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Conservative Tubal Surgery in Ectopic Pregnancy
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Conservative Tubal Surgery in Ectopic Pregnancy David J. Wexler, M.D., Anthony Kohn, M.D., and Charles H. Birnberg, M.D.
SALPINGECTOMY, with or without oophorectomy, has long been the traditional operation in tubal pregnancy, and in most cases is the wisest method of treatment. Some authors take the position that not only should the affected tube be removed but, in order to prevent the possibility of a second ectopic pregnancy, the other tube should also be removed, or at least occluded. Two go so far as to state: "Surely in the presence of a damaged residual tube sterility seems better than the increased risk of a repeated ectopic pregnancyY The reason cited is a recurrence rate of 14.3 per centa figure, incidentally, much higher than that of seven other authors quoted in this same report-between 1.7 and 6.6 per cent. In women who have children, removal of a residual tube for ectopic pregnancy may make good sense. In the nullipara, however, pregnancy in a remaining tube is catastrophic. Salpingectomy removes the last possibility of such a conception, with its resulting psychologic trauma. This report concerns the residual tube, and the possibility of a subsequent tubal pregnancy where the contralateral tube has been previously or concurrently removed because of irremediable pathology. The larger topic
From the Surgical Service, Southside Hospital, Bay Shore, N. Y., and the Female Sex Endocrine Clinic, Jewish Hospital, Brooklyn, N. Y. Presented on the scientific program of the Eleventh Annual Meeting of the American Society for the Study of Sterility, Atlantic City, N. J., June 4-5, 1955. Thanks are due Dr. Miguel Nadal of Brentwood, New York, and Dr. Theodore Fried of Lake Ronkonkoma, New York, for help in translating, respectively, the Spanish, and the French, German and Hungarian references. 241
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of whether to conserve the pregnant tube where the opposite tube remains is beyond the scope of this presentation. Technically, of course, the easiest procedure is to perform salpingectomy or salpingo-oophorectomy. The question arises, then, of whether it is feasible to save the tube and give the woman another chance at pregnancy, or whether the technical hazards or the incidence of repeated tubal pregnancy are too great to warrant the risk.
REPORTS ON MANAGEMENT AND OUTCOME There is little in the American literature on this topic. Priddle et al. mention 8 cases of second ectopic pregnancy in the remaining tube in 4 of whom evacuation of the pregnancy and salpingostomy were done. The subsequent course of these cases, however, is not indicated. Rubin clearly takes the same general position that we advocate. He states: "... In cases of repeated ectopic pregnancy, where the patient is anxious to have a child and is willing to risk a third ectopic pregnancy, a partial salpingectomy with a plastic operation on the tube stump may be performed .... The feasibility and value of this procedure await future experience. Newer developments in suture material may prove beneficial." In this connection the linear salpingostomy of Israel and the use of cortisone by Kurzrok may prove valuable. In the foreign literature, the report of Gauss in 1941 mentions Ott as the first to advocate a conservative approach to tubal pregnancy in 1889, although Callier gives priority to M uret (1893). According to Gauss, Ott was followed by Muret, in Strasburg; Prochownic (1894); Martin (1897); Strasmann (1902); Winkel (1904); Mitteilung (1913); and Mangiagalli (1921); the details of their contributions are in some cases somewhat hazy. Gauss reported 27 conservative operations out of 161 ectopics of his own in 1941, none of which were followed by pregnancy (Table 1). Callier in 1941 reported to the Vienna Gynecological Society on 10 cases; 4 of these patients subsequently had an intrauterine pregnancy, and 1 had another tubal pregnancy. Seguy in 1947 reported 3 cases, in only 1 of which had the contralateral tube previously been removed. This patient subsequently had a normal pregnancy. One patient whose right tube was normal and whose left tube was operated on conservatively for ectopic subsequently had 2 normal pregnancies. He quotes a Dr. Gordard, who reported a subsequent normal
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pregnancy after a conservative ectopic operation, but details are lacking. In 1951 Ludwig reported 1 repeat ectopic and 1 nonnal pregnancy out of 2 cases conservatively managed, where the opposite tube had previously been removed. TABLE 1.
Reported Cases of Conservative Operation on Pregnancy in a Residual Tube
Uterine preg.
