MICROSURGICAL TUBOCORNUAL ANASTOMOSIS FOR REVERSAL OF STERILISATION

284

significant differences in the post-treatment plasmaphosphorus concentrations in any of the groups. Mean post-treatment

plasma-magnesium

concentration

was

significantly higher in the magnesium sulphate treated In the calcium and phenobarbitone group (P<0-001). treated groups mean post-treatment plasma-magnesium concentrations were still below the normal range for breast-fed infants. Only 1 infant in the magnesium-treated group was still convulsing after 48 hours’ treatment, whereas 13 infants were still convulsing in the calcium-treated group and 10 in the phenobarbitone-treated group. This is a highly significant difference (r=0001). There was also a very significant difference in the number of treatment doses required in the three groups

(table n).

ferably the vastus lateralis. Overdosage can produce hypotonia (which is rapidly corrected by calcium salts) and local necrosis can occur if the injection is sited superficially. The mode of action of magnesium sulphate is not clearly established. It has an independent anticonvulsant action and is used for this purpose in the treatment of eclampsia. In the gastrointestinal tract it improves and is essential for calcium absorption and at the neuromuscular level it reduces muscle hyper-excitability. It seems to be involved in promoting the release of ionised calcium from the calcium pool.4 Work in animals suggests that magnesium may be necessary for the release of parathyroid hormone, which in turn mobilises calcium from bone sites.5 It would thus appear that in the treatment of neonatal hypocalcsemia secondary to high-phosphate feeding, magnesium sulphate is the treatment of choice whether or not hypomagnesaemia is

Discussion

present.

idiopathic neonatal hyppcalcaemia-i.e., . oral calcium salts-often provokes gastrointestinal symptoms. Intravenous calcium glu-

Edinburgh,

The standard

treatment

for

has also been used but it has a short-lived effect and can produce dangerous cardiovascular effects unless used with extreme caution. Oral calcium salts and phenobarbitone are not readily accepted by newborn infants and this may pose problems for inexperienced nursing staff. Large doses of phenobarbitone may produce profound sedative effects. In the correct dosage magnesium sulphate, used as a 50% intramuscular solution, is free from major sideeffects provided it is injected deeply into the muscle, pre-

We thank the Department of Clinical Chemistry, Royal Infirmary, for their cooperation and technical assistance and to Dr J. K. Brown and our other medical and nursing colleagues for their stimulation and cooperation.

conate

Preliminary Communication MICROSURGICAL TUBOCORNUAL ANASTOMOSIS FOR REVERSAL OF STERILISATION

Requests for reprints should be addressed to T.L.T., Pasdiatric Department, Simpson Memorial Maternity Pavilion, Lauriston Place, Edinburgh EH3 9EF. REFERENCES

Brown, J. K., Cockburn, F., Forfar, J. O. Lancet, 1972, i, 135. Cockburn, F., Brown, J. K., Belton, N. R., Forfar, J. O. Archs Dis. Childh. 1973, 48, 99. 3. Fiske, C. H., Subbarow, Y. J. biol. Chem. 1925, 66, 375. 4. Zimmet, P., Breidahl, H. D., Nayler, W. G. Br. Med. J. 1968, i, 622. 5. Rojo-Ortega, J. M., Brecht, H. M., Genest, J. Virchows Arch. B Zellpath. 1971, 7, 81. 1. 2.

ally shortened, tubal vasculature is impaired, and the uterotubal junction is damaged. Microsurgical tubocornual anastomosis is a new procedure which avoids these disadvantages. It is performed by joining the remaining healthy tube directly to the intramural portion of the uterine wall, using an operating microscope. METHOD

R. M. L. WINSTON Institute of Obstetrics and Gynœcology, Hammersmith Hospital, Du Cane Road, London W12 OHS

11 of 16 patients had intrauterine pregnancies after microsurgical tubocornual anastomosis for reversal of sterilisation. This procedure has several important advantages over tubal reimplantation and may be of benefit in the treatment of infertile women with inflammatory blockage of the isthmus of the fallopian tube.

Summary

INTRODUCTION

LIGATION or diathermy of the isthmic portion of the oviduct near the uterine cornu is often used for female sterilisation. This destroys at least 2cm of the isthmus, leaving the intramural part of the tube and the ampulla undamaged. The standard operation for dealing with medial isthmic injury is tubal reimplantation, but even in the best series’less than 40% of patients subjected to reimplantation following tubal ligation subsequently achieve normal pregnancy. There are very few reports of successful pregnancy following reversal of diathermy sterilisation. The results of tubal reimplantation are poor-probably because the remaining tube is drastic-

16 sterilised patients were considered to have suitable grounds for an attempt to be made at restoring their fertility. 8 patients had had partial resection of the isthmus with ligaat the cornu, and 8 had been sterilised at laparoscopy by diathermy of the isthmus. In each case the isthmus on the uter-

tion

ine side was either absent or too fibrotic for tubotubal anastomosis. All patients had at least 2 cm of isthmus missing on both sides. Regular ovulation and a positive postcoital test were confirmed in each patient before tuboplasty. Hysterography demonstrated some cornual filling, and laparoscopy showed that the fimbria and ampulla were normal and reasonably free uf adhesions. A midline incision was made, and a fine diathermy needle3 was used to divide adhesions. Methylene-blue solution was injected into the uterine cavity, and both cornua were inspected under a Zeiss operating microscope. Repeated thin slices of myometrium were taken from each cornu at the point of maximum fluctuance. At each slice the cornua were inspected at magnifications between x 16 and x 35. All fibrotic tissue was resected, and bleeding-points were treated with fine bipolar coagulation. Cornual dissection was discontinued when healthy stained striations of circular muscle surrounding the four primary epithealial folds of intramural tube were clearly seen with x 30 magnification. A polyethylene splint (0-4$nun external diameter) was then passed through the intramural portion of the tube into the uterine cavity.

