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., 1998), 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, 1995). Our results add further information to this issue. Figure 1
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 19931997, 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 19901992 in 30%, 19931995 in 18% and 19961997 in 21% (differences not significant).
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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, 596601.[ISI][Medline]
Dubuisson, J.B., Morice, P., Chapron, C. et al. (1996) Salpingecotomy the laparoscopic surgical choice for ectopic pregnancy. Hum. Reprod., 11, 11991203.[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, 203207.[Abstract]
Rempen, A. (1995) The introduction of laparoscopic surgery in ectopic pregnancy. Geburtsh. u. Frauenheilk., 55, 357364.[ISI]
Rempen, A. and Haubitz, I. (1996) Longitudinal observations of human chorionic gonadotropin in serum following surgery for ectopic pregnancy. Arch. Gynecol. Obstet., 258, 181192.[ISI][Medline]
Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
Dear Sir,
In agreement with our study (Landström et al., 1998), 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, 203207.[Abstract]