Gynecology-endocrinology '
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Vol. 55, No.1, January 1991
FERTILITY AND STERILITY
Printed on acid-free paper in U.S.A.
Copyright© 1991 The American Fertility Society
Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy*
Togas Tulandi, M.D.t Melvin Guralnick, M.D. Department of Obstetrics and Gynecology, Sir Mortimer B. Davis Jewish General Hospital, and Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada
Thirty-four women with unruptured tubal ectopic pregnancy (EP) were randomly assigned to undergo salpingotomy without tubal suturing (n = 15) or salpingotomy with tubal suturing (n = 19). The reproductive performance of these patients was compared with 24 patients who underwent salpingectomy for their EP (historical control). Using life table analysis, the cumulative probability of intrauterine pregnancy (IUP) at 12 and 24 months was 45% and 45% after salpingotomy without tubal suturing and 21% and 4 7% after salpingotomy with tubal suturing, respectively. The cumulative probability of IUP after salpingectomy (21% and 26% at 12 and 24 months, respectively) was significantly lower than after salpingotomy with or without tubal suturing. There was no difference in the cumulative probability of EP after salpingotomy with or without tubal suturing, but it was significantly higher than after salpingectomy. In 18 women who subsequently underwent laparoscopy or laparotomy, no significant difference was found between the degree of adhesions after salpingotomy with or without tubal suturing. These findings suggest that IUP after conservative treatment is higher than after salpingectomy, but recurrent EP is also higher. Intrauterine pregnancy occurs earlier after salpingotomy without tubal suturing than after salpingotomy with tubal suturing. This might be because of rapid return of tubal function after healing by secondary intention. Fertil Steril55:53, 1991
Serial measurements of serum ~-human chorionic gonadotropin and early ultrasound examination have enabled detection of early and unruptured tubal ectopic pregnancy (EP). This early diagnosis has further allowed conservative treatment of EP without removing the tube. In the majority of cases, this is done by salpingotomy without tubal suturing, in which the tubal incision is left open to heal by secondary intention or salpingotomy with tubal suturing, in which the edge of tubal incision is approximated with sutures at the time of surgery. Primary closure with sutures covers raw surfaces, Received May 1, 1990; revised and accepted September 11, 1990. * Presented at the 46th Annual Meeting of The American Fertility Society, Washington, D.C., October 15 to 18, 1990. t Reprint requests: Togas Tulandi, M.D., Division of Reproductive Endocrinology/Infertility, Department of Obstetrics and Gynecology, McGill University, 687 Pine Avenue West, Montreal, Quebec, Canada, H3A 1Al. Vol. 55, No.1, January 1991
whereas healing by secondary intention eliminates more tissue injury and suture materials which might act as a foreign body. Some surgeons prefer salpingotomy without tubal suturing1- 4 ; others prefer salpingotomy with tubal suturing. 5 •6 The impact ofleavingthe tubal incision open to heal by secondary intention or closing with sutures is still not clear. The present study was undertaken to compare the reproductive performance of women after conservative treatment of EP by salpingotomy with or without tubal suturing. The results were then compared with those after salpingectomy. MATERIALS AND METHODS
Thirty-four women, who were found to have an unruptured ampullary EP by laparotomy, were randomly assigned to undergo salpingotomy without tubal suturing (n = 15) or salpingotomy with
Tulandi and Guralnick
Ectopic, salpingotomy, tubal suturing
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Figure 1 Cumulative probability of IUP after conservative surgical treatment of tubal EP by salpingotomy without tubal suturing (e--e), salpingotomy with tubal suturing (0---0), and after salpingectomy ( . - - ) .
tubal suturing (n = 19). The study was approved by The Ethics Committee, Department of Obstetrics and Gynecology, McGill University. All operations were done by the first author (T.T.). Patients with recurrent tubal pregnancy, ruptured tube, or with a solitary tube were excluded from the study. The procedure was done by first injecting a solution of diluted vasopressin (1 U/mL of physiological saline) into the adjacent mesosalpinx and into the wall of the tube on the antemesosalpinx side of the dilated tube. A 10- to 15-mm longitudinal incision along the area of maximal distension of the tube was then made with the use of an insulated microdiathermy needle. The product of conception was gently removed. Hemostasis was achieved by light application of microdiathermy needle and by ligating the vessels in the mesosalpinx with 6-0 Vicryl. The tubal incision was either left open to heal by secondary intention or approximated with 2 to 3 interrupted sutures of 6-0 Vicryl. During the procedure, peritoneal surfaces were continuously irrigated with Ringer's lactate solution. No patient received antibiotics, corticosteroids, antihistamines, or dextran. The reproductive outcome of these patients was then compared with 24 patients who underwent salpingectomy for their unruptured ampullary EP (historical control). Patients with solitary tube had been excluded. The data were analyzed by the Student's t-test, ANOVA, and life table analysis.
