Case report：Septic shock after endometrial polypectomy with tissue removal system

Case report：Septic shock after endometrial polypectomy with tissue removal system | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case report：Septic shock after endometrial polypectomy with tissue removal system Danna Su, Jiajie She, Ying Li, Yan Guo, Yajie Yang, Qiao Tan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2665154/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract As an emerging surgical technology, tissue removal systems have been widely used in the treatment of endometrial polyps due to its characteristics of less endometrial damage, shorter learning curve and clearer vision of the operative field. There are few cases in the literature reporting serious complications after endometrial polypectomy using tissue removal systems. As known, septic shock is a rare complication following hysteroscopic polypectomy. Now, we present the case of a 23-year-old woman who developed septic shock after polypectomy with tissue removal system. The patient had a history of recurrent vaginitis for more than half a year. Due to EPs, she was admitted to our hospital and scheduled to undergo hysteroscopic endometrial polypectomy. Three hours after the endometrial polypectomy using the tissue removal system, the patient had shock symptoms such as increased body temperature, decreased blood pressure and increased heart rate. Then, the patient was successfully treated and discharged after anti-infection and anti-shock treatments. The purpose of this case report is to remind clinicians to consider the possibility of serious infection and comprehensively evaluate the risk of infection before choosing hysteroscopic devices for EPs, especially for patients who choose the mechanical hysteroscopic tissue removal systems. Furthermore, the mechanical hysteroscopic tissue removal systems should be used with caution in patients with previous recurrent vaginitis. Hysteroscopy Hysteroscopic tissue removal system Endometrial polypectomy Postoperative complications Shock Septic Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Endometrial polyps (Eps) are caused by overgrowth of endometrium. The formation of EPs is closely related to the high level of estrogen. Other factors such as long-term inflammatory stimulation, puerperal infection, intrauterine device, abortion, delivery and intrauterine operation may also lead to the occurrence of EPs. EPs can lead to abnormal uterine bleeding and infertility. They may even become cancerous if not treated for a long time. Therefore, hysteroscopic surgery is recommended for large and symptomatic polyps. Hysteroscopic surgery is the first choice for the treatment of EPs( 1 ). The complication rate of hysteroscopic polypectomy is low, only about 0.22%( 2 ). The traditional hysteroscopic resection system is the most common method to treat EPs, which has a history of several decades. As a new surgical device emerging in recent years, the mechanical hysteroscopic tissue removal systems have significantly shortened operation time and improves success rate of surgery while not increasing complication rates( 1 , 3 , 4 ). Herein, we reported a patient with a history of recurrent vaginitis who suffered septic shock after endometrial polypectomy with the tissue removal system. This is the first case report of serious complication after hysteroscopic morcellation. Case presentation On June 29, 2022, a 23-year-old young woman with a BMI of 18.2kg/m 2 was admitted to our hospital because of EPs found more than half a year ago. The patient lacked exercise at ordinary times and denied previous history of surgery as well as chronic diseases in the past. The examination of ovarian reserve function in another hospital found that AMH was low (less than 1ng/ml), indicating primary ovarian insufficiency. She had regular menstruation and had never been pregnant. No special family disease history. More than half a year ago, EPs was seen by the uterine ultrasound examination in this patient, whose vaginal discharge, meanwhile, were positive for mycoplasma, bacteria and fungi. The vaginal discharge was performed again after treatment with "nifuratel nystatin vaginal soft capsules and doxycycline hyclate tablets", and was negative for mycoplasma and bacteria but still positive for fungi. The patient was then treated with "clotrimazole tablet" for 4 times. However, her subsequent vaginal discharge still showed positive for fungus. Luckily, the fungus finally turned negative after receiving the treatment of "fluconazole tablets". Therefore, the patient was admitted to the hospital for hysteroscopic surgery. The patient's routine hysical examination and gynecological examination at admission was negative. After admission, blood routine, coagulation function, liver and kidney function, preoperative evaluation