The Clinical Analysis Of Different Laparoscopic Surgical Approach In The Treatment Of Ampullary Pregnancy

BackgroundEctopic pregnancy (EP) is that a fertilized egg implants and develops outside the uterus cavit, which is a common disease in women of childbearing age and the most commom gynecological acute abdomen. Tubal pregnancy (TP) accounts for95%~98%in ectopic pregnancy, of which about78%is ampullary pregnancy. The treatments of ectopic pregnancy include drug treatment, operation treatment and so on. At the beginning of the90’s, the first case of laparoscopic operation in treatment of ectopic pregnancy succeeded. After nearly30years explorating and developing, the laparoscopic exploration is determined to be the primary position to cure ectopic pregnancy.At present, the laparoscopic operation cureing ectopic pregnancy is divided into radical operation and conservative operation. Radical operation is salpingectomy. According to the different situation, conservative operation is divided into oviduct fenestration, pregnancy extrusion technique and so on. Early diagnosis and fertility-preserving treatment of ectopic pregnancy have become a trend in recent years. Most scholars believe that oviduct fenestration has good effects on cureing ectopic pregnancy for little influence on fertility after the operation, specially in conjunction with methotrexate drug therapy. Yang Wenlan [8] through following up562cases of tubal pregnancy patients found that the postoperative intrauterine pregnancy rate of conservative operation was significantly greater than salpingectomy in30patients before30years old but was not significant different in patients older than30years old. But Rashid [10] thinks that the postoperative pregnancy rate has no difference between conservative operation and radical operation. At the same time, quite a number of experts believe that salpingectomy will affect the blood supply of ipsilateral ovarian and thus affect its function. Tan Xiuqun by monitoring ovarian response in promoting ovulation treatment process of patients with salpingectomy history found that salpingectomy in the following short period does not affect the ovarian’s size, but has significant influence on its reserve function. Verhulst G and Dar P all think that salpingectomy has no effect on ovarian’s function and reproductive outcome.The ovarian cancer dualism makes us puts forward a new method to deal with tubal disease, which points out that oviduct is closely related with high grade ovarian serous adenocarcinoma. Kong Beihua et al indicate that preventative bilateral adnexectomy is an important method to prevent ovarian cancer. Ness also points out that salpingectomy is an important measure to reduce the incidence of ovarian cancer.In short, whether to retain oviduct and the advantages and disadvantages of it are still controversial in domestic. In the mature operation conditions, this study focuses on perioperative and postoperative complications, long term outcomes and affects to fertility of salpingectomy and oviduct fenestration, further to discuss their therapeutic value and postoperative pregnancy rates.ObjectiveAnalyze perioperative and postoperative complications, long term outcomes and postoperative pregnancy rates of laparoscopic salpingectomy and oviduct fenestration in cureing ampullary pregnancy, and the postoperative complications, therapeutic value and postoperative pregnancy rates of laparoscope salpingotomy and oviduct fenestration suture all blong to laparoscopic salpingectomy to provide reference for clinical diagnosis and treatment. MethodsRetrospectively analyze350patients diagnosed as ampullary pregnancy and then underwent laparoscopic operation from2011November to2013February in The Third Affiliated Hospital of Zhengzhou University. According to operation manner, make the110cases of salpingectomy as salpingectomy group, and the240patients underwent tubal fenestration as fenestration group. And then according to the method of dealing with oviduct linear incision, divide the salpingectomy group into salpingotomy group (158cases without sutureing the linear incision) and oviduct fenestration suture group (82cases with sutureing the linear incision interruptedly). Collect the data and then statistically analyze the operation time, intraoperatve blood soss, postoperative decreased blood T-HCG level and postoperative complications of the groups respectively. And the postoperative mass recovery condition of salpingotomy group and oviduct fenestration suture group also are analyzed.There are230cases conformed to the standard of following-up postoperative pregnancy rate and followed up successfully, of which tubal fenestration group has166cases (110cases of salpingotomy group and with56cases of oviduct fenestration suture group) and salpingectomy group has64cases. The follow-up time was12months starting from restoring normal sexy life. Statistically analyze the postoperative conditions about ectopic pregnant and normal intrauterine pregnancy.Results1The comparison of operation time and intraoperatve blood sossThe operation time and intraoperatve blood soss of the salpingectomy and fenestration group has no significant difference.(P=0.667;0.337). The intraoperatve blood soss of salpingotomy group and oviduct fenestration suture group has no significant difference.(P=0.575), but the operation time of oviduct fenestration suture group was higher than salpingotomy group with significant difference (P=0.000).2Postoperative decreased blood T-HCG levelThere was no significant difference of the decreased blood T-HCG level3days after operation between the salpingectomy and fenestration group (P＝0.243;0.074). And the decreased blood T-HCG level7days after operation of the salpingectomy and fenestration group was significant different (P＝0.021), but was’t significant different (P＝0.234) of salpingotomy group and oviduct fenestration suture group. The number of the case whose blood T-HCG dropped to normal level (T-HCG<1IU/L)1week after operation of the salpingectomy and fenestration group had significant difference (P=0.001), but had no significant difference of the salpingotomy group and oviduct fenestration suture group (P=0.564).Conditions about blood T-HCG dropped to normal level1month after operation: all the patients’ blood T-HCG dropped to normal level1month after operation.It indicates that the blood T-HCG of salpingectomy group is dropped faster than fenestration group and needs a shorter time to reach the normal level, but there is no difference between the salpingotomy and oviduct fenestration suture group.3Postoperative complicationsThere was no case happening subcutaneous emphysema, subcutaneous abdominal wall congestion, incision hernia and so on. There was1case accurring persistent ectopic pregnancy and then received methotrexate and mifepristone treatment.But the effect was’t significant. So the patient refused medical treatment and underwent laparoscopic salpingectomy8days after the first operation. The blood T-HCG3days after the second operation was439IU/L and the dropped tatio is88.47%and then dropped to normal level1weeek after the second operation.4Postoperative pregnanciesThere are230cases conformed to the standard of following-up postoperative pregnancy rate and followed up successfully, of which tubal fenestration group has166cases (110cases of salpingotomy group and56cases of oviduct fenestration suture grou) and salpingectomy group has64cases. The follow-up time was12months starting from restoring normal sexy life. The rate of intrauterine pregnancy, ectopic pregnancy, secondary infertility had no significant difference between the salpingectomy and fenestration group (P=0.503;0.794;0.265). The rate of secondary infertility had no significant difference between the salpingotomy group and oviduct fenestration suture group (P=0.918), but the rate of intrauterine pregnancy, ectopic pregnancy of the two group had significant difference (P=0.019;0.006). It indicates that the salpingectomy and fenestration group has the same intrauterine pregnancy rate and compared with the salpingotomy group, the oviduct fenestration suture group has a lower intrauterine pregnancy rate but a higher secondary infertility rate.Conclusion1Laparoscopic salpingectomy has same therapeutic effects with tubal fenestration in cureing ampullary pregnancy, without difference in operation time, intraoperatve blood soss, postoperative decreased blood T-HCG level. Tubal fenestration can not improve the patients’ postoperative intrauterine pregnancy rate.So on the premise that patients don’t urge to retain oviduct, salpingectomy can be used as the preferred method.2The oviduct fenestration suture group has a lower intrauterine pregnancy rate but a higher secondary infertility rate than the salpingotomy group.So in the process of tubal fenestration we should prevent suturing the oviduct incision to ensure the operation effects.