salpingotomy with tubal suturing 31.5 ± 0.8 years, and salpingectomy 30.5 ± 0.9 years, respectively. The gestational age of EP was 6.3 ± 0.3 weeks (range: 5~ to 7 weeks) in patients who underwent salpingotomy without tubal suturing, 6.4 ± 0.2 weeks (range: 5~ to 8 weeks) in those who underwent salpingotomy with tubal suturing, and 6.8 ± 0.2 weeks (range: 5~ to 8 weeks) in those who underwent salpingectomy. The size of the tubal pregnancy was between 2 and 3 em in the three groups of patients. Postoperative course in all patients was uneventful. Eighteen of these patients (7 patients who underwent salpingotomy without tubal suturing and 11 patients who underwent salpingotomy with tubal suturing) subsequently underwent a second-look laparoscopy or another laparotomy for recurrent EP. Periadnexal adhesions were found in 3 of 7 patients who underwent salpingotomy without tubal suturing and in 5 of 11 patients who underwent salpingotomy with tubal suturing. The degrees of adhesions were 6.9 ± 4.4 in patients who underwent salpingotomy without tubal suturing and 6.4 ± 3.0 in those who underwent salpingotomy with tubal suturing (The American Fertility Society Classification of adnexal adhesions 7 ). No tubal fistula or salpingitis isthmica nodosa was noted in these patients. The cumulative probability of intrauterine pregnancy (IUP) was higher after conservative surgical treatment than after salpingectomy (salpingotomy without tubal suturing versus salpingectomy: p < 10-6 , salpingotomy with tubal suturing versus salpingectomy: P < 0.05, Fig. 1). There was a higher incidence of cumulative probability of IUP after salpingotomy without tubal suturing than after salpingotomy with tubal suturing (P < 0.01). 40
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RESULTS
The age of the patients who underwent salpingotomy without tubal suturing was 30.3 ± 0.9 years, 54
Tulandi and Guralnick
Figure 2 Cumulative probability of recurrent EP after conservative surgical treatment of tubal EP by salpingotomy without tubal suturing (e-e), salpingotomy with tubal suturing (0---0), and after salpingectomy(.--).
Ectopic, salpingotomy, tubal suturing
Fertility and Sterility
The difference was clearly seen at 12 months' follow-up (45% after salpingotomy without tubal suturing versus 21% after salpingotomy with tubal suturing, Fig. 1). The cumulative probability of recurrent tubal EP after conservative treatment of EP was higher than after salpingectomy (Fig. 2, salpingotomy without tubal suturing versus salpingectomy: P < 0.01; salpingotomy with tubal suturing versus salpingectomy: P < 10-6 ). The cumulative probability of EP after salpingotomy without tubal suturing, however, was not significantly different than after salpingotomy with tubal suturing.
DISCUSSION
The cumulative probability of IUP at 6 and 12 months' follow-up was 6% and 21% after salpingotomy without tubal suturing and 35% and 45% after salpingotomy with tubal suturing, respectively (Fig. 1). This suggests that IUP occurs earlier after salpingotomy without tubal suturing than those after salpingotomy with tubal suturing. It is possible that leaving the tubal incision open to heal by secondary intention allows better healing and facilitates rapid return of tubal function. It has been noted that mucosal folds were oriented transversally after tubal suturing but longitudinally in cases without primary closure.8 The cumulative probability of IUP at 18 months 1 follow-up after salpingotomy without tubal suturing (45%), however, was not significantly different than those after salpingotomy with tubal suturing (47%). It appears that tubal suturing delays the return of tubal function, but it does not decrease the ultimate occurrence of IUP. This is in agreement with the results of animal studies in which the incidence of postsurgical adhesions and the pregnancy rate after salpingotomy with or without suturing are similar.9·10 Using women who underwent salpingectomy for their EP as a historical control, we found that conservative treatment of tubal EP by salpingotomy with or without tubal suturing is associated with a higher incidence of IUP than by salpingectomy. This is in agreement with the previous findings that conservative treatment of EP increases the number of live births. 11 This previous report also suggests that there is no difference in the incidence of recurrent tubal
Vol. 55, No.1, January 1991
pregnancy after conservative surgical treatment by salpingotomy and after salpingectomy .11 By using a life table analysis, however, we found that the occurrence of recurrent EP after conservative treatment is higher than after salpingectomy. Our findings suggest that IUP after conservative surgical treatment of tubal pregnancy is higher than after salpingectomy, but recurrent EP is also higher. Although, the ultimate incidence of IUP is similar, salpingotomy without tubal suturing is associated with earlier occurrence of IUP. It is possible that leaving the tubal incision open to heal by secondary intention allows better healing and facilitates rapid return of tubal function. It appears that salpingotomy without tubal suturing should be the procedure of choice for tubal pregnancy in women wishing to preserve their fertility.
