Adhesion formation after tubal surgery: results of the eighth-day laparoscopy in 188 patients

Transcription

1 FERTILITY AND STERILITY Copyright 1985 The American Fertility Society Vol. 43, No.3, March 1985 Printed in U.SA. Adhesion formation after tubal surgery: results of the eighth-day laparoscopy in 188 patients Trudy C. M. Trimbos-Kemper, M.D.* J. Baptist Trimbos, M.D. Eylard V. van Hall, M.D. Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands First-look laparoscopy (FL) on the eighth day after salpingostomy, fimbrioplasty, or adhesiolysis was performed in 188 patients. Behavior of postoperative adhesions and the occurrence of pregnancy after tubal surgery were compared with a similar group of 127 patients in whom no FL was performed. In > 50% of the cases ( ), adhesions were found on the eighth postoperative day around both adnexa or the only remaining adnexum. Adhesions were mainly located between the ampulla and the ovary and between the ovary and the lateral pelvic wall or broad ligament. More than hair of the adhesions that were separated at FL did not recur. It was concluded that FL significantly diminished the occurrence of permanent pelvic adhesions. The incidence of ectopic pregnancy after salpingostomy was significantly lower when FL was performed. FL on the eighth postoperative day can be regarded as a well-accepted procedure with few complications. Fertil SteriI43:395, 1985 Postoperative tubal reocclusion and adhesion formation are important factors in failure rates of reconstructive tubal surgery.1 The last decade has provided more insight into the etiology and pathophysiology of adhesion formation. It has been shown that local ischemia hampers the ability of the peritoneum to perform spontaneous fibrinolysis. 2,3 Thus, one of the main reasons to advocate nontraumatic techniques in tubal surgery is to avoid tissue ischemia in the operation field. 4,5 Despite these precautions, postoperative adhesion formation continues to occur in a large number of cases.s Early postoperative laparos- copy has been advocated as a method of cleaving fresh adhesions when they are still friable and gelatinous. 7 In our department we started a prospective clinical trial in 1980 to assess the value of the eighth-day laparoscopy after tubal surgery. This trial was designed to provide information about a possibly beneficial effect on the occurrence and outcome of pregnancy and to increase insight into the mechanism underlying adhesion formation after tubal surgery. In the present article the results obtained with this approach in a relatively large group of patients with a relatively long follow-up period are analyzed. Received August 8, 1984; revised and accepted November 14,1984. *Reprint requests: Trudy C. M. Trimbos-Kemper, M.D., Department of Obstetrics and Gynecology, Leiden University Medical Center, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands. MATERIALS AND METHODS Between August 1, 1980 and January 1,1984, adhesiolysis, fimbrioplasty, or salpingostomy was performed in 202 patients in our department. Early laparoscopy on the eighth postoperative Vol. 43, No.3, March 1985 Trimbos-Kemper et ai. Early laparoscopy after tubal surgery 395

