Complication rates after surgical treatment of ectopic pregnancy

Andreas Rempen1,2 and Johannes Dietl2

1 Diakonie-Krankenhaus, Department of Obstetrics and Gynaecology, Diakoniestr. 10, D-74523 Schwäbish Hall, Germany and 2 Department of Obstetrics and Gynecology University of Würzburg, Josef-Schneider-Str.4 D-97080 Würzburg, Germany

Dear Sir,

We read with interest the worthwhile article of Landström and colleagues (Landström et al., 1998Go), in which they report an increasing complication rate after the introduction of laparoscopic surgery of ectopic pregnancy. Thus the complication rate reached 24% after conservative laparoscopic surgery even when laparoscopic surgery was established as a routine procedure after the inevitable learning phase. The authors stressed that laparoscopic surgery should be restricted to skilled surgeons.

Since the introduction of videolaparoscopy for the treatment of ectopic pregnancy in our hospital in June 1991 (only one laparoscopic surgery without videoequipment was performed for ectopic pregnancy before that time) we are analysing the complication and failure rate of this new surgical modality (Rempen, 1995Go). Our results add further information to this issue. Figure 1Go depicts the proportion of laparoscopic surgery in 221 consecutive cases of ectopic pregnancy from 1990 to 1997. When laparoscopic surgery for ectopic pregnancy was established as the routine procedure in 1993–1997, it was performed in 94% out of 135 consecutive cases. In addition the frequency of conservative procedures (Lindström et al., 1998) are demonstrated. Local injection of pharmacological agents into the ectopic pregnancy was not performed. During the last 2 years the proportion of conservative procedures dropped again to 40% after it has temporarily reached 80% in 1995 demonstrating a changing attitude towards tubal preservation. Tubal rupture occurred during the period 1990–1992 in 30%, 1993–1995 in 18% and 1996–1997 in 21% (differences not significant).



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Figure 1. Percentages of laparoscopic operations and conservative procedures in 221 consecutive ectopic pregnancies between 1990 and 1997 (95% confidence intervals).

 
Persistence of trophoblast requiring reoperation or methotroxate treatment was observed in 10 of the total 161 laparoscopic cases in 1990–1997 (6%). Two additional complications after radical laparoscopic surgery, i.e. one ileus and one acute abdominal pain of unknown origin, required a second surgical intervention. After laparotomy neither persistent trophoblast nor other post-operative complications were seen. Table IGo shows the complications with regard to the different procedures and the time periods 1990–1992 and 1993–1997. The complication rate was significantly higher after laparoscopy than after laparotomy only when the whole study period was analysed. When the two periods were compared, no significant differences were found, neither concerning the whole study population nor in the various subgroups.


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Table I. Complications after various procedures in ectopic pregnancy during 1990–1992 and 1993–1997 (n = 221)
 
After the introduction of videolaparoscopy in June 1991 in our hospital 13 surgeons performed a total of 160 laparoscopic procedures with a median of six operative laparoscopies per surgeon (range: 1–68) in ectopic pregnancy. One surgeon especially experienced in endoscopy performed >40% of the laparoscopic surgery. Whereas the proportion of laparoscopic surgery was correlated with the number of operations performed by each surgeon there was no correlation between the experience in laparoscopic surgery and the rate of post-operative complications (Table IIGo) that mainly consist of trophoblast persistence. Thus experience with laparoscopic surgery increased the number of cases treated endoscopically but left the failure rate unchanged. Thus holds also true when only conservative laparoscopic procedures were analysed.


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Table II. Proportion of laparoscopic procedures and complication rates after operative laparoscopy in 160 ectopic pregnancy (EP) after the introduction of videolaparoscopy (6/1991). Figures in parentheses are percentages
 
In conclusion, we fully agree with other authors (Dubuisson et al., 1996Go; Clasen and et al., 1997) that operative laparoscopy is the treatment of choice for ectopic pregnancy today. Like Landström and colleagues (Landström et al., 1997) we also observed more complications, i.e. failures to completely remove the trophoblast through laparoscopy compared to laparotomy. However, our failure rate was lower than that of these authors. The highest rate was seen after conservative laparoscopic surgery being 9% (95% confidence intervals: 4–16%). While the successful accomplishment of the primary intervention by laparoscopy depended indeed on the skill of the surgeon, the post-operative complication rate was not correlated with the experience in laparoscopic surgery of ectopic pregnancy. The data highlight the importance of a close follow-up of patients by serial human chorionic gonadotrophin (HCG) measurements especially after conservative laparoscopic treatment for ectopic pregnancy (Rempen and Haubitz, 1996Go).

References

Clasen, K., Camus, M., Tournaye, H. and Devroey, P. (1997) Ectopic pregnancy: let's cut! Strict laparoscopic approach to 194 consecutive cases and review of literature on alternatives. Hum. Reprod., 12, 596–601.[ISI][Medline]

Dubuisson, J.B., Morice, P., Chapron, C. et al. (1996) Salpingecotomy – the laparoscopic surgical choice for ectopic pregnancy. Hum. Reprod., 11, 1199–1203.[Abstract]

Landström, G., Thorburn, J. and Bryman, I. (1998) Treatment, failures and complications of ectopic pregnancy: changes over a 20 year period. Hum. Reprod., 13, 203–207.[Abstract]

Rempen, A. (1995) The introduction of laparoscopic surgery in ectopic pregnancy. Geburtsh. u. Frauenheilk., 55, 357–364.[ISI]

Rempen, A. and Haubitz, I. (1996) Longitudinal observations of human chorionic gonadotropin in serum following surgery for ectopic pregnancy. Arch. Gynecol. Obstet., 258, 181–192.[ISI][Medline]


 
Gunvor Landström and Jane Thorburn

Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden

Dear Sir,

In agreement with our study (Landström et al., 1998Go), Rempen and Dietl present a rising and high frequency of laparoscopic surgery and a trend of declining conservative procedures. As in our study, laparotomy and radical surgery are affiliated with few complications whereas laparoscopic conservative surgery is subjected to higher frequencies.

Contrary to our results, the overall complication rates are lower. Interestingly, surgeons with experience in laparoscopic surgery present the same complication rate as surgeons who have performed fewer than 10 procedures. We have not done such a calculation. However, during our first study period when laparoscopy was introduced, only surgeons with special interest in infertility and with laparoscopic experience were operating. The complication rate was than lower and more acceptable than during the later period. Thus our data do not present a traditional `inevitable learning phase' according to surgeons.

In the discussion, we have stressed the importance of stringent criteria for patient selection in case of laparoscopic conservative treatment to reduce the risk of complications. During our last study period, no upper limit of the size of the ectopic pregnancy, of the preoperative serum concentrations of human chorionic gonadotrophin (HCG) or progesterone were used. Drs Rempen and Dietl do not present any details for the patient selection. If the material includes only selected cases this might well explain the lower complication rate, especially as the authors conclude that complications are not related to the skill of the surgeons. Inclusion criteria for patient selection for conservative laparoscopic surgery could thus be the most important factor associated with post-operative complications.

References

Landström, G., Thorbum, J. and Bryman, I. (1998) Treatment, failures and complications of ectopic pregnancy changes over a 20 year period. Hum. Reprod., 13, 203–207.[Abstract]





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