REFERENCES 1. DeCherney AH, Maheux R, Naftolin F: Salpingostomy for ectopic pregnancy in the sole patent oviduct: reproductive outcome. Fertil Steril37:619, 1982 2. Valle J A, Lifchez AS: Reproductive outcome following con· servative surgery for tubal pregnancy in women with a single fallopian tube. Fertil Steril 39:316, 1983 3. Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA: Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steril46:1093, 1986 4. Tulandi T: Reproductive performance of women after two tubal ectopic pregnancies. Fertil Steril50:164, 1988 5. Langer R, Bukovsky I, Herman A, Sherman D, Sadovsky G, Caspi E: Conservative surgery for tubal pregnancy. Fertil Steril38:427, 1982 6. Semm K: Advances in pelviscopy surgery. Curr Probl Obstet Gynecol Fertil 5:20, 1982 7. The American Fertility Society: The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril49:944, 1988 8. McComb PF, Gomel V: Linear ampullary salpingotomy heals better by secondary versus primary closure. (Abstr. 104) Fertil Steril41:45S, 1984 9. Gordji M, Henry-Suchet J, Pigeaud F, Tesquier L, Debache C, Achard B, Chahine N, Loffredo V: Etude comparee des salpingostomies avec et sans suture. Recherche microchirurgicale experimentale sur la trompe de lapine. J Gynecol Obstet Biol Reprod (Paris) 10:765, 1981 10. Nelson LM, Margara RA, Winston RML: Primary and secondary closure of ampullary salpingotomy compared in the rabbit. Fertil Steril45:292, 1986 11. DeCherney A, Kase N: The conservative surgical management ofunruptured ectopic pregnancy. Obstet Gynecol54: 451, 1979
Tulandi and Guralnick Ectopic, salpingotomy, tubal suturing
55
,
'
~
0
'
'
Vol. 55, No.1, January 1991
FERTILITY AND STERILITY
Printed on acid-free paper in U.S.A.
Copyright© 1991 The American Fertility Society
Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy*
Togas Tulandi, M.D.t Melvin Guralnick, M.D. Department of Obstetrics and Gynecology, Sir Mortimer B. Davis Jewish General Hospital, and Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada
Thirty-four women with unruptured tubal ectopic pregnancy (EP) were randomly assigned to undergo salpingotomy without tubal suturing (n = 15) or salpingotomy with tubal suturing (n = 19). The reproductive performance of these patients was compared with 24 patients who underwent salpingectomy for their EP (historical control). Using life table analysis, the cumulative probability of intrauterine pregnancy (IUP) at 12 and 24 months was 45% and 45% after salpingotomy without tubal suturing and 21% and 4 7% after salpingotomy with tubal suturing, respectively. The cumulative probability of IUP after salpingectomy (21% and 26% at 12 and 24 months, respectively) was significantly lower than after salpingotomy with or without tubal suturing. There was no difference in the cumulative probability of EP after salpingotomy with or without tubal suturing, but it was significantly higher than after salpingectomy. In 18 women who subsequently underwent laparoscopy or laparotomy, no significant difference was found between the degree of adhesions after salpingotomy with or without tubal suturing. These findings suggest that IUP after conservative treatment is higher than after salpingectomy, but recurrent EP is also higher. Intrauterine pregnancy occurs earlier after salpingotomy without tubal suturing than after salpingotomy with tubal suturing. This might be because of rapid return of tubal function after healing by secondary intention. Fertil Steril55:53, 1991
Serial measurements of serum ~-human chorionic gonadotropin and early ultrasound examination have enabled detection of early and unruptured tubal ectopic pregnancy (EP). This early diagnosis has further allowed conservative treatment of EP without removing the tube. In the majority of cases, this is done by salpingotomy without tubal suturing, in which the tubal incision is left open to heal by secondary intention or salpingotomy with tubal suturing, in which the edge of tubal incision is approximated with sutures at the time of surgery. Primary closure with sutures covers raw surfaces, Received May 1, 1990; revised and accepted September 11, 1990. * Presented at the 46th Annual Meeting of The American Fertility Society, Washington, D.C., October 15 to 18, 1990. t Reprint requests: Togas Tulandi, M.D., Division of Reproductive Endocrinology/Infertility, Department of Obstetrics and Gynecology, McGill University, 687 Pine Avenue West, Montreal, Quebec, Canada, H3A 1Al. Vol. 55, No.1, January 1991
whereas healing by secondary intention eliminates more tissue injury and suture materials which might act as a foreign body. Some surgeons prefer salpingotomy without tubal suturing1- 4 ; others prefer salpingotomy with tubal suturing. 5 •6 The impact ofleavingthe tubal incision open to heal by secondary intention or closing with sutures is still not clear. The present study was undertaken to compare the reproductive performance of women after conservative treatment of EP by salpingotomy with or without tubal suturing. The results were then compared with those after salpingectomy. MATERIALS AND METHODS
Thirty-four women, who were found to have an unruptured ampullary EP by laparotomy, were randomly assigned to undergo salpingotomy without tubal suturing (n = 15) or salpingotomy with
Tulandi and Guralnick
Ectopic, salpingotomy, tubal suturing
53
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6
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24
Time (months)
Figure 1 Cumulative probability of IUP after conservative surgical treatment of tubal EP by salpingotomy without tubal suturing (e--e), salpingotomy with tubal suturing (0---0), and after salpingectomy ( . - - ) .