Tubal preg.
27 Gauss, 1941 1 Martin, 1897a 3 Mitteilung, 1913a Mangiagalli, 1921 a 13 10 Caffier, 1941
0 1 2 4 4
0
Prochownic b Newmanb Seguy,1947 Gordard c Ludwig, 1951 Szendi, 1953 Jauchd
1 1 1 1 2 15 1
1 1 1 1 1 2 1
Graham, 1954
1
1
2 79
1 21
Author and date
Wexler, Kohn, & Birnberg,1956 TOTALS
No. cases
1
Notes
5 not pregnant 1 tubal pregnancy 1 abortion (criminal) 3 uterine pregnancies; 2 to term, 1 miscarried; each also had 1 abortion
1 1 This patient had 2 normal pregnancies and then another ectopic This patient had an ectopic on right and later on left, both conservative operations, later had living baby 1 patient had 2 normal pregnancies after operation 3
Other cases are cited by several of the above authors which are here omitted since, although a conservative operation was done, there is no specific mention of the absence of the opposite tube. a Quoted by Gauss. b Quoted by Caffier. o Quoted by Seguy. a Quoted by Szendi.
Szendi in 1953 reported on 15 cases of pregnancy in a residual tube resulting in 2 nonnal pregnancies and 1 ectopic. Graham reports 3 cases, in only 1 of which had the other tube previously been removed. This case resulted in a normal pregnancy.
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It is difficult to determine in some of these reports whether the authors are reporting all their cases or only their successful cases. It is probable that many cases of this type have been salvaged by different operators, but it seems odd that so few cases have been reported, especially in American periodicals. Table 1 shows a total of 79 conservatively managed cases of pregnancy in a residual tube which were found after intensive search of the literature, of which 21 had 1 or more subsequent normal pregnancies.
Incidence of Repeated Ectopic Pregnancy Table 2 summarizes those cases where the descriptions are clear and complete enough to tabulate in terms of percentages. Out of 45 cases, 15 (33.3 per cent) had 1 or more intrauterine pregnancies and 2 (4.4 per TABLE 2.
Pregnancies in Reported Cases Complete Enough to Tabulate
Author
Mitteilung Mangiagalli Caffier Seguy Szendi Graham Wexler et al. TOTALS
No. cases
3 13 10
1 15 1 2 45
Uterine preg.
2 4 4 1 2 1 1 15 (33.3%)
Tubal preg.
1
1
2 (4.4% )
cent) had a second ectopic pregnancy. It is significant that when these figures are compared with Table 1 (in which all reported cases are included, although some of them may represent only the successful, rather than all, cases of the author) the percentages are very similar (26.6 per cent pregnancies as against 33.3 per cent, and 3.8 per cent ectopics as against 4.4 per cent). Perhaps of even more importance is the fact that the figures for repeated ectopic pregnancy generally are almost identical. In other words, the incidence of repeated ectopics in the conservatively treated residual tubes is no greater than in the average postectopic residual tube. Type of Conservative Operation The type of conservative operation performed is of some interest. One
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must admire the daring of the earlier surgeons who, without our modern resources of limitless transfusions and antibiotics, operated on some of these undoubtedly dangerously ill patients with such apparent good results. In most instances where the tube was unruptured, a linear incision with removal of the products of conception, and resuture in one or two layers. was employed. If the pregnancy was at the ampullar end, some expressed the products manually with or without accompanying curettage of the tube. Where the pregnancy had ruptured the tube the torn edges were debrided and sutured in layers, or the edges were tied back as in the case to be reported. Most of the writers comment on the ease and completeness of hemostasis after the products of conception have been removed. It would seem that suturing the incision would predispose to scar-tissue formation and the resultant narrowing of the lumen which might favor another tubal pregnancy. Yet Caffier reported a case which, on reoperation, showed no contracture at the site on gross or histologic examination. Needless to say, in any procedure of this sort the patient's condition must be stabilized and adequate blood available.