2 p day was performed in 188 of these 202 patients. This procedure will be referred to here as first-. look laparoscopy (FL). Nine patients refused to undergo a second operation after 8 days, and in five patients FL was not performed because of an increased risk factor, such as extensive adhesions in the upper abdomen, hematoma formation in the abdominal wall, and postoperative infection. The eighth day after tubal surgery was chosen so that the laparoscopy could be performed during the same admission period, contrary to the performance of this procedure at a later date, as advocated by others. 8 All operations were performed by us without magnification and with the use of such microsurgical techniques as electrocautery, gentle tissue handling, fine instruments and fine atraumatic suture materials, constant irrigation of tissues, and excision of all adhesions. Measures to prevent postoperative adhesion formation consisted of leaving 200 to 300 ml 32% dextran 70 in the abdomen at the end of the operation, perioperative administration of corticosteroids and antibiotics, and five or six postoperative hydrotubations between tubal surgery and FL.9 The hydrotubation fluid contained corticosteroids in combination with a local anesthetic agent. All FLs were performed by us and with general anesthesia. A double-puncture technique was used in all cases. When a Pfannenstiel wound was present, the second puncture incision for introduction of a probe was made several inches above the scar, to avoid disturbance of the fresh wound. On the eighth postoperative day any newly formed pelvic adhesions were still soft and gelatinous and could be separated easily by moving the probe along them. Occasionally, this procedure caused some bleeding of already vascularized adhesions. In such cases, the pelvic cavity was rinsed with Ringer's lactate solution and cleaned with suction. At the end of the FL, hydrotubation was performed with a solution containing methylene blue and corticosteroids, after which 100 to 200 ml 32% dextran 70 was instilled into the abdominal cavity. All patients were discharged on the ninth or tenth day after tubal surgery. During the second year after the operation, all patients in whom pregnancy had not occurred were offered a second-look laparoscopy (SL) to permit final assessment of the surgical results and the fertility prognosis. Up to January 1984, SL had been performed in 64 of the 188 patients studied. Table 1. Relevant Data on the Patients With and Without FL After Tubal Surgery No. of patients Time of tubal surgery Type of operation Salpingostomy Fimbrioplasty Adhesiolysis Mean age (yrs) Mean duration of infertility (yrs) Duration of followup (yrs) NoFL 127 1/8178 to 1/8/80 68 (54%) 33 (26%) 26 (20%) FL 188 1/8/80 to 1/1/84 95 (50%) 52 (28%) 41 (22%) In further analysis of the data collected in this study, attention was paid to two aspects: (1) General aspects of adhesion formation included the incidence of postoperative adhesions, preferred localization, the time of developing of adhesions, and the relation between the severity of adhesions at tubal surgery and eventual reoccurrence. Adhesions at the time of tubal surgery and at SL were graded according to the classification of Siegler. lo Because the newly formed adhesions found at FL have completely different qualities and consistency, they cannot be defined on the basis ofthis classification. (2) Pregnancy rates in the group of 188 patients who underwent FL were compared with those of a group of 127 women who had undergone similar tubal surgery in our department just prior to the institution of the FL. The duration of follow-up for the patients who underwent FL ranged from 0 to 3.5 years. In the group of 127 patients without FL the follow-up period ranged from 3.5 to 5.5 years. To correct for this difference, pregnancy rates were calculated according to the life-table method. 11 Table 1 shows the various characteristics of the two groups studied. GENERAL ASPECTS RESULTS Acceptance of the eighth-day laparoscopy after tubal surgery by the 188 patients of the present series was generally good. Some of them had to overcome their reluctance to undergo anesthesia twice within a relatively short time, but all of them recovered quickly and left the hospital in good condition 1 or 2 days after laparoscopy. The complications of the procedure were all minor: hemorrhage from the second puncture wound 396 Trimbos-Kemper et al. Early laparoscopy after tubal surgery Fertility and Sterility

3 Table 2. Correlation Between the Presence of Adhesions at 298 Adnexa in 188 Patients at the Time of Tubal Surgery and atfl" Adhesions at Adhesions at FL tubal surgery Not present Present Total None or grade I Grade IIIIII Total "X2 = 10.06; P < (four cases), leakage of dextran through one of the two incisions (four cases, in one with subcutaneous spread of fluid to the groin), preperitoneal insufflation (two cases), and small disruption of the Pfannenstiel wound (two cases). In 104 of the 188 FLs, postoperative adhesions were found around both adnexa or the only remaining adnexum. In 39 patients adhesions were found around one of the two adnexa present, and in 45 patients no adhesions at all were seen. It was possible in almost all cases to separate these adhesions with the use of the probe. The most frequent site of the adhesions was between the ampulla of the fallopian tube and the ovary and between the ovary and the lateral pelvic wall or broad ligament. The data on the occurrence of adhesions at the time of tubal surgery and at FL are summarized in Table 2. Here the numbers refer to individual adnexa; because 78 patients had undergone unilateral salpingo-oophorectomy at or before tubal surgery, the total number of adnexa studied was 298. Development of adhesions after salpingostomy, fimbrioplasty, or adhesiolysis was more frequent when the adhesions removed during the operation were moderate or severe. This difference was statistically significant (P < 0.01; chisquare test). Table 3. Classification of the Presence of Adhesions at l04 Adnexa in 64 Patients at the Time of FL and SL Adhesions at SL Adhesions atfl None or Grade Grade Total grade I II III None " 42 Avascular } 26 } Vascular 1~ Dense Total "Two patients developed pelvic inflammatory disease between FL and SL, one of them 8 months and the other 12 months after FL; in one patient intraperitoneal hemorrhage was detected at FL. Table 4. Presence of Adhesions at SL in Patients With and Without FL After Tubal Surgery" Adhesions at SL Grade of adhesions FL performed FL not performed (n = 104 adnexa) (n = 69 adnexa) None/grade I Grade II 13 } } 42 Grade III Total "X 2 = 9.1; P < In 64 patients the effect of the FL could be assessed during an SL, and the same comparison was made for the adnexa. In 42 cases no peritubal or periovarian adhesions were found at FL, and in 33 of them no adhesions were found at SL. Where adhesions had been removed at FL, they had not recurred in 52% (32/62) of the adhexa at SL (Table 3). One could argue that some of the newly formed adhesions may tend to disappear spontaneously. If this hypothesis were valid, the effect of FL in diminishing the number of permanent adhesions would be of less importance. To shed some light on this point, we investigated the presence of adhesions at SL in the 127 patients who had not undergone FL 8 days after salpingostomy, fimbrioplasty, or adhesiolysis. In 44 of these 127 patients an SL was done during the second year after tubal surgery. When adnexal adhesions at SL in this group were compared with those of the 64 patients who underwent FL as well as SL, significantly more of those in whom FL had been performed were found to have no adhesions (P < 0.01, chi-square test; Table 4). The mean intervals between tubal surgery and SL were similar in both groups, which strengthened the conclusion that an effective decrease 'in permanent adnexal adhesions can be gained by performing FL. PREGNANCY RATES Intrauterine Pregnancies The cumulative intrauterine pregnancy rates after 3 years were similar in both groups, although the pregnancies in the FL group tended to occur earlier than in the other group (Fig. 1). The cumulative intrauterine pregnancy rate was further classified according to the different types of operation within the three groups. No significant difference was found between the cumulative in- Vol. 43, No.3, March 1985 Trimbos-Kemper et a1. Early laparoscopy after tubal surgery 397

