Experimental Recanalization of the Fallopian Tubes in the Macacus Rhesus Monkey

Transcription

1 Experimental Recanalization of the Fallopian Tubes in the Macacus Rhesus Monkey Mario A. Castallo, M.D. with the technical assistance of JoHN M. STACK, M.D., AND AMos S. WAINER, M.D. THis PAPER REPORTS the results of experiments on the Macacus rhesus monkey with the purpose of developing a satisfactory method for recanalizing fallopian tubes. Intubated salpingostomy was done with various materials to study the possibility of recanalization and regeneration of the fallopian tube. A review. of the literature reveals consistently poor results of various plastic operations done on the occluded fallopian tube in the human to overcome sterility. Greenhill studied the literature regarding salpingostomy and tubal implantation and found it did not present a favorable surgical answer to. sterility. There were relatively few pregnancies following these procedures, together with a relatively high incidence of ectopic pregnancies and other complications. Gepfert, after perfecting a new technic experimentally in the rhesus monkey, using bovine allantoic membrane as a cover for the resected fimbriated end of the tube, applied the principle in the human being. In 28 cases in which the procedure was done, 3 pregnancies occurred with only one normal term infant. This gives an 8.7 per cent successful result as From the Department of Obstetrics and Gynecology, Jefferson Medical College and Hospital. We wish to acknowledge a grant from the Special Gynecological and Obstetrical Fund under the supervision of the Head of the Department of Obstetrics and Gynecology and Director of the Division of Gynecology, Dr. Lewis C. Scheffey, which made this experiment possible. 435

2 436 CASTALLO [Fertility & Sterility compared with Greenhill's national survey of tubal plastic surgery, which was 6.6 per cent (818 operations and 54 pregnancies), while Snaith reports 21 cases with 13 fully patent tubes. Polowe, Jokob, Douay, Spangler, Solomon, and Holder and Sovak have all reported surgical procedures such as implantations of the tube into the uterus, salpingostomy, or other reconstructive surgical technics with but little success. FIGURE 1. Wire in situ after removal of middle section of tube. The same technic was used with the Polyethylene tubing. It is a clinical fact that many fallopian tubes which are closed due to an early N eisserean infection do become recanalized after a period of years, resulting in pregnancy late in the childbearing period. Habbe observed 75 cases of gonorrheal pelvic inflammatory disease not operated upon; 14 became pregnant. It was assumed by the author that a possibility existed whereby an operative procedure might be evolved to produce physiologic recanalization of the fallopian tube since the natural tendency of that organ is to re-establish its lumen.

3 Vol. I, No.5, 1950] RECANALIZATION OF FALLOPIAN TUBES 437 Davis, Strong, and Drake, both experimentally on dogs and by operations on the human, were able to re-establish the lumen in ureteropelvic and upper ureteral narrowing by simple intubated ureterotomy. Ormand and Mciver have performed similar operations. In the experiments by Davis et al. it was found that a gap made in the ureter grew over a splint tube anatomically and physiologically. The healing time was approximately four weeks. The reconstructed ureter was capable of peristalsis and it was shown that a normal peristaltic wave passed over the reconstructed portion of the ureter without any disturbance or slowing, and that an adynamic dilatation FIGURE 2. Diagrammatic drawing of Figure 1. of the ureter was not observed. Recurrences of obstruction have not been observed even in infected cases. Since the ureter and the fallopian tubes have a growth urge which is similar-the tendency to re-establish their lumina-the following experiments were performed for the purpose of observing the phenomenon. TECHNIC The fallopian tubes of medium sized, sexually mature rhesus monkeys were severed in their midportion and the resulting gap studied as to growth urge and recanalization. Each monkey weighed more than 2.5 kg. Dial anesthesia was used and no special instruments were necessary (see Figures 1, 2and 3).

4 438 CAS TALLO [Fertility & Sterility Monkey #1 An area 2 em. in length was removed from the middle portion of the right tube, and the cut edges uniformly vertically severed. Lumen of the proximal cut portion was threaded with #32 silver wire and the gap bridged to the distal portion of remaining tube. The wire was threaded through the proximal portion into the uterus. The left tube was threaded in like manner, except that the edges were cut on a bias and layers of serosa, muscularis, and mucosa were not of equal length. FIGURE 3. Diagrammatic drawing of regenerated tubes. Monkey #2 The same procedure was carried out, but the bridging material was stainless steel wire of #26 calibre. Monkey #3 The same amount of tube was removed. The gapping material on the left was #26 stainless steel wire while on the right a fine whalebone filament was used to bridge the cut edges. Monkey #4 Each tube was divided as in the foregoing experiments. The material used to bridge the gap was a synthetic plastic, Polyethylene tubing (DuPont)