of infectious diseases, electrocardiogram, and chest X-ray were performed and no obvious abnormalities were found. Given the patient had fertility requirements, she met the inclusion criteria of a clinical study being conducted in our hospital (clinical trial numbers: ChiCTR2200058712). After signing informed consent, the patient was recruited into the study (ethical review approval number: 20210620213357026-FS01). In addition, the patient required tubal hydrotubation during the operation because she failed in trying to conceive for more than half a year. The vital signs of the patient were stable before the operation (Fig. 1). During the operation, a catheter was inserted into the uterine cavity, and 20 mL of physiological saline was injected without obvious resistance, indicating that the fallopian tube was unobstructed. Under hysteroscopy, there were five polyps in uterine cavity. The largest one was about 0.8*0.5cm, while the smallest one was about 0.3*0.3cm. All the polyps in uterine cavity were cut to the base by the rotating movements of the inner blade, and the abraded fragments were aspirated and sent for pathological examination. The operation was successfully completed in about 8 minutes and she was sent to the ward for observation after surgery. About 3 hours after surgery, the patient developed mild lower abdominal pain with elevated body temperature (up to 38.7°C)、heart rate (up to 92–120 bpm)、respiratory rate (up to 27 bpm), and hypotension (about 72–83/35-54mmHg) (Fig. 1). Laboratory examination showed that white blood cells decreased to 3.18×10 9 /L (up to 22.39×10 9 /L later), the proportion of neutrophil increased (up to 98.5%), and the index of infection increased significantly, including hypersensitive C-reactive protein (up to 45.13mg/l), procalcitonin (up to 42ng/ml), interleukin (up to 3120pg/ml) (Fig. 2). Combined with the clinical manifestations and laboratory examination, the patient was considered to have postoperative septic shock. Then she was transferred to ICU for further treatment. ICU physicians gave piperacillin tazobactam combined with tinidazole for anti-infection, epinephrine for vasoconstriction, fluid replacement, supplementation of albumin, etc. After treatment, the patient's condition was gradually relieved, which was characterized by stable recovery of vital signs, gradual decline of white blood cells and infection indicators. At this moment, the blood culture result was negative. So, she was returned to Gynecology ward on the 3rd day after operation. After antibiotic therapy for 10 days, abdominal ultrasound was performed and showed a small amount of effusion. The results of white blood cells and various infection indicators were normal before discharged. Ultrasound imaging and hysteroscopic view were shown in Fig. 3. Histopathologic examination of EPs was shown in Fig. 4. Discussion Our study was the first case to report a septic shock, a severe operative complication, after the hysteroscopic polypectomy with the tissue removal system. Different kinds of tissue removal systems share the same structural design and operating principle with others. All tissue removal devices use mechanical energy to simultaneously cut and aspirate tissue and the shaver blades consist of an outer sheath and an inner hollow tube with windows for simultaneous suction and cutting. Tissue removal system has advantages compared with conventional electroresection, being able to control the cutting depth by wrapping around the inner rotating blade with outer sheath, which plays an important role in the protection for endometrium. This technique has very promising features( 5 ), making the operation faster, easier and with low potential complication rates( 6 , 7 ). Therefore, it is meaningful to improve the clinicians' understanding of complications when using this system through this case. All previous vaginitis of this patient had been treated before preoperative preparation, and no sign of infection was observed before the operation. Aseptic procedures were also strictly followed during the whole operation. Herein, we discussed three possible reasons that might lead to the postoperative septic shock of the patient in order to avoid similar events in the future clinical work. Firstly, this patient was prone to recurrent vaginitis probably due to the impaired immune response. Dysbiosis of the vaginal microbiota might not be excluded though no vaginitis were observed in the preoperative leucorrhea routine detection. Secondly, the patient required evaluation of tubal patency by hydrotubation, which might also result in the spread of infection theoretically if with chronic salpingitis. However, hydrotubation was one of clinical methods to treat chronic salpingitis, and no cases about severe septic shock after hydrotubation were ever reported before( 8 ). Based on these