285 small vessel can be diathermied under magnification. Because bleeding is less, fewer adhesions are formed. Reimplantation also has the theoretical disadvantage that the narrow intramural portion, a potential sphincter, is destroyed. Because reimplantation weakens the uterine wall, there is a danger of uterine rupture if the patient becomes pregnant, and caesarean section before term is usually advocated. It is noteworthy that in this series delivery by caesarean section was considered necessary in only 1 patient. 11 of 16 patients undergoing tubocornual anastomosis for reversal of sterilisation have had normal intrauterine pregnancies. 5 pregnant patients had had diathermy sterilisation, and this appears to be the first published series which includes successful reversal after laparoscopic diathermy. The results indicate that microsurgical tubocornual anastomosis is a useful procedure and that the use of the microscope is valuable in achieving accurate luminal apposition at the cornu where the diameter of the lumen is usually less than 0-5 mm. This approach has also been applied6 successfully to patients with inflammatory disease of the tubal isthmus. Rockerpointed out that the intramural portion is often patent in cases of so-called cornual occlusion. Microsurgical cornual anastomosis would seem to be a logical method for dealing with this common problem in infertile patients. Cornual anastomosis.

mesosalpinx.

The first anastomotic

Scar tissue was then similarly removed from the ampullary end of the tube. Haemostasis was achieved with a tubal clamp applied 2 mm from the cut end of the tube. This clamp is an enlarged version of the clamp previously reported for use in animals.4 The free end of the splint was introduced into the cut end of the oviduct and brought out through the fimbria. A stay suture was placed between the mesosalpinx and the broad ligament. Cornual anastomosis was performed with two layers of 8/0 nylon. Anastomotic sutures were placed only in the circular muscle and serosal coats of the tube and uterus. Accurate epithelial apposition was greatly aided by use of the microscope. The splint was removed on completion of the anastomosis. Dye was again injected into the uterus and tubal patency confirmed. Dye spilt freely from the fimbria, and in most cases there was no leakage of dye at the anastomosis. RESULTS

5 out of 8 patients who had anastomosis after diathermy sterilisation have had normal intrauterine pregnancies. 3 patients delivered vaginally, and 2 are still pregnant. 6 out of 8 patients who had anastomosis following ligation and resection of part of the isthmus have had intrauterine pregnancies. 3 delivered at term and 3 are still pregnant. 1 patient required cxsarean section for fetal distress. 1 other patient had an ectopic pregnancy in the left tube, but the right tube appeared

healthy at laparotomy. CONCLUSION

Tubocornual anastomosis was first described by Ehrler in pointed out that the standard operation of tubal reimplantation has a low success-rate and suggested that cornual anastomosis might be more physiological. He used a macrosurgical technique and introduced a relatively large splint into the uterus on the end of a needle. This has the disadvantage that a false passage may result. Microsurgical tubocornual anastomosis seems to have distinct advantages over Ehrler’s technique and tubal reimplantation. Only by microscopical dissection is all scar tissue removed and the maximum length of tube conserved. Tubal reimplantation inevitably shortens the tube and leads to interference with its cornual blood-supply. Copious bleeding occurs because boring a hole through the uterine wall damages uterine vessels. Cornual anastomosis disturbs uterine vasculature far less, and each

1963.5 He

Prof. J. C. McClure Browne and Mr D. F. Hawstudy their patients, to Mr Robert Acland for his expert advice with microsurgical techniques, and to Messrs. Spingler-Tntt, Chirurgische Nadeln, Jestetten, West Germany, who manufactured the tubal clamps and supplied the fine suture material. The work was supported by the Medical Research Council and the WellI

The stay suture is in place in the sutch is about to be tied.

am

grateful

to

kins, who allowed

come

me to

Trust. REFERENCES

1. 2

3 4. 5. 6 7.

Williams, G. F. Br. med. J. 1973, i, 599. Siegler, A., Perez, R. J Fert Steril. 1975, 26, 383. Swolin, K Am. J. Obstet. Gynec. 1975, 121, 418. Winston, R. M. L. Lancet, 1974, ii, 494. Ehrler, P Zentbl. Gynäk. 1963, 85, 393. Winston, R. M. L. in Operative Gynæcology (edited by D. W T Roberts). London (in the press). Rocker, I. Proc. R. Soc. Med. 1964, 57, 707.

Methods and Devices HAIR-ROOTS IN SCREENING AND DIAGNOSIS OF TAY-SACHS DISEASE PETER HÖSLI LARRY SCHNECK

DANIEL AMSTERDAM BRUNO W. VOLK

Pasteur Institute, Paris, Downstate Medical Center of the State University of New York, and Kingsbrook Jewish Medical Center, Brooklyn, New York

IN screening-tests for Tay-Sachs disease, activity of hexosaminidase A is usually measured in serum.’ Tears have also been used,2but conjunctival contamination can affect results. Urine has been suggested as an alternative secretory material but has not been widely used.4 With serum tests confirmation is sometimes required -e.g., when hormonal variations induced by oral contraceptives or pregnancy are suspected of giving falsepositive results, when values are in the borderline heterozygote range, or when there is doubt about the sampling procedure. In such instances it has been usual for investigators to rely on leucocyte tests,5-7 but the preparation of leucocytes is time-consuming and requires the drawing of blood. Gartler suggested using hair-roots as an alternative cellular material for studying X-linked diseases,8 and this was more extensively explored by