5 Vol. 1, No.5, 1950] RECANALIZATION OF FALLOPIAN TUBES 439 of firie calibre, the ends of which can be fused to form a probe. As in the above. experiments, a distance of 2 em. remained between the divided ends of each tube. The entire tube was then fixed with silk sutures to its corresponding side. RESULTS After a period of four weeks a laparotomy was again done on each monkey. Monkeys #1 and #2 The operative sites were covered with omentum. After adhesions were removed the tubes were examined and it was found that each had bridged the gap of silver wire and palpation showed the wire within the lumen of the tubes. Monkey #3 (Stainless steel wire left side, whale bone filament right side.) No adhesions were encountered. The gross findings showed both gaps bridged by the tubes and palpation showed the gapping material within the lumen extending throughout the tubes. Monkey #4 As with #3, no adhesions were enco~ntered. Gaps had been bridged over the Polyethylene tubing and no point of junctions of the cut ends of the tube could be found. After the specimens were removed, with the gapping material left in situ in the tubes, the specimens were fixed, serial sections were made and studied. All specimens were sectioned transversely. HISTOLOGIC FINDINGS Routine stains were used on all sections while Masson's stain was used to bring out inflammatory cells or fibrous tissue formation. The slides were read by Dr. Joseph Stasney of the Pathological Department at Jefferson Medical College. Sections from Monkeys #1 and #2 are shown in Fig. 4. Microscopic sections of the left tube of Monkey #3 revealed moderate inflammatory cell infiltration, some fibrous tissue formation, and in the tube where the whale bone was used some destruction of the epithelium was noted. The slide showed no histological structure resembling tube.

6 440 CAS TALLO [Fertility & Sterility A B c FIGURE 4. A, Normal monkey fallopian tube. Section of normal tube shows wellpreserved mucosa forming papillary projections into the lumen. The lining epithelium is columnar in type arranged in one layer. The nuclei are near the basal membrane. The connective tissue beneath these epithelial cells consists of pale blue, loose connective tissue with few lymphocytes, eosinophiles, and polymorphonuclears. The muscularis layer and the sub-serosa show mild edema and the presence of lymphocytes and few polymorphonuclears. B, Normal monkey fallopian tube (Masson stain). The Masson's trichrome stain reveals also slight edema. The different layers of the wall appear to be regular. Sections through the distal portions of the tube show more tortuousness with increased edematous mucosal foldings. C, Experimental fallopian tube slide (wire). The transverse section of the tube reveals a patent lumen lined by one layer of tall columnar epithelial cells. The nuclei of these cells are oval and darkly stained. Occasionally, the lining epithelium forms finger-like projections into the lumen. The tissue D

7 Vol. 1, No. 5, 1950] RECANALIZATION OF FALLOPIAN TUBES 441 A section from Monkey #4 is shown in Fig. 5. No gangrene or gross hemorrhage had occurred in any of the specimens. Because of the small calibre of the materials used, anemia necrosis was not encountered. No animals were lost during the experiments and none showed morbidity. FIGURE 5. Experimental monkey tube slide (Polyethylene tubing). The lumen of the tube is patent and lined by one layer of epithelial cells. These epithelial cells are columnar with darkly stained nuclei. The submucosa shows edema and numerous lymphocytes, plasma cells, and polymorphonuclears. The Masson's trichrome stain shows slight increase of fibrillar connective tissue. The outer layers of the wall show some hyperemia and edema. SUMMARY The experiments have demonstrated: 1. That recanalization and regeneration of the fallopian tubes in monkeys will take place after intubation. beneath the epithelium consists of a loose connective tissue with a number of lymphocytes, plasma cells, and few polymorphonuclears. The outer layers of the wall show hyperemia. The lumen of the tube contains pink granular material. The Masson's trichrome stain reveals the increase of a fibrillar connective tissue. D, Experimental monkey tube slicie (wire). The lumen of the tube is patent and lined by one layer of columnar epithelial cells. The basal membrane is well preservd. The nuclei of these lining cells are stained darkly. Occasional finger-like projections into the lumen were noted. Beneath the epithelium the tissue is edematous and contains a number of lymphocytes, plasma cells, and polymorphonuclears. The outer layer of the wall shows hyperemia and edema. The Masson's trichrome stain reveals a slight increase of fibrillar connective tissue.

8 442 CASTALLO [Fertility & Sterility 2. Silver wire and steel wire filaments used in the intubation produced unsatisfactory results with inflammation, fibrosis, and adhesions, while whalebone produced fibrosis. 3. A new plastic, Polyethylene tubing (Dupont) lends itself well as an innocuous bridging agent. The possibilities of overcoming human sterility by plastic surgery on occluded fallopian tubes by this method seems favorable. REFERENCES 1. Davis, D. M., Strong, G. H., and Drake, W. M., Jr.: J. Urol. 59:851, Douay, E.: Paris med. 36:568, Greenhill, J.P.: Am. J. Obst. & Gynec. 33:39, Guppert, J. R.: Am. J. Obst. & Gynec. 45:1031, Habbe, K.: Zentralbl. f. Gewerbehyg. 44:103, Holder and Sovak: Am. J. Obst. & Gynec. 24:684, Jakob, A.: Obst. & ginec.latino-am. 2:632, Mciver, R. B.: J. Urol. 42:1069, Ormond, J. K.: J. Urol. 36:512, Polowe, D.: Am. J. Surg. 68:208, Snaith, L.: J. Obst. & Gynaec. Brit. Emp. 54:496, Solomons, B.: Surg., Gynec. & Obst. 60:352, Spangler, C. M.: S. Clin. North America 25:1345, 1945.