foundings, it might be less likely to draw a conclusion that the spread of tubal-colonizing bacteria into abdominal cavity by hydrotubation could lead to postoperative infection. Thirdly, endometritis might not be excluded in this patient who failed in trying to conceive for more than half a year. However, immunohistochemical staining of the postoperative specimens revealed no positive staining for CD38 or CD138 (Fig. 4), which might not be supposed chronic endometritis. Therefore, endometritis was not considered to be the reason of septic shock in this case. Based on these above results, the history of recurrent vaginitis in the present case was more likely to be an important factor contributing to septic shock. Using mechanical energy to cut tissue is the most significant feature of tissue removal system(Table 1 ), indicating a potential disadvantage is the lack of high-frequency electrocoagulation possibilities. In other words, it is unable to cauterize blood vessels through thermal energy during the removal of lesions. It remains to be explored whether the slow closure of blood vessels provides an opportunity for pathogens to enter vascular system, thus leading to an increased risk of surgical infection. During the cutting process, the pathogens may spread through the unclosed blood vessels, thus having the possibility of inducing infectious shock. In this case report, the possibility of Gram-positive bacterial (in vivo) infection was considered according to the laboratory test indicators and successful empirical antibiotic treatment although the blood culture was negative. Therefore, for patients with a history of repeated vaginitis or poor body resistance, hysteroscope with tissue removal system should be carefully or not chosen for avoiding the risk of serious infection. In conclusion, the purpose of this case report is to remind clinicians to pay attention to the selection and use of hysteroscope with tissue removal system, especially for patients with a history of repeated vaginitis. In addition, early identification of septic shock and timely application of antibiotic treatment are crucial, which can improve the prognosis of patients and avoid more serious outcomes. Table legend : Table 1 Comparison of Hysteroscope with radiofrequency energy and tissue removal system. Surgical approaches Primary indications Characteristics of energy Reports on postoperative septic shock Hysteroscope with radiofrequency energy 1. Removal of endometrial polyps; Electric energy and heat energy Not available 2. Resection of uterine submucosal myoma; 3. Excision of uterine cavity residual pregnancy tissue; 4. Separation of uterine septum. Hysteroscope with tissue removal system 1. Removal of endometrial polyps; Mechanical energy Not available 2. Resection of some types of submucosal myomas; 3. Removal of residual pregnancy tissue in the uterine cavity. Declarations Acknowledgements Not applicable Conflict of interest statement The authors declare that they have no conflict of interest and there are no financial conflicts of interest with any manufacturer. Authors’ contributions D.S. and R.D. designed the case report. D.S. and J.S. wrote the first draft of the manuscript. Y.L., Y.G. and T.Q. systematically edited the manuscript. Y.Y. and L.W. created figures and tables. R.D. reviewed and revised the manuscript. All authors have read and approved the manuscript. Funding This study was funded by the Shenzhen Science and Technology Innovation Committee (Grant No. JCYJ20210324103606017) and the Guangdong Province Natural Science Foundation, China (Grant No. 2019A1515011693). Availability of data and materials Not applicable. Ethics approval and consent to participate Ethical approval was obtained by Ethics Committee of Shenzhen Second People's Hospital(ethical review approval number: 2023-019-01PJ). Written informed consent was obtained from the individual for the publication of any identifiable images or data included in this article. References Raz N, Feinmesser L, Moore O, Haimovich S. Endometrial polyps: diagnosis and treatment options - a review of literature. Minim Invasive Ther Allied Technol. 2021;30(5):278-87. Aydeniz B, Gruber IV, Schauf B, Kurek R, Meyer A, Wallwiener D. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol. 2002;104(2):160-4. Rovira Pampalona J, Degollada Bastos M, Mancebo Moreno G, et al. Outpatient Hysteroscopic Polypectomy: Bipolar Energy System (Versapoint®) versus Mechanical Energy System (TRUCLEAR System®) - Preliminary Results. Gynecol Obstet Invest. 2015;80(1):3-9. Pampalona JR, Bastos MD, Moreno GM, et al. A comparison of hysteroscopic mechanical tissue removal with bipolar electrical resection for the management of endometrial polyps in an ambulatory care setting: preliminary results. J Minim Invasive Gynecol. 