is not good.After septic shock of postoperative lymphocyst infection in patients with diabetes,the larger esidual lymphocyst should be intervened actively to avoid serious infection again.