CASE REPORTS
Case 1 P.S.," aged 27, had been married for 2 years; menses had been regular and there was no history of previous operations, pregnancy, or pelvic inflammation. She was operated on December 8, 1950, for ectopic pregnancy. At operation the peritoneal cavity was filled with old and fresh blood. There was a mass of blood clot in the right adnexal region. The distal end of the right tube was dilated, and there was a recent 3~-inch laceration along its ventral surface extending proximally from the fimbriated end, the site of rupture, with some active bleeding. The uterus was soft and enlarged to about the size of a 6-weeks' gestation. The left adnexal region was the site of a hopelessly tangled mass; the left ovary was replaced by a large endometrial cyst and was firmly adherent to the tube, both being peppered with endometrial implants. The entire tubo-ovarian mass was adherent to the left broad ligament (Fig. 1). The right tube, outside of the rupture site, appeared grossly normal. It was decided to perform left salpingo-oophorectomy and a conservative procedure on the right tube. Bleeding was controlled by fine silk ligatures. The fimbriae and the torn edges of the right tube were turned back and tied with fine silk (Fig. 2), in effect creating a linear salpingostomy. Salpingo-oophorectomy was then carried out on the left. Convalescence was uneventful and the patient was discharged on December 15, 1950.
* Referred by Dr. Herman LeBow of Bayport.
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One week later tubal insufHation done at the office showed patency at between 50 and 100 mm. Hg after initial resistance at 150 mm. Hg had been overcome. Tubal insufHation was repeated at 1- or 2-week intervals after that, the last graph
2 Fig. 1. Case 1. Appearance of tubes and ovaries at operation. Note tuba-ovarian mass on left and ampullar rupture on right. Fig. 2. Operation completed, residual right tube.
on February 13, 1951, showing normal tubal peristalSis maintained at between 50 and 100 mm. Hg (Fig. 3). In January, 1953, the patient conceived, and after an uneventful pregnancy was delivered of a normal infant on October 19, 1953. One year later she again conceived; she is now well along in an uneventful pregnancy.*
Case 2 C. S., age 29, was first seen in November, 1947, as a sterility case, having been married 4 years. There was a history of a neisserian infection 3 years before marriage. One year after marriage she became pregnant but aborted at 3 months.
* Normal spontaneous delivery of 7 lb. 5 oz. male child on August 20, 1955.
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A hyste~osalpingogram showed bilateral fimbrial closure; repeated CO 2 insuffiation tests were all negative. Two years later, on August 7, 1949, she was operated on by another surgeon for a right tubal abortion. The operative note reported resection of the right tube proximal to site of implantation. The left tube and ovary were buried in fine adhesions in the cul-de-sac; they appeared grossly normal after being freed from the adhesions. Convalescence was uneventful. Insuffiation
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Insufflation graphs showing initial breakthrough at 150-160 mm. Hg and normal tubal peristalsis at 50-100 mm. Hg.
tests on August 25, 1949 (27f weeks after operation), and thereafter were persistently negative. Two-and-one"half years later, on Apr. 28, 1952, she was again seen by us with a diagnosis of ectopic pregnancy. At operation a tubal abortion was found in the left tube. There was a circular constriction in the midportion of the tube. A linear salpingostomy beginning at the fimbriae and extending Jf inch proximal to the constriction was performed, leaving about 1 inch of apparently normal tube extending to the cornu. The stump of the right tube remaining after
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her first operation was then opened and the flaps pinned back with fine silk. Convalescence was uneventful. Insufflation tests 2 weeks after operation, and subsequently, remained persistently negative. In any future case, insufflation would be undertakenimmediately postoperatively, as recommended by Weisman.
DISCUSSION A study of the tables strengthens our conviction that a woman who has had a conservative operation for pregnancy in a residual tube does not run any greater risk of having another ectopic than she did before the first ectopic pregnancy. As a matter of fact, although the total number of collected cases is small, it seems that such a woman has approximately a 7-to-l chance, if she does conceive, of a normal rather than an ectopic pregnancy. If the woman desires children and is willing to accept this risk, small as it is, the surgeon should make every effort to salvage the remaining tube. These tubes, although often the site of disease, may be normal anatomically and physiologically. Figure 3 (Case 1) indicates normal tubal physiology; this probably accounts for the successful outcome. The prognosis in Case 2, on the other hand, is poor. The probability of a subsequent normal pregnancy, in view of the negative insufflation tests and past history of salpingitis, is slight for this patient. However, as long as she retains even a damaged fallopian tube, the possibility exists that some development in the future might restore it sufficiently to permit a normal pregnancy. Other more seemingly hopeless problems in medicine have been conquered in the past. Certainly most of these women who desire a child would want the psychologic prop of knowing that they retain at least the possibility of pregnancy, however slight, rather than face a future of certain barrenness. CONCLUSIONS 1. The value of conservative tubal surgery in a residual tube has been discussed. 2. The literature of conservative surgery under these conditions has been reviewed. 3. Study of the collected cases indicates that a woman who has had a conservative operation for pregnancy in a residual tube does not run any greater risk of having another ectopic than she did before the ectopic pregnancy, for which a tube was removed.