2015;22(3):439-45. Smith PP, Middleton LJ, Connor M, Clark TJ. Hysteroscopic morcellation compared with electrical resection of endometrial polyps: a randomized controlled trial. Obstet Gynecol. 2014;123(4):745-51. Hamerlynck TW, Schoot BC, van Vliet HA, Weyers S. Removal of Endometrial Polyps: Hysteroscopic Morcellation versus Bipolar Resectoscopy, A Randomized Trial. J Minim Invasive Gynecol. 2015;22(7):1237-43. Arnold A, Ketheeswaran A, Bhatti M, Nesbitt-Hawes E, Abbott J. A Prospective Analysis of Hysteroscopic Morcellation in the Management of Intrauterine Pathologies. J Minim Invasive Gynecol. 2016;23(3):435-41. Zhengyu L, Jin L, Wenjiao M, Dan Z, Xiao Y, Ying S. Intra-operative hydrotubation improves fertility of women with distal tubal occlusion after reproductive surgery. Arch Gynecol Obstet. 2013;287(1):83-9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2665154","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":181651166,"identity":"5fbe7ccc-17c3-4747-b168-5972601c584c","order_by":0,"name":"Danna Su","email":"","orcid":"","institution":"The First Affiliated Hospital of Shenzhen University","correspondingAuthor":false,"prefix":"","firstName":"Danna","middleName":"","lastName":"Su","suffix":""},{"id":181651167,"identity":"45fcc025-a0df-4cf5-aec7-87bda8ced2e3","order_by":1,"name":"Jiajie She","email":"","orcid":"","institution":"The First Affiliated Hospital of Shenzhen 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The formation of EPs is closely related to the high level of estrogen. Other factors such as long-term inflammatory stimulation, puerperal infection, intrauterine device, abortion, delivery and intrauterine operation may also lead to the occurrence of EPs. EPs can lead to abnormal uterine bleeding and infertility. They may even become cancerous if not treated for a long time. Therefore, hysteroscopic surgery is recommended for large and symptomatic polyps.\u003c/p\u003e \u003cp\u003eHysteroscopic surgery is the first choice for the treatment of EPs(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The complication rate of hysteroscopic polypectomy is low, only about 0.22%(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The traditional hysteroscopic resection system is the most common method to treat EPs, which has a history of several decades. As a new surgical device emerging in recent years, the mechanical hysteroscopic tissue removal systems have significantly shortened operation time and improves success rate of surgery while not increasing complication rates(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Herein, we reported a patient with a history of recurrent vaginitis who suffered septic shock after endometrial polypectomy with the tissue removal system. This is the first case report of serious complication after hysteroscopic morcellation.\u003c/p\u003e "},{"header":"Case presentation","content":"\u003cp\u003eOn June 29, 2022, a 23-year-old young woman with a BMI of 18.2kg/m\u003csup\u003e2\u003c/sup\u003e was admitted to our hospital because of EPs found more than half a year ago. The patient lacked exercise at ordinary times and denied previous history of surgery as well as chronic diseases in the past. The examination of ovarian reserve function in another hospital found that AMH was low (less than 1ng/ml), indicating primary ovarian insufficiency. She had regular menstruation and had never been pregnant. No special family disease history.\u003c/p\u003e\u003cp\u003eMore than half a year ago, EPs was seen by the uterine ultrasound examination in this patient, whose vaginal discharge, meanwhile, were positive for mycoplasma, bacteria and fungi. The vaginal discharge was performed again after treatment with \"nifuratel nystatin vaginal soft capsules and doxycycline hyclate tablets\", and was negative for mycoplasma and bacteria but still positive for fungi. The patient was then treated with \"clotrimazole tablet\" for 4 times. However, her subsequent vaginal discharge still showed positive for fungus. Luckily, the fungus finally turned negative after receiving the treatment of \"fluconazole tablets\". Therefore, the patient was admitted to the hospital for hysteroscopic surgery.\u003c/p\u003e\u003cp\u003eThe patient's routine hysical examination and gynecological examination at admission was negative. After admission, blood routine, coagulation function, liver and kidney function, preoperative evaluation of infectious diseases, electrocardiogram, and chest X-ray were performed and no obvious abnormalities were found. Given the patient had fertility requirements, she met the inclusion criteria of a clinical study being conducted in our hospital (clinical trial numbers: ChiCTR2200058712). After signing informed consent, the patient was recruited into the study (ethical review approval number: 20210620213357026-FS01). In addition, the patient required tubal hydrotubation during the operation because she failed in trying to conceive for more than half a year.