4 30 29.p 30 0/0 CLM. CONe PERC. feup) AFTER SALPINGOSTOMY Ith_y kap.k. : y... _ ",, :- no []o- -- D n:l 61./.,... p.o.ol I 10 n= ' ,' : no [)-... [J nz 127 L-----~-----~----_~_yrs 2 3.Figure 1 Cumulative conception percentages of intrauterine pregnancies in patients with and without FL on the eighth day after salpingostomy, fimbrioplasty, or adhesiolysis. 2 3 Figure 2 Cumulative conception percentages of ectopic pregnancies in patients with and without FL on the eighth day after salpingostomy. trauterine pregnancy rates after 3 years (Table 5). Ectopic Pregnancies The cumulative ectopic pregnancy rate after 3 years was 10% in the FL group and 17% in the other group. No significant differences in cumulative pregnancy percentages 3 years after fimbrioplasty or adhesiolysis were found between the FL group and the non-fl group. However, after salpingostomy, the occurrence of ectopic pregnancy in the FL group was significantly less than in the other group. This difference held for the total'follow-up period (Fig. 2). DISCUSSION The finding that in> 50% of the cases (104/188) adhesions at both adnexa or at the only remain- Table 5. Cumulative Intrauterine Pregnancies ([UP) After Salpingostomy, Fimbrioplasty, or Adhesiolysis in the Patients With and Without FL Type of operation Cumulative conception Salpingostomy Fimbrioplasty Adhesiolysis percentage..(iup) after -FL +FL -FL +FL -FL +FL mos ing adnexum were seen during FL accounted for an unexpectedly high incidence of postoperative adhesion formation. Because adhesion formation shortly after tubal surgery in the human has not been studied systematically so far, comparable data from the literature are not available. In our department success rates after tubal surgery are quite similar to or compare favorably with the results obtained in other centers, regardless of whether an operating microscope was used or not. This conclusion, which is based on large series of patients evaluated after long-term follow-up,9, 12 makes it unlikely that lack of surgical expertise might explain the great number of postoperative adhesions found in our study. One of the possible explanations might be the fact that according to our procedure, every minimal attachment between adjacent structures was described at FL. Another explanation might be found in the selection criteria we used for the adhesiolysis group. It has long been our policy to postpone adhesiolysis until at least 1 year after diagnosticlaparoscopy if at least one fallopian tube is patent. The reason for this policy is to permit spontaneous pregnancy to occur,13 but such postponement will of course lead to selection of more unfavorable patients and this might contribute to the relatively high incidence of postoperative adhesions assessed by FL. The great majority (70%) of the adhesions seen at FL in our series were located between the ampulla and the ipsilateral ovary and between the 398 Trimbos-Kemper et ai. Early laparoscopy after tubal surgery Fertility and Sterility