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4. Two cases are reported of conservatively managed tubal pregnancy. One of these resulted in two subsequent normal pregnancies; the other to date has remained sterile.
111 Carlton Ave. Islip Terrace, N. Y. REFERENCES 1. COOK, D. G., and BUTT, J. A. Hysterosalpingography studies following ectopic pregnancy. Am. I. Obst. & Gynec. 66:626, 1953. 2. PRIDDLE, H. D., MOULTON, C. W., and DENNIS, M. S. Ectopic pregnancy. Am. I. Obst. & Gynec. 64:1093, 1952. 3. RUBIN,1. C. Uterotubal Insufflation. St. Louis, Mo., Mosby, 1947, pp. 226-42. 4. ISRAEL, S. L. Total linear salpingostomy: Clinical and experimental observations. Fertil. & Steril. 2:505, 1951. 5. KURZROK, L., and STREIM, E. Cortogen treatment for sterility due to nonpatent tubes. Fertil. & Steril. 5:515, 1954. 6. GAUSS, C. J. Erhaltung der Tube bei Tubargraviditat. Wien. klin. Wchnschr. 54:877, 1941. 7. CAFFIER, P. Die Konservative Operation des Schwangeren Eileiters. Arch. Gyniik. 173:261,1941. 8. SEGUY, J. Ectopic pregnancy treated by enucleation of ovum with conservation of fallopian tube. Gynec. et obst. 46:244, 1947. 9. LUDWIG, F. Preservation of fallopian tube in surgical therapy of tubal pregnancy. Gynaecologia 131 :379, 1951. 10. SZENDI, B. Adatok A Tubaris Terhessegek Konservativ, A Kurtat VisszahagyoMuteteinek Jogassagahoz. Magyar Noor. Lap. 16:182, 1953. 11. GRAHAM, J. C. Terapeutica quirurgica conservadora en el embarazo tubario. Rev. med. Hosp. gen. Mexico 8:45, 1954. 12. WEISMAN, A. 1. Rapidity of human fallopian tube wound healing as cause for poor results from reparative tubal surgery. Am. I. Surg. 82:278, 1951.
DISCUSSION Philadelphia, Pa.: Any surgical procedure that is conservative both as to physiology and anatomy is and will be sought by gynecologists who deal with the infertile patient. The authors are to be congratulated on bringing to our attention these most interesting cases and their management. The fear of allowing a damaged fallopian tube to remain in situ has been with us for many years. Not until Israel's paper of 4 years ago did we even think of tubal salvage by linear salpingostomy. That tubal continuity and tubal ability to transport an ovum could be regained after salpingostomy was indeed revealing to us all. And now the authors show that normal pregnancies can take place seven times more often than a repeat ectopic can be expected. This gives new hope to the patient with ectopic pregnancies. However, the academic question as to the basic cause for the ectopic pregnancy remains unanswered. If the basic reason is tubal infection of specific origin will the results be as good? If the fertilized ovum DR. A. H.
MARBACH,
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remains in a tube because of a spasm and the ectopic ensues, will the result be better? It is our considered opinion that in the latter instance there will be a better anatomic and phYSiologic result. Then if the emotional cause for the tubal spasm be learned· the functional result ( pregnancy) will be as desired and become intrauterine. The authors give us diagnosis and surgical management of their cases. Perhaps the dangers of further ectopic pregnancies in these patients can be obviated by a better understanding of the "functional spasms" in fallopian tubes. Up to now we have been wondering and studying-can the unconscious hold the answer?
r
Conservative Tubal Surgery in Ectopic Pregnancy David J. Wexler, M.D., Anthony Kohn, M.D., and Charles H. Birnberg, M.D.
