Complications of Tubal Reimplantation

Transcription

1 Complications of Tubal Reimplantation Report of Two Cases Herman I. Kantor, M.D., and Jack H. Kamholz, M.D. SINCE POLYETIlYLENE OBTURATORS have been introduced as an adjunct in tubal plastic surgery, the incidence of both tubal patency and pregnancy has improved significantly. In 1937, Greenhil12 collected 818 patients in whom tubal plastic procedures were performed by leading gynecologists. The incidence of 6.6 per cent pregnancies, which he reported, has been widely and discouragingly quoted. Now, at long last, it should probably be revised upward. Among patients in whom the newer surgical technics were used, pregnancy incidence as high as 30 per cent has been reported. 1 7 The over-all figure for a collected group similar to Greenhill's would probably be more encouraging than his. In many of the reports on salpingoplasty, the condition in which the tubes were found has not been specifically related to the incidence of pregnancy. Occlusion, when associated with a relatively normal tubal epithelium, is quite amenable to successful surgery. On the other hand, the tube which bears the battle scars of prolonged combat with chronic infection may he incapable of encouraging the trysting of the ovum and the sperm. Patency, the first goal of the surgeon, may be reached, while pregnancy, the only yardstick which the patient can use, remains elusive. It is recommended, therefore, that the results of surgery must be correlated with the From the Deparbnents of Obstetrics and Gynecology, Baylor and St. Paul's Hospitals, Dallas, Texas. This paper was presented at the Thirteenth Annual Meeting of the American Society for the Study of Sterility, New York, N. Y., May 81, to June 2, We wish to express our gratitude to Dr. M. H. Grossman for the tissue studies, and to Dr. Henry Ash for the animal experiments. Received for publication June 7,

2 Vol. 8, No.5, 1957 COMPLICATIONS OF TUBAL REIMPLANTATION 439 tubal epithelium as noted grossly or by tissue examination. It seems plausible that this approach may clarify some of the differences in the incidence of patency and pregnancy. POLYETHYLENE Polyethylene is a polymer of paraffin wax which is unusually resistant to chemical action. 8 Because of its low melting point, cold sterilization is preferred. The recommended method, which we use, is to soak the material in 1: 1000 Zephiran chloride for at least 2 hours. Before surgery, it is rinsed in sterile normal saline. Reactions to polyethylene have been studied rather extensively in animals and man. 3,4 The tissues are not usually irritated by the pure material,5,9 and it has, therefore, assumed an important role as an obturator in tubal plastic procedures. However, some degree of inflammatory reaction follows any tubal surgery, and it is not prevented by antibiotics or polyethylene. 1 The newer technics in salpingoplasty usually include these obturators as an integral part of the procedure. The increased occurrence of pregnancy may further justify this popularity. Therefore, it seems judicious to report the complications of these operations as they are encountered. Only in this manner may they be anticipated, treated, or avoided. CASE REPORTS Case 1: Foreign-Body Reaction to Polyethylene with Formation of a Sterile Abscess Mrs. P. G., a 30-year-old nulligravida of Latin-American extraction, complained of infertility for 2 years. Pertinent in her past history was an attack of salpingitis "years ago," which had responded completely to biotherapy. There were no recurrences. A complete infertility investigation revealed only occlusion of the cornual portions of both tubes. They could not be visualized by hysterosalpinography on two occasions. During repeated attempts at insuffiation with carbon dioxide, the obstruction was not relieved even with a pressure of 250 mm. Hg. On June 19, 1956, salpingoplasty was performed. The uterus, tubes, and ovaries appeared to be grossly normal. Bilateral tubal patency, almost to the cornua, was demonstrated by the passage of air from the fimbrial portion and gentle probing. The uterine ends of the tubes, however, presented a solid obstruction. These were excised with a large cork borer, and reimplantation over polyethylene obturators was carried out. The polyethylene was fixed at the fimbriated end of the tube and at the cervix with chromic catgut.

