背景:全盆腔切除术是放射治疗引起的直肠膀胱阴道瘘的最终解决方案,然而,全盆腔切除术经常导致术中并发症和术后并发症。这些并发症是下肢功能障碍的原因,生活质量受损,甚至长期的高发病率,因此,多学科合作和早期干预预防并发症是必要的。发现物理治疗可减少术后并发症并促进康复,然而,物理治疗如何预防和治疗全盆腔切除术和盆腔淋巴结清扫术后并发症的效果尚不清楚。
方法:一位50岁的中国女性逐渐出现肛周和盆底疼痛和不适,右下肢麻木,以及半年前因宫颈癌复发和转移引起的阴道非自愿排液。诊断为放射性引起的直肠膀胱阴道瘘,她接受了全盆腔切除术,随后出现了严重的下肢水肿,肿胀疼痛,闭孔神经损伤,和运动障碍。该患者被转诊至物理治疗师,该治疗师进行了康复评估,并发现下肢水肿。右腹股沟区疼痛(数字疼痛率量表5/10),右侧下肢大腿内侧的温度感觉和轻微触摸降低,右髋内收肌力(手动肌肉测试1/5)和右髋屈肌力(手动肌肉测试1/5)下降,不能积极地通过膝盖伸展来加合和弯曲右臀部,低德莫顿流动指数得分(0/100),和低修正Barthel指数得分(35/100)。2周内进行常规理疗,包括治疗性锻炼,机械刺激和电刺激以及手动治疗。结果显示,物理治疗可显着减轻下肢疼痛和肿胀,改善了髋关节的活动范围,运动功能,和日常生活活动,但仍不能预防血栓形成。
结论:标准化物理治疗对盆腔全切除术和盆腔淋巴结清扫术后并发症的影响。这支持了多学科合作和早期物理治疗干预的必要性。需要进一步的研究来确定标准化干预后血栓形成的原因,需要更多的随机对照试验来研究全盆腔切除术后物理治疗的疗效。
BACKGROUND: Total pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes intraoperative complications and postoperative complications. These complications are responsible for the dysfunction of lower extremities, impaired quality of life, and even the high long-term morbidity rate, thus multidisciplinary cooperation and early intervention for prevention of complications are necessary. Physical therapy was found to reduce the postoperative complications and promote rehabilitation, yet the effect on how physiotherapy prevents and treats complications after total pelvic exenteration and pelvic lymphadenectomy remains unclear.
METHODS: A 50-year-old Chinese woman gradually developed perianal and pelvic floor pain and discomfort, right lower limb numbness, and involuntary vaginal discharge owing to recurrence and metastasis of cervical cancer more than half a year ago. Diagnosed as rectovesicovaginal fistula caused by radiation, she received total pelvic exenteration and subsequently developed severe lower limb edema, swelling pain, obturator nerve injury, and motor dysfunction. The patient was referred to a physiotherapist who performed rehabilitation evaluation and found edema in both lower extremities, right inguinal region pain (numeric pain rate scale 5/10), decreased temperature sensation and light touch in the medial thigh of the right lower limb, decreased right hip adductor muscle strength (manual muscle test 1/5) and right hip flexor muscle strength (manual muscle test 1/5), inability actively to adduct and flex the right hip with knee extension, low de Morton mobility Index score (0/100), and low Modified Barthel Index score (35/100). Routine physiotherapy was performed in 2 weeks, including therapeutic exercises, mechanical stimulation and electrical stimulation as well as manual therapy. The outcomes showed that physiotherapy significantly reduced lower limb pain and swelling, and improved hip range of motion, motor function, and activities of daily living, but still did not prevent thrombosis.
CONCLUSIONS: Standardized physical therapy demonstrates the effect on postoperative complications after total pelvic exenteration and pelvic lymphadenectomy. This supports the necessity of multidisciplinary cooperation and early physiotherapy intervention. Further research is needed to determine the causes of thrombosis after standardized intervention, and more randomized controlled trials are needed to investigate the efficacy of physical therapy after total pelvic exenteration.