\u003c/p\u003e\u003cp\u003eThe vital signs of the patient were stable before the operation (Fig.\u0026nbsp;1). During the operation, a catheter was inserted into the uterine cavity, and 20 mL of physiological saline was injected without obvious resistance, indicating that the fallopian tube was unobstructed. Under hysteroscopy, there were five polyps in uterine cavity. The largest one was about 0.8*0.5cm, while the smallest one was about 0.3*0.3cm. All the polyps in uterine cavity were cut to the base by the rotating movements of the inner blade, and the abraded fragments were aspirated and sent for pathological examination. The operation was successfully completed in about 8 minutes and she was sent to the ward for observation after surgery.\u003c/p\u003e\u003cp\u003eAbout 3 hours after surgery, the patient developed mild lower abdominal pain with elevated body temperature (up to 38.7°C)、heart rate (up to 92–120 bpm)、respiratory rate (up to 27 bpm), and hypotension (about 72–83/35-54mmHg) (Fig.\u0026nbsp;1). Laboratory examination showed that white blood cells decreased to 3.18×10\u003csup\u003e9\u003c/sup\u003e/L (up to 22.39×10\u003csup\u003e9\u003c/sup\u003e/L later), the proportion of neutrophil increased (up to 98.5%), and the index of infection increased significantly, including hypersensitive C-reactive protein (up to 45.13mg/l), procalcitonin (up to 42ng/ml), interleukin (up to 3120pg/ml) (Fig.\u0026nbsp;2). Combined with the clinical manifestations and laboratory examination, the patient was considered to have postoperative septic shock. Then she was transferred to ICU for further treatment. ICU physicians gave piperacillin tazobactam combined with tinidazole for anti-infection, epinephrine for vasoconstriction, fluid replacement, supplementation of albumin, etc. After treatment, the patient's condition was gradually relieved, which was characterized by stable recovery of vital signs, gradual decline of white blood cells and infection indicators. At this moment, the blood culture result was negative. So, she was returned to Gynecology ward on the 3rd day after operation. After antibiotic therapy for 10 days, abdominal ultrasound was performed and showed a small amount of effusion. The results of white blood cells and various infection indicators were normal before discharged. Ultrasound imaging and hysteroscopic view were shown in Fig.\u0026nbsp;3. Histopathologic examination of EPs was shown in Fig.\u0026nbsp;4.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study was the first case to report a septic shock, a severe operative complication, after the hysteroscopic polypectomy with the tissue removal system. Different kinds of tissue removal systems share the same structural design and operating principle with others. All tissue removal devices use mechanical energy to simultaneously cut and aspirate tissue and the shaver blades consist of an outer sheath and an inner hollow tube with windows for simultaneous suction and cutting. Tissue removal system has advantages compared with conventional electroresection, being able to control the cutting depth by wrapping around the inner rotating blade with outer sheath, which plays an important role in the protection for endometrium. This technique has very promising features(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), making the operation faster, easier and with low potential complication rates(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Therefore, it is meaningful to improve the clinicians' understanding of complications when using this system through this case.\u003c/p\u003e \u003cp\u003eAll previous vaginitis of this patient had been treated before preoperative preparation, and no sign of infection was observed before the operation. Aseptic procedures were also strictly followed during the whole operation. Herein, we discussed three possible reasons that might lead to the postoperative septic shock of the patient in order to avoid similar events in the future clinical work. Firstly, this patient was prone to recurrent vaginitis probably due to the impaired immune response. Dysbiosis of the vaginal microbiota might not be excluded though no vaginitis were observed in the preoperative leucorrhea routine detection. Secondly, the patient required evaluation of tubal patency by hydrotubation, which might also result in the spread of infection theoretically if with chronic salpingitis. However, hydrotubation was one of clinical methods to treat chronic salpingitis, and no cases about severe septic shock after hydrotubation were ever reported before(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Based on these foundings, it might be less likely to draw a conclusion that the spread of tubal-colonizing bacteria into abdominal cavity by hydrotubation could lead to postoperative infection. Thirdly, endometritis might not be excluded in this patient who failed in trying to conceive for more than half a year. However, immunohistochemical staining of the postoperative specimens revealed no positive staining for CD38 or CD138 (Fig.