5 ovary aild the lateral pelvic wall or the broad ligament. Future pregnancy could not be regarded as impossible in all of these cases, but tubal motility would have been impaired and the ovum pick-up consequently hampered. During tubal surgery, peritoneal tissue was prepared for transplantation in nine patients to cover a denuded peritoneal surface. Seven patients showed no adhesions with this transplant at the time of laparoscopy, and two patients had adhesions between the transplant and an adjacent structure. It has been suggested that FL should be performed by preference at a time later than 8 days after surgery, e.g., 4 to 6 weeks later.8 It has been shown, however, that the conversion from "fibrinous attachments" to permanent adhesions starts during the third or fourth day after surgery. 1, 2 Henry-Suchet and Loffred0 7 describe postoperative adhesions 4 weeks after surgery as thick, velamentous, and predominantly organized. Laparoscopic adhesiolysis of such adhesions is more difficult, more traumatic, and bloodier than the simple adhesiolysis of gelatinous attachments on the eighth postoperative day. Furthermore, performance of the FL during the same hospital stay as the initial tubal surgery should be regarded as a practical and psychologic advantage. It goes beyond saying that this advantage is not applicable under circumstances where patients are dismissed before the eighth postoperative day. Our comparison of pregnancy rates in patients with and without FL was not done on a randomized basis, and this might be put forward as an objection to the conclusions we have drawn. It should be kept in mind, however, that a randomized trial of postoperative laparoscopy involves major practical and psychologic drawbacks. In our department we perform two to four tubal operations a week, and we have a common ward for all of our infertility patients. The study design we used may be considered to be a close approximation of the best possible comparative trial within existing possibilities. Age, duration of infertility, and type of tubal operation were similar for the two groups, i.e., the 188 patients with FL and the 127 patients in whom FL was not performed, and the life-table method was used to correct for the difference in duration of the follow-up between the two groups. All operations in both.groups were performed by the present authors, and success rates after tubal surgery did not differ significantly between them. We made a thorough analysis of the pregnancy rates after tubal surgery in our department during a period of several years prior to the introduction of FL and were unable to detect an improving trend in cumulative pregnancy rates on a year-to-year basis, which led us to conclude that no factors such as improved surgical skill or changes in selection criteria for tubal surgery had introduced bias into the present study. The only statistically significant beneficial effect of FL on pregnancy rates is the decrease in the number of ectopic pregnancies after salpingostomy. Because it is well known that the great majority of ectopic pregnancies after tubal surgery occur after salpingostomy, it seems logical that the change in the rate of ectopic pregnancies would appear first in the salpingostomy group. It has been stated that the condition of the endosalpinx is the most definite etiologic factor in the occurrence of extrauterine pregnancies. 14 The results of the present study suggest that the condition of the endosalpinx might not necessarily be the only factor responsible for ectopic pregnancy. A combination of unfavorable conditions could be involved, e.g., a malfunctioning endosalpinx together with peritubal adhesions hampering tubal motility and delaying the ovum pickup mechanism. In summary, the present study has shown that FL on the eighth day after tubal surgery is a well-accepted procedure with minor complications. Furthermore, the operation provides valuable information on the mechanism of postoperative adhesion formation. More than half of the adhesions removed at FL did not recur, and it is concluded that FL has a significant effect by reducing. the number of permanent pelvic adhesions. FL after salpingostomy significantly diminished the occurrence of ectopic pregnancies. The question as to whether the performance of FL after adhesiolysis and that after fimbrioplasty are equally appropriate cannot be answered from the results of the present study. To settle this point, studies in a greater number of patients are required and possibly a different study design. REFERENCES 1. Holtz G: Prevention and management of peritoneal adhesions. Fertil Steril 41:497, Ellis H: Internal overhealing: the problem of intraperitoneal adhesions. World J Surg 4:303, 1980 VoL 43, No.3, March 1985 Trimbos-Kemper et ai. Early laparoscopy after tubal surgery 399

6 3. Raftery AT: Effect of peritoneal trauma on peritoneal fibrinolytic activity and intraperitoneal adhesion formation. Eur Surg Res 13:397, Diamond E: Lysis of postoperative pelvic adhesions in infertility. Fertil SteriI31:287, Levinson CJ, Swolin K: Postoperative adhesions: etiology, prevention, and therapy. Clin Obstet Gynecol 23:1213, Holtz G, Kling OR: Effect of surgical technique on peritoneal adhesion reformati{)n after lysis. Fertil Steril37:494, Henry-Suchet J, Loffredo V: Prevention and treatment of adhesions after tuboplasty: early laparoscopy eight days after the plasty. Presented at the Tenth World Congress on Fertility and Sterility, July 5 to 11, 1980, Madrid. Published in Abstracts of Free Communications, Abstract Swolin K: Electromicrosurgery and salpingostomy: longterm results. Am J Obstet GynecoI121:418, van Hall EV, Trimbos-Kemper GCM: The surgical management of tubal infertility. In Gynecology and Obstetrics: Proceedings of the Ninth World Congress of Gynecology and Obstetrics, Edited by S Sakamoto, S Tojo, T Nakayma. Amsterdam-Oxford-Princeton, Excerpta Medica, 1980, p Siegler AM: Surgical treatments for tuboperitoneal causes ofinfertility since Fertil Steril28:1019, Umezaki C, Katayama KP, Jones HW Jr: Pregnancy rates after reconstructive surgery. on the fallopian tubes. Obstet Gynecol 43:418, van Hall EV, Trimbos-Kemper GeM: Long-term results of tubal surgery. Int J Fertil 28:26, Trimbos-Kemper GeM, Trimbos JB, van Hall EV: Pregnancy rates after laparoscopy for infertility. Eur J Obstet Gynecol Reprod Bioi 18:127, Vasquez G, Winston RML, Brosens IA: Tubal mucosa and ectopic pregnancy. Br J Obstet Gynaecol 90:468, Trimbos-Kemper et al. Early laparoscopy after tubal surgery Fertility and Sterility