SALPINGECTOMY, with or without oophorectomy, has long been the traditional operation in tubal pregnancy, and in most cases is the wisest method of treatment. Some authors take the position that not only should the affected tube be removed but, in order to prevent the possibility of a second ectopic pregnancy, the other tube should also be removed, or at least occluded. Two go so far as to state: "Surely in the presence of a damaged residual tube sterility seems better than the increased risk of a repeated ectopic pregnancyY The reason cited is a recurrence rate of 14.3 per centa figure, incidentally, much higher than that of seven other authors quoted in this same report-between 1.7 and 6.6 per cent. In women who have children, removal of a residual tube for ectopic pregnancy may make good sense. In the nullipara, however, pregnancy in a remaining tube is catastrophic. Salpingectomy removes the last possibility of such a conception, with its resulting psychologic trauma. This report concerns the residual tube, and the possibility of a subsequent tubal pregnancy where the contralateral tube has been previously or concurrently removed because of irremediable pathology. The larger topic
From the Surgical Service, Southside Hospital, Bay Shore, N. Y., and the Female Sex Endocrine Clinic, Jewish Hospital, Brooklyn, N. Y. Presented on the scientific program of the Eleventh Annual Meeting of the American Society for the Study of Sterility, Atlantic City, N. J., June 4-5, 1955. Thanks are due Dr. Miguel Nadal of Brentwood, New York, and Dr. Theodore Fried of Lake Ronkonkoma, New York, for help in translating, respectively, the Spanish, and the French, German and Hungarian references. 241
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of whether to conserve the pregnant tube where the opposite tube remains is beyond the scope of this presentation. Technically, of course, the easiest procedure is to perform salpingectomy or salpingo-oophorectomy. The question arises, then, of whether it is feasible to save the tube and give the woman another chance at pregnancy, or whether the technical hazards or the incidence of repeated tubal pregnancy are too great to warrant the risk.
REPORTS ON MANAGEMENT AND OUTCOME There is little in the American literature on this topic. Priddle et al. mention 8 cases of second ectopic pregnancy in the remaining tube in 4 of whom evacuation of the pregnancy and salpingostomy were done. The subsequent course of these cases, however, is not indicated. Rubin clearly takes the same general position that we advocate. He states: "... In cases of repeated ectopic pregnancy, where the patient is anxious to have a child and is willing to risk a third ectopic pregnancy, a partial salpingectomy with a plastic operation on the tube stump may be performed .... The feasibility and value of this procedure await future experience. Newer developments in suture material may prove beneficial." In this connection the linear salpingostomy of Israel and the use of cortisone by Kurzrok may prove valuable. In the foreign literature, the report of Gauss in 1941 mentions Ott as the first to advocate a conservative approach to tubal pregnancy in 1889, although Callier gives priority to M uret (1893). According to Gauss, Ott was followed by Muret, in Strasburg; Prochownic (1894); Martin (1897); Strasmann (1902); Winkel (1904); Mitteilung (1913); and Mangiagalli (1921); the details of their contributions are in some cases somewhat hazy. Gauss reported 27 conservative operations out of 161 ectopics of his own in 1941, none of which were followed by pregnancy (Table 1). Callier in 1941 reported to the Vienna Gynecological Society on 10 cases; 4 of these patients subsequently had an intrauterine pregnancy, and 1 had another tubal pregnancy. Seguy in 1947 reported 3 cases, in only 1 of which had the contralateral tube previously been removed. This patient subsequently had a normal pregnancy. One patient whose right tube was normal and whose left tube was operated on conservatively for ectopic subsequently had 2 normal pregnancies. He quotes a Dr. Gordard, who reported a subsequent normal
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pregnancy after a conservative ectopic operation, but details are lacking. In 1951 Ludwig reported 1 repeat ectopic and 1 nonnal pregnancy out of 2 cases conservatively managed, where the opposite tube had previously been removed. TABLE 1.
Reported Cases of Conservative Operation on Pregnancy in a Residual Tube
Uterine preg.
Tubal preg.