3 440 KANTOR & KAMHOLZ Fertility & Sterility The postoperative course was afebrile, and the patient was discharged from the hospital in 8 days. The polyethylene was to be left in place for 5 to 6 weeks. During the second and third postoperative weeks, the patient complained of minor abdominal discomfort which was within the limit of expectation. Examination confirmed the location of the catheters to be satisfactory, and the slight adnexal thickening and tenderness were not unusual. During the fourth week she exhibited more abdominal tenderness and her temperature rose to 102 F. The patient was hospitalized because parametritis or salpingitis was suspected. However, the response to antibiotics was prompt, and she was discharged after several days. During the sixth week, one of the polyethylene tubes came out and the other was removed without difficulty. On August 27, 1956, the tenth week after surgery, tubal insufflation revealed bilateral patency at 40 mm. Hg. Complaints of occasional abdominal pains, more in the right lower quadrant, were registered. The adnexal areas were still thickened and tender. Since her general condition was satisfactory, restrictions against pregnancy were withdrawn. The patient's third period after surgery began on September 15, and it was accompanied by intense abdominal pain. On the following day she fainted, but these symptoms were all attributed by her to a "severe menstrual period." When the pain did not subside, she reported for examination on September 18. The patient appeared acutely ill, although she had no fever. Her blood pressure was 110/60, and her hemoglobin was unchanged from previous studies. Pelvic examination revealed an exquisitely tender, orange-sized mass in the right adnexal area. The hospital admitting diagnosis was ectopic pregnancy or hematosalpinx due to retrograde menstruation. After 3 days, during which the signs and symptoms persisted, exploration was carried out. The mass was formed by an abscess involving mainly the right ovary and tube (Fig. 1). The omentum, the appendix, and a loop of ileum were included in the wall of the abscess. On the left side there were numerous adhesions between fhe tube, the omentum, the uterus, and the broad ligament. These were not grossly involved in the inflammatory process, and the adhesions were therefore not disturbed. The large amount of induration and the impairment of the blood supply made salvage of the right tube and ovary impractical. They were removed with the appendix and the involved portion of the omentum. The postoperative course was satisfactory and no difficulties have been encountered since. Tubal insufflation 3 and 4 months later have proved patency of the left tube. It is hoped, therefore, that the patient's desire for motherhood may yet surmount this unhappy complication. Comment. Tissue studies indicated that this syndrome was unusual, and not explained by either simple tubal infection or retrograde menstruation. The acute and chronic infection of the tube and ovary as well as the peri-

4 Vol. 8, No.5, 1957 COMPLICATIONS OF TUBAL REIMPLANTATION 441 OI'fEIYTv l'1 - -I/PPEIVDIX- - j'./iill OF" 1/65( lE/'/SE f!in!r:;,or/s ;Yr. TV Fig. 1. Findings at surgery, Case 1. appendicitis were anticipated. However, the abscess wall presented evidence of extensive foreign-body reaction. Many typical giant cells were found. Cultures from the abscess remained sterile. Specially stained preparations revealed no organisms. It seems probable, therefore, that this sequence represents a foreign-body reaction to the polyethylene obturator. On the left side it resulted in excessive adhesion formation. On the right side, it gradually progressed to result in impairment of the circulation to the tube and ovary, with the formation of a sterile abscess. The delay of 3 months may perhaps be explained by the gradual nature of the fibrous tissue response. The purity of the polyethylene as well as the technic of sterilization were unimpeachable. A somewhat similar tissue reaction was noted in one of our animal experiments from another investigation. 6 A piece of polyethyl~ne tubing, sterilized and prepared in the usual manner, was embedded in the subcutaneous tissues of a dog. After 2 months the entire area was removed for microscopic study. Sections demonstrated a typical foreign-body reaction with the formation of micro~copic sterile abscesses. Case 2: Rupture of the Uterus at the Site of Tubal Reimplantation Mrs. W. R., age 22, was found to have bilateral cornual occlusion as the only demonstrable etiologic factor responsible for her infertility. Multiple insuillations