tubal suturing (n = 19). The study was approved by The Ethics Committee, Department of Obstetrics and Gynecology, McGill University. All operations were done by the first author (T.T.). Patients with recurrent tubal pregnancy, ruptured tube, or with a solitary tube were excluded from the study. The procedure was done by first injecting a solution of diluted vasopressin (1 U/mL of physiological saline) into the adjacent mesosalpinx and into the wall of the tube on the antemesosalpinx side of the dilated tube. A 10- to 15-mm longitudinal incision along the area of maximal distension of the tube was then made with the use of an insulated microdiathermy needle. The product of conception was gently removed. Hemostasis was achieved by light application of microdiathermy needle and by ligating the vessels in the mesosalpinx with 6-0 Vicryl. The tubal incision was either left open to heal by secondary intention or approximated with 2 to 3 interrupted sutures of 6-0 Vicryl. During the procedure, peritoneal surfaces were continuously irrigated with Ringer's lactate solution. No patient received antibiotics, corticosteroids, antihistamines, or dextran. The reproductive outcome of these patients was then compared with 24 patients who underwent salpingectomy for their unruptured ampullary EP (historical control). Patients with solitary tube had been excluded. The data were analyzed by the Student's t-test, ANOVA, and life table analysis.
salpingotomy with tubal suturing 31.5 ± 0.8 years, and salpingectomy 30.5 ± 0.9 years, respectively. The gestational age of EP was 6.3 ± 0.3 weeks (range: 5~ to 7 weeks) in patients who underwent salpingotomy without tubal suturing, 6.4 ± 0.2 weeks (range: 5~ to 8 weeks) in those who underwent salpingotomy with tubal suturing, and 6.8 ± 0.2 weeks (range: 5~ to 8 weeks) in those who underwent salpingectomy. The size of the tubal pregnancy was between 2 and 3 em in the three groups of patients. Postoperative course in all patients was uneventful. Eighteen of these patients (7 patients who underwent salpingotomy without tubal suturing and 11 patients who underwent salpingotomy with tubal suturing) subsequently underwent a second-look laparoscopy or another laparotomy for recurrent EP. Periadnexal adhesions were found in 3 of 7 patients who underwent salpingotomy without tubal suturing and in 5 of 11 patients who underwent salpingotomy with tubal suturing. The degrees of adhesions were 6.9 ± 4.4 in patients who underwent salpingotomy without tubal suturing and 6.4 ± 3.0 in those who underwent salpingotomy with tubal suturing (The American Fertility Society Classification of adnexal adhesions 7 ). No tubal fistula or salpingitis isthmica nodosa was noted in these patients. The cumulative probability of intrauterine pregnancy (IUP) was higher after conservative surgical treatment than after salpingectomy (salpingotomy without tubal suturing versus salpingectomy: p < 10-6 , salpingotomy with tubal suturing versus salpingectomy: P < 0.05, Fig. 1). There was a higher incidence of cumulative probability of IUP after salpingotomy without tubal suturing than after salpingotomy with tubal suturing (P < 0.01). 40
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24
Time (months)
RESULTS
The age of the patients who underwent salpingotomy without tubal suturing was 30.3 ± 0.9 years, 54
Tulandi and Guralnick
Figure 2 Cumulative probability of recurrent EP after conservative surgical treatment of tubal EP by salpingotomy without tubal suturing (e-e), salpingotomy with tubal suturing (0---0), and after salpingectomy(.--).