27 Gauss, 1941 1 Martin, 1897a 3 Mitteilung, 1913a Mangiagalli, 1921 a 13 10 Caffier, 1941
0 1 2 4 4
0
Prochownic b Newmanb Seguy,1947 Gordard c Ludwig, 1951 Szendi, 1953 Jauchd
1 1 1 1 2 15 1
1 1 1 1 1 2 1
Graham, 1954
1
1
2 79
1 21
Author and date
Wexler, Kohn, & Birnberg,1956 TOTALS
No. cases
1
Notes
5 not pregnant 1 tubal pregnancy 1 abortion (criminal) 3 uterine pregnancies; 2 to term, 1 miscarried; each also had 1 abortion
1 1 This patient had 2 normal pregnancies and then another ectopic This patient had an ectopic on right and later on left, both conservative operations, later had living baby 1 patient had 2 normal pregnancies after operation 3
Other cases are cited by several of the above authors which are here omitted since, although a conservative operation was done, there is no specific mention of the absence of the opposite tube. a Quoted by Gauss. b Quoted by Caffier. o Quoted by Seguy. a Quoted by Szendi.
Szendi in 1953 reported on 15 cases of pregnancy in a residual tube resulting in 2 nonnal pregnancies and 1 ectopic. Graham reports 3 cases, in only 1 of which had the other tube previously been removed. This case resulted in a normal pregnancy.
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It is difficult to determine in some of these reports whether the authors are reporting all their cases or only their successful cases. It is probable that many cases of this type have been salvaged by different operators, but it seems odd that so few cases have been reported, especially in American periodicals. Table 1 shows a total of 79 conservatively managed cases of pregnancy in a residual tube which were found after intensive search of the literature, of which 21 had 1 or more subsequent normal pregnancies.
Incidence of Repeated Ectopic Pregnancy Table 2 summarizes those cases where the descriptions are clear and complete enough to tabulate in terms of percentages. Out of 45 cases, 15 (33.3 per cent) had 1 or more intrauterine pregnancies and 2 (4.4 per TABLE 2.
Pregnancies in Reported Cases Complete Enough to Tabulate
Author
Mitteilung Mangiagalli Caffier Seguy Szendi Graham Wexler et al. TOTALS
No. cases
3 13 10
1 15 1 2 45
Uterine preg.
2 4 4 1 2 1 1 15 (33.3%)
Tubal preg.
1
1
2 (4.4% )
cent) had a second ectopic pregnancy. It is significant that when these figures are compared with Table 1 (in which all reported cases are included, although some of them may represent only the successful, rather than all, cases of the author) the percentages are very similar (26.6 per cent pregnancies as against 33.3 per cent, and 3.8 per cent ectopics as against 4.4 per cent). Perhaps of even more importance is the fact that the figures for repeated ectopic pregnancy generally are almost identical. In other words, the incidence of repeated ectopics in the conservatively treated residual tubes is no greater than in the average postectopic residual tube. Type of Conservative Operation The type of conservative operation performed is of some interest. One
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must admire the daring of the earlier surgeons who, without our modern resources of limitless transfusions and antibiotics, operated on some of these undoubtedly dangerously ill patients with such apparent good results. In most instances where the tube was unruptured, a linear incision with removal of the products of conception, and resuture in one or two layers. was employed. If the pregnancy was at the ampullar end, some expressed the products manually with or without accompanying curettage of the tube. Where the pregnancy had ruptured the tube the torn edges were debrided and sutured in layers, or the edges were tied back as in the case to be reported. Most of the writers comment on the ease and completeness of hemostasis after the products of conception have been removed. It would seem that suturing the incision would predispose to scar-tissue formation and the resultant narrowing of the lumen which might favor another tubal pregnancy. Yet Caffier reported a case which, on reoperation, showed no contracture at the site on gross or histologic examination. Needless to say, in any procedure of this sort the patient's condition must be stabilized and adequate blood available.