\u0026nbsp;4), which might not be supposed chronic endometritis. Therefore, endometritis was not considered to be the reason of septic shock in this case. Based on these above results, the history of recurrent vaginitis in the present case was more likely to be an important factor contributing to septic shock.\u003c/p\u003e \u003cp\u003eUsing mechanical energy to cut tissue is the most significant feature of tissue removal system(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), indicating a potential disadvantage is the lack of high-frequency electrocoagulation possibilities. In other words, it is unable to cauterize blood vessels through thermal energy during the removal of lesions. It remains to be explored whether the slow closure of blood vessels provides an opportunity for pathogens to enter vascular system, thus leading to an increased risk of surgical infection. During the cutting process, the pathogens may spread through the unclosed blood vessels, thus having the possibility of inducing infectious shock. In this case report, the possibility of Gram-positive bacterial (in vivo) infection was considered according to the laboratory test indicators and successful empirical antibiotic treatment although the blood culture was negative. Therefore, for patients with a history of repeated vaginitis or poor body resistance, hysteroscope with tissue removal system should be carefully or not chosen for avoiding the risk of serious infection.\u003c/p\u003e\u003cp\u003eIn conclusion, the purpose of this case report is to remind clinicians to pay attention to the selection and use of hysteroscope with tissue removal system, especially for patients with a history of repeated vaginitis. In addition, early identification of septic shock and timely application of antibiotic treatment are crucial, which can improve the prognosis of patients and avoid more serious outcomes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable legend\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Hysteroscope with radiofrequency energy and tissue removal system.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary indications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCharacteristics\u0026nbsp;of energy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReports\u0026nbsp;on\u0026nbsp;postoperative\u0026nbsp;septic\u0026nbsp;shock\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHysteroscope with radiofrequency energy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Removal of\u0026nbsp;endometrial\u0026nbsp;polyps;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eElectric\u0026nbsp;energy\u0026nbsp;and\u0026nbsp;heat\u0026nbsp;energy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eNot\u0026nbsp;available\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.\u0026nbsp;Resection\u0026nbsp;of\u0026nbsp;uterine\u0026nbsp;submucosal myoma;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.\u0026nbsp;Excision\u0026nbsp;of\u0026nbsp;uterine\u0026nbsp;cavity\u0026nbsp;residual pregnancy\u0026nbsp;tissue;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.\u0026nbsp;Separation\u0026nbsp;of\u0026nbsp;uterine\u0026nbsp;septum.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHysteroscope\u0026nbsp;with\u0026nbsp;tissue removal system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.\u0026nbsp;Removal\u0026nbsp;of\u0026nbsp;endometrial\u0026nbsp;polyps;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMechanical energy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNot\u0026nbsp;available\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.\u0026nbsp;Resection\u0026nbsp;of\u0026nbsp;some\u0026nbsp;types\u0026nbsp;of submucosal\u0026nbsp;myomas;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.\u0026nbsp;Removal\u0026nbsp;of\u0026nbsp;residual\u0026nbsp;pregnancy tissue\u0026nbsp;in\u0026nbsp;the\u0026nbsp;uterine\u0026nbsp;cavity.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eConflict of interest statement\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest and there are no financial conflicts of interest with any manufacturer.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eD.S.\u0026nbsp;and\u0026nbsp;R.D. designed the case report. D.S.\u0026nbsp;and J.S.\u0026nbsp;wrote the first draft of the manuscript. Y.L., Y.G. and T.Q. systematically edited the manuscript.\u0026nbsp;Y.Y.\u0026nbsp;and\u0026nbsp;L.W.\u0026nbsp;created figures and tables. R.D. reviewed and revised the manuscript. