腹腔镜下输卵管部分切除+端端吻合术与输卵管切开取胚缝合术对输卵管妊娠患者输卵管复通和生育预后的影响

Effects of laparoscopic partial salpingectomy followed by end-to-end reanastomosis versus salpingotomy on tubal recanalization and fertility prognosis in women with tubal pregnancy

摘要:

目的 探讨腹腔镜下输卵管部分切除+端端吻合术与输卵管切开取胚缝合术对输卵管妊娠患者输卵管复通和生育预后的疗效。方法 前瞻性纳入2018年4月至2021年4月具有生育期望且存在生育能力下降风险的输卵管妊娠拟行手术患者98例，随机分为切除吻合组（n=50）和切开缝合组（n=48）。切除吻合组行腹腔镜下输卵管妊娠部切除+端端吻合术，术中输卵管逆行插管（自输卵管伞端插入硬膜外麻醉导管并贯穿输卵管2个断端），作为支撑物辅助吻合并行术中通液。切开缝合组行腹腔镜下输卵管切开取胚缝合术，术中常规向输卵管妊娠囊附近系膜处注射甲氨蝶呤50 mg。2组常规术后避孕3个月，常规术后3个月行输卵管碘油造影术观察术侧输卵管通畅情况。对比2组手术时间、术中出血量、术后持续性异位妊娠发生率、术后3个月术侧输卵管通畅率。术后长期随访，观察2组宫内妊娠和再次输卵管妊娠发生情况。结果 切除吻合组手术时间［（52.3±5.7） min vs. （48.6±5.5） min，P=0.002］明显长于切开缝合组，术中出血量［（6.1±3.9） mL vs. （9.6±5.7） mL，P=0.000］明显少于切开缝合组，术后持续性异位妊娠发生率（0.0% vs. 14.6%，P=0.016）明显低于切开缝合组，差异均具有统计学意义（P<0.05）。术后3个月，切除吻合组术侧输卵管复通率（94.0% vs. 79.2%，P=0.030）明显高于切开缝合组。所有患者均获随访，随访（18.5±5.7）个月，切除吻合组术后宫内妊娠率（58.0% vs. 37.5%，P=0.042）明显高于切开缝合组，再次输卵管妊娠发生率（2.0% vs. 16.7%，P=0.031）明显低于切开缝合组。2组术后宫内妊娠不良结局的发生率差异无统计学意义。结论 腹腔镜下输卵管妊娠部切除+端端吻合术治疗输卵管妊娠的效果安全可靠，能够降低术后持续性异位妊娠和再次输卵管妊娠风险，提高术后输卵管复通率和宫内妊娠率。

Abstract:

Objective To investigate the therapeutic effect of laparoscopic partial salpingectomy followed by end-to-end reanastomosis versus salpingotomy on tubal recanalization and fertility prognosis in women with tubal pregnancy.Methods A total of 98 patients with tubal pregnancy with fertility expectation and risk of fertility decline from April 2018 to April 2021 were prospectively included in the study. They were randomly divided into salpingectomy & anastomosis group（n=50） and salpingotomy & suture group（n=48）. The salpingectomy & anastomosis group underwent laparoscopic partial salpingectomy and end-to-end anastomosis. The fallopian tube was retrogradely intubated（the epidural anesthesia catheter was inserted from the umbrella end of the fallopian tube and ran through the two broken ends of the fallopian tube），which was used as a support to assist the anastomosis and hydrotubation during the operation in the salpingectomy & anastomosis group. The salpingotomy & suture group underwent laparoscopic salpingotomy and embryo suture，and 50 mg of methotrexate was routinely injected into the mesangium near the tubal pregnancy sac. The two groups had routine contraception for 3 months after the operation，and salpingography was performed 3 months after operation to observe the patency of fallopian tubes. The operation time，intraoperative bleeding，the incidence of postoperative persistent ectopic pregnancy and the patency of fallopian tubes 3 months after the operation were compared between the two groups. The patients were followed up to observe the occurrence of intrauterine pregnancy and re-tubal pregnancy in the two groups.Results The salpingectomy & anastomosis group had a significantly longer operation time [（52.3±5.7） min vs. （48.6±5.5） min，P=0.002]，less amount of intraoperative bleeding [（6.1±3.9） mL vs.（9.6 ± 5.7） mL，P=0.000]，and lower incidence of postoperative persistent ectopic pregnancy（0.0% vs. 14.6%，P=0.016）than the salpingotomy & suture group，with statistical significance（P<0.05）. Three months after operation，the recanalization rate of fallopian tube was significantly higher in the salpingectomy & anastomosis group（94.0% vs. 79.2%，P=0.030） than the salpingotomy & suture group. All patients were followed up. After（18.5±5.7） months of follow-up，the intrauterine pregnancy rate in the salpingectomy & anastomosis group was significantly higher（58.0% vs. 37.5%，P=0.042），and the incidence of re-tubal pregnancy was significantly lower（2.0% vs. 16.7%，P=0.031） than those in the salpingotomy & suture group respectively. There was no significant difference in the incidence of adverse outcomes of intrauterine pregnancy between the two groups.Conclusion Laparoscopic partial salpingectomy and end-to-end anastomosis is safe and reliable in the treatment of tubal pregnancy，which can reduce the risk of postoperative persistent ectopic pregnancy and re-tubal pregnancy，and improve the postoperative tubal recanalization rate and intrauterine pregnancy rate.