5 442 KANTOR & KAMHOLZ Fertility & Sterility were unsuccessful, and the tubes were not visualized by hysterosalpinography. The cause for the occlusion was attributed to old infection, and this was later confinned by tissue examination. On September 27, 1955, salpingoplasty was perfonned. The obstructed cornual portions of the tubes were excised with a fine scalpel. The remaining portions, which appeared grossly nonnal, were reimplanted into the uterus over polyethylene obturators. The cut edges of the uterus were then approximated in the usual manner. The obturators were fixed at the fimbria and the cervix, and were removed 8 weeks later. Incidentally, the polyethylene tubes did not interfere with the two nonnal menstrual periods which occurred while they were in place. Insufflation following the November period was successful. After an initial rise to 170 mm. Hg. patency was demonstrated bilaterally at 80 mm. Pregnancy was achieved in this same cycle, and the patient's E.D.C. was August 31, Except for a minor attack of gastroenteritis, the pregnancy was entirely nonnal. It was reasoned that since the postoperative course was afebrile and uneventful, the pelvis quite adequate, and the baby not unusually large, vaginal delivery should be planned. Fig. 2. Findings at surgery, Case 2.

6 Vol. 8. No COMPLICATIONS OF TUBAL REIMPLANTATION 443 On August 17, 2 weeks before estimated term, the patient was awakened with severe, steady abdominal pain. She also felt quite weak. She was sent to the hospital and arrived in mild shock which increased steadily. The abdominal rigidity and the absent fetal heart tones further pointed to the diagnosis of placental separation or uterine rupture. The patient was immediately transferred to the operating room where a transfusion of Group a Rh-negative blood was started and the abdomen was opened. Approximately 1500 cc. of free blood, both fresh and with clots, were found. The uterus had ruptured across the fundus beginning at the area of the reimplantation of the right tube (Fig. 2). About one third of the placenta was extruded through this rent. The left side appeared to be in good condition. In order to avoid the region of the tubes, a low classical incision was made, and a stillborn fetus and the placenta were removed. The uterine openings were then carefully repaired, and the abdomen was closed. Following an uneventful postoperative course the patient was discharged on the seventh day. Insuffiation subsequently showed patency of the left tube at 100 mm. Hg. It is hoped that pregnancy with a more successful outcome will follow shortly. Postpartum examination of the fetus revealed no abnormalities, and the cause of death was listed as anoxia. SUMMARY 1. The results of salpingoplasties may be evaluated better if they are reported in relation to the condition of the tubes at the time of surgery. 2. With the use of polyethylene obturators, the success of tubal plastic procedures is improving. 3. With this improvement an increasing number of complications may be anticipated. 4. Two complications of tubal reimplantation have been reported. 5. Consideration should be given to abdominal delivery for patients who achieve pregnancy following tubal reimplantation Maple Ave. Dalla.Y, Texas REFERENCES 1. ANDREWS, M. C., and ANDREWS, W. C. Am.]. Obst. & Gynec. 70: 1232, GREENHILL, J. P. Am. J. Obst. & Gynee. 88:39, GRINDLEY, J. H. Surgery 24:22, GRINDLEY, J. H., and MANN, F. C. Arch. Surg. 56:794, INGRAHAM, F. D., ALEXANDER, E., JR., and MATSON, D. D. New England ]. Med. 286:362, KANTOR, H. I., and KAMHOLZ, J. H. Investigation now in progress. 7. MULLIGAN, W. J., ROCK, J., and EASTERDAY, C. L. Fertil. & Stenl. 4:428, SCHLUMBERGER, F. C., and RIPASE'ITI, P. P. ]. Ural. 68:158, YEAGER, G. H., and COWLEY, R. A. Ann. Surg. 128:509, 1948.