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Shenzhen Science and Technology Innovation Committee (Grant No. JCYJ20210324103606017) and the Guangdong Province Natural Science Foundation, China (Grant No. 2019A1515011693).\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained by Ethics Committee of Shenzhen Second People\u0026apos;s Hospital(ethical review approval number: 2023-019-01PJ). Written informed consent was obtained from the individual for the publication of any identifiable images or data included in this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRaz N, Feinmesser L, Moore O, Haimovich S. Endometrial polyps: diagnosis and treatment options - a review of literature. Minim Invasive Ther Allied Technol. 2021;30(5):278-87.\u003c/li\u003e\n\u003cli\u003eAydeniz B, Gruber IV, Schauf B, Kurek R, Meyer A, Wallwiener D. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol. 2002;104(2):160-4.\u003c/li\u003e\n\u003cli\u003eRovira Pampalona J, Degollada Bastos M, Mancebo Moreno G, et al. Outpatient Hysteroscopic Polypectomy: Bipolar Energy System (Versapoint\u0026reg;) versus Mechanical Energy System (TRUCLEAR System\u0026reg;) - Preliminary Results. Gynecol Obstet Invest. 2015;80(1):3-9.\u003c/li\u003e\n\u003cli\u003ePampalona JR, Bastos MD, Moreno GM, et al. A comparison of hysteroscopic mechanical tissue removal with bipolar electrical resection for the management of endometrial polyps in an ambulatory care setting: preliminary results. J Minim Invasive Gynecol. 2015;22(3):439-45.\u003c/li\u003e\n\u003cli\u003eSmith PP, Middleton LJ, Connor M, Clark TJ. Hysteroscopic morcellation compared with electrical resection of endometrial polyps: a randomized controlled trial. Obstet Gynecol. 2014;123(4):745-51.\u003c/li\u003e\n\u003cli\u003eHamerlynck TW, Schoot BC, van Vliet HA, Weyers S. Removal of Endometrial Polyps: Hysteroscopic Morcellation versus Bipolar Resectoscopy, A Randomized Trial. J Minim Invasive Gynecol. 2015;22(7):1237-43.\u003c/li\u003e\n\u003cli\u003eArnold A, Ketheeswaran A, Bhatti M, Nesbitt-Hawes E, Abbott J. A Prospective Analysis of Hysteroscopic Morcellation in the Management of Intrauterine Pathologies. J Minim Invasive Gynecol. 2016;23(3):435-41.\u003c/li\u003e\n\u003cli\u003eZhengyu L, Jin L, Wenjiao M, Dan Z, Xiao Y, Ying S. Intra-operative hydrotubation improves fertility of women with distal tubal occlusion after reproductive surgery. Arch Gynecol Obstet. 2013;287(1):83-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hysteroscopy, Hysteroscopic tissue removal system, Endometrial polypectomy, Postoperative complications, Shock, Septic","lastPublishedDoi":"10.21203/rs.3.rs-2665154/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2665154/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAs an emerging surgical technology, tissue removal systems have been widely used in the treatment of endometrial polyps due to its characteristics of less endometrial damage, shorter learning curve and clearer vision of the operative field. There are few cases in the literature reporting serious complications after endometrial polypectomy using tissue removal systems. As known, septic shock is a rare complication following hysteroscopic polypectomy. Now, we present the case of a 23-year-old woman who developed septic shock after polypectomy with tissue removal system. The patient had a history of recurrent vaginitis for more than half a year. Due to EPs, she was admitted to our hospital and scheduled to undergo hysteroscopic endometrial polypectomy. Three hours after the endometrial polypectomy using the tissue removal system, the patient had shock symptoms such as increased body temperature, decreased blood pressure and increased heart rate. Then, the patient was successfully treated and discharged after anti-infection and anti-shock treatments. The purpose of this case report is to remind clinicians to consider the possibility of serious infection and comprehensively evaluate the risk of infection before choosing hysteroscopic devices for EPs, especially for patients who choose the mechanical hysteroscopic tissue removal systems. Furthermore, the mechanical hysteroscopic tissue removal systems should be used with caution in patients with previous recurrent vaginitis.\u003c/p\u003e","manuscriptTitle":"Case report：Septic shock after endometrial polypectomy with tissue removal system","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-13 14:49:53","doi":"10.21203/rs.3.rs-2665154/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dbc1bad8-ebe2-4d9a-8184-831bfc20c544","owner":[],"postedDate":"March 13th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-07-10T04:14:25+00:00","versionOfRecord":[],"versionCreatedAt":"2023-03-13 14:49:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2665154","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2665154","identity":"rs-2665154","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}