Ectopic, salpingotomy, tubal suturing
Fertility and Sterility
The difference was clearly seen at 12 months' follow-up (45% after salpingotomy without tubal suturing versus 21% after salpingotomy with tubal suturing, Fig. 1). The cumulative probability of recurrent tubal EP after conservative treatment of EP was higher than after salpingectomy (Fig. 2, salpingotomy without tubal suturing versus salpingectomy: P < 0.01; salpingotomy with tubal suturing versus salpingectomy: P < 10-6 ). The cumulative probability of EP after salpingotomy without tubal suturing, however, was not significantly different than after salpingotomy with tubal suturing.
DISCUSSION
The cumulative probability of IUP at 6 and 12 months' follow-up was 6% and 21% after salpingotomy without tubal suturing and 35% and 45% after salpingotomy with tubal suturing, respectively (Fig. 1). This suggests that IUP occurs earlier after salpingotomy without tubal suturing than those after salpingotomy with tubal suturing. It is possible that leaving the tubal incision open to heal by secondary intention allows better healing and facilitates rapid return of tubal function. It has been noted that mucosal folds were oriented transversally after tubal suturing but longitudinally in cases without primary closure.8 The cumulative probability of IUP at 18 months 1 follow-up after salpingotomy without tubal suturing (45%), however, was not significantly different than those after salpingotomy with tubal suturing (47%). It appears that tubal suturing delays the return of tubal function, but it does not decrease the ultimate occurrence of IUP. This is in agreement with the results of animal studies in which the incidence of postsurgical adhesions and the pregnancy rate after salpingotomy with or without suturing are similar.9·10 Using women who underwent salpingectomy for their EP as a historical control, we found that conservative treatment of tubal EP by salpingotomy with or without tubal suturing is associated with a higher incidence of IUP than by salpingectomy. This is in agreement with the previous findings that conservative treatment of EP increases the number of live births. 11 This previous report also suggests that there is no difference in the incidence of recurrent tubal
Vol. 55, No.1, January 1991
pregnancy after conservative surgical treatment by salpingotomy and after salpingectomy .11 By using a life table analysis, however, we found that the occurrence of recurrent EP after conservative treatment is higher than after salpingectomy. Our findings suggest that IUP after conservative surgical treatment of tubal pregnancy is higher than after salpingectomy, but recurrent EP is also higher. Although, the ultimate incidence of IUP is similar, salpingotomy without tubal suturing is associated with earlier occurrence of IUP. It is possible that leaving the tubal incision open to heal by secondary intention allows better healing and facilitates rapid return of tubal function. It appears that salpingotomy without tubal suturing should be the procedure of choice for tubal pregnancy in women wishing to preserve their fertility.
REFERENCES 1. DeCherney AH, Maheux R, Naftolin F: Salpingostomy for ectopic pregnancy in the sole patent oviduct: reproductive outcome. Fertil Steril37:619, 1982 2. Valle J A, Lifchez AS: Reproductive outcome following con· servative surgery for tubal pregnancy in women with a single fallopian tube. Fertil Steril 39:316, 1983 3. Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA: Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steril46:1093, 1986 4. Tulandi T: Reproductive performance of women after two tubal ectopic pregnancies. Fertil Steril50:164, 1988 5. Langer R, Bukovsky I, Herman A, Sherman D, Sadovsky G, Caspi E: Conservative surgery for tubal pregnancy. Fertil Steril38:427, 1982 6. Semm K: Advances in pelviscopy surgery. Curr Probl Obstet Gynecol Fertil 5:20, 1982 7. The American Fertility Society: The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril49:944, 1988 8. McComb PF, Gomel V: Linear ampullary salpingotomy heals better by secondary versus primary closure. (Abstr. 104) Fertil Steril41:45S, 1984 9. Gordji M, Henry-Suchet J, Pigeaud F, Tesquier L, Debache C, Achard B, Chahine N, Loffredo V: Etude comparee des salpingostomies avec et sans suture. Recherche microchirurgicale experimentale sur la trompe de lapine. J Gynecol Obstet Biol Reprod (Paris) 10:765, 1981 10. Nelson LM, Margara RA, Winston RML: Primary and secondary closure of ampullary salpingotomy compared in the rabbit. Fertil Steril45:292, 1986 11. DeCherney A, Kase N: The conservative surgical management ofunruptured ectopic pregnancy. Obstet Gynecol54: 451, 1979
Tulandi and Guralnick Ectopic, salpingotomy, tubal suturing
55