CASE REPORTS
Case 1 P.S.," aged 27, had been married for 2 years; menses had been regular and there was no history of previous operations, pregnancy, or pelvic inflammation. She was operated on December 8, 1950, for ectopic pregnancy. At operation the peritoneal cavity was filled with old and fresh blood. There was a mass of blood clot in the right adnexal region. The distal end of the right tube was dilated, and there was a recent 3~-inch laceration along its ventral surface extending proximally from the fimbriated end, the site of rupture, with some active bleeding. The uterus was soft and enlarged to about the size of a 6-weeks' gestation. The left adnexal region was the site of a hopelessly tangled mass; the left ovary was replaced by a large endometrial cyst and was firmly adherent to the tube, both being peppered with endometrial implants. The entire tubo-ovarian mass was adherent to the left broad ligament (Fig. 1). The right tube, outside of the rupture site, appeared grossly normal. It was decided to perform left salpingo-oophorectomy and a conservative procedure on the right tube. Bleeding was controlled by fine silk ligatures. The fimbriae and the torn edges of the right tube were turned back and tied with fine silk (Fig. 2), in effect creating a linear salpingostomy. Salpingo-oophorectomy was then carried out on the left. Convalescence was uneventful and the patient was discharged on December 15, 1950.
* Referred by Dr. Herman LeBow of Bayport.
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One week later tubal insufHation done at the office showed patency at between 50 and 100 mm. Hg after initial resistance at 150 mm. Hg had been overcome. Tubal insufHation was repeated at 1- or 2-week intervals after that, the last graph
2 Fig. 1. Case 1. Appearance of tubes and ovaries at operation. Note tuba-ovarian mass on left and ampullar rupture on right. Fig. 2. Operation completed, residual right tube.
on February 13, 1951, showing normal tubal peristalSis maintained at between 50 and 100 mm. Hg (Fig. 3). In January, 1953, the patient conceived, and after an uneventful pregnancy was delivered of a normal infant on October 19, 1953. One year later she again conceived; she is now well along in an uneventful pregnancy.*
Case 2 C. S., age 29, was first seen in November, 1947, as a sterility case, having been married 4 years. There was a history of a neisserian infection 3 years before marriage. One year after marriage she became pregnant but aborted at 3 months.
* Normal spontaneous delivery of 7 lb. 5 oz. male child on August 20, 1955.
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A hyste~osalpingogram showed bilateral fimbrial closure; repeated CO 2 insuffiation tests were all negative. Two years later, on August 7, 1949, she was operated on by another surgeon for a right tubal abortion. The operative note reported resection of the right tube proximal to site of implantation. The left tube and ovary were buried in fine adhesions in the cul-de-sac; they appeared grossly normal after being freed from the adhesions. Convalescence was uneventful. Insuffiation
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tests on August 25, 1949 (27f weeks after operation), and thereafter were persistently negative. Two-and-one"half years later, on Apr. 28, 1952, she was again seen by us with a diagnosis of ectopic pregnancy. At operation a tubal abortion was found in the left tube. There was a circular constriction in the midportion of the tube. A linear salpingostomy beginning at the fimbriae and extending Jf inch proximal to the constriction was performed, leaving about 1 inch of apparently normal tube extending to the cornu. The stump of the right tube remaining after
248
WEXLER ET At.
Fertility & Sterility
her first operation was then opened and the flaps pinned back with fine silk. Convalescence was uneventful. Insufflation tests 2 weeks after operation, and subsequently, remained persistently negative. In any future case, insufflation would be undertakenimmediately postoperatively, as recommended by Weisman.
DISCUSSION A study of the tables strengthens our conviction that a woman who has had a conservative operation for pregnancy in a residual tube does not run any greater risk of having another ectopic than she did before the first ectopic pregnancy. As a matter of fact, although the total number of collected cases is small, it seems that such a woman has approximately a 7-to-l chance, if she does conceive, of a normal rather than an ectopic pregnancy. If the woman desires children and is willing to accept this risk, small as it is, the surgeon should make every effort to salvage the remaining tube. These tubes, although often the site of disease, may be normal anatomically and physiologically. Figure 3 (Case 1) indicates normal tubal physiology; this probably accounts for the successful outcome. The prognosis in Case 2, on the other hand, is poor. The probability of a subsequent normal pregnancy, in view of the negative insufflation tests and past history of salpingitis, is slight for this patient. However, as long as she retains even a damaged fallopian tube, the possibility exists that some development in the future might restore it sufficiently to permit a normal pregnancy. Other more seemingly hopeless problems in medicine have been conquered in the past. Certainly most of these women who desire a child would want the psychologic prop of knowing that they retain at least the possibility of pregnancy, however slight, rather than face a future of certain barrenness. CONCLUSIONS 1. The value of conservative tubal surgery in a residual tube has been discussed. 2. The literature of conservative surgery under these conditions has been reviewed. 3. Study of the collected cases indicates that a woman who has had a conservative operation for pregnancy in a residual tube does not run any greater risk of having another ectopic than she did before the ectopic pregnancy, for which a tube was removed.
Vol. 7, No.3, 1956
SALPINGOSTOMY FOR RESIDUAL TUBE
249
4. Two cases are reported of conservatively managed tubal pregnancy. One of these resulted in two subsequent normal pregnancies; the other to date has remained sterile.
111 Carlton Ave. Islip Terrace, N. Y. REFERENCES 1. COOK, D. G., and BUTT, J. A. Hysterosalpingography studies following ectopic pregnancy. Am. I. Obst. & Gynec. 66:626, 1953. 2. PRIDDLE, H. D., MOULTON, C. W., and DENNIS, M. S. Ectopic pregnancy. Am. I. Obst. & Gynec. 64:1093, 1952. 3. RUBIN,1. C. Uterotubal Insufflation. St. Louis, Mo., Mosby, 1947, pp. 226-42. 4. ISRAEL, S. L. Total linear salpingostomy: Clinical and experimental observations. Fertil. & Steril. 2:505, 1951. 5. KURZROK, L., and STREIM, E. Cortogen treatment for sterility due to nonpatent tubes. Fertil. & Steril. 5:515, 1954. 6. GAUSS, C. J. Erhaltung der Tube bei Tubargraviditat. Wien. klin. Wchnschr. 54:877, 1941. 7. CAFFIER, P. Die Konservative Operation des Schwangeren Eileiters. Arch. Gyniik. 173:261,1941. 8. SEGUY, J. Ectopic pregnancy treated by enucleation of ovum with conservation of fallopian tube. Gynec. et obst. 46:244, 1947. 9. LUDWIG, F. Preservation of fallopian tube in surgical therapy of tubal pregnancy. Gynaecologia 131 :379, 1951. 10. SZENDI, B. Adatok A Tubaris Terhessegek Konservativ, A Kurtat VisszahagyoMuteteinek Jogassagahoz. Magyar Noor. Lap. 16:182, 1953. 11. GRAHAM, J. C. Terapeutica quirurgica conservadora en el embarazo tubario. Rev. med. Hosp. gen. Mexico 8:45, 1954. 12. WEISMAN, A. 1. Rapidity of human fallopian tube wound healing as cause for poor results from reparative tubal surgery. Am. I. Surg. 82:278, 1951.
DISCUSSION Philadelphia, Pa.: Any surgical procedure that is conservative both as to physiology and anatomy is and will be sought by gynecologists who deal with the infertile patient. The authors are to be congratulated on bringing to our attention these most interesting cases and their management. The fear of allowing a damaged fallopian tube to remain in situ has been with us for many years. Not until Israel's paper of 4 years ago did we even think of tubal salvage by linear salpingostomy. That tubal continuity and tubal ability to transport an ovum could be regained after salpingostomy was indeed revealing to us all. And now the authors show that normal pregnancies can take place seven times more often than a repeat ectopic can be expected. This gives new hope to the patient with ectopic pregnancies. However, the academic question as to the basic cause for the ectopic pregnancy remains unanswered. If the basic reason is tubal infection of specific origin will the results be as good? If the fertilized ovum DR. A. H.
MARBACH,
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remains in a tube because of a spasm and the ectopic ensues, will the result be better? It is our considered opinion that in the latter instance there will be a better anatomic and phYSiologic result. Then if the emotional cause for the tubal spasm be learned· the functional result ( pregnancy) will be as desired and become intrauterine. The authors give us diagnosis and surgical management of their cases. Perhaps the dangers of further ectopic pregnancies in these patients can be obviated by a better understanding of the "functional spasms" in fallopian tubes. Up to now we have been wondering and studying-can the unconscious hold the answer?