Silastic band 결찰에 의한 가토난관의 병리조직학적 연구

Abstract

[한글]

난관불임수술방법은 다양하며 (Madlener, 1919; Irying, 1924: Pomeroy, 1930; Aldridge, 1934; Kroener, 1935; Uchida, 1961) 현재에 이르기까지 많은 여러가지 불임수술이 개발되어 최근에는 복강경을 사용한 전기소작법 (Anderson, 1937; Power 및 Barnes, 1941; Palmer, 1962; Steptoe, 1967)의 위험성을 극복하기 위하여 Yoon등(1974)이 고안한 silastic band에 의한 난관결찰법이 각광을 받고 있다.

그러나 난관을 결찰한후 난관이 폐쇄되어가는 병리조직학적 변화에 관한 문헌은 그다지 많지 않으며 특히 silastic band에 의한 난관폐쇄과정 및 기전은 체계적으로 설명되지 않고있다.

이에 저자는 종래에 사용하여 오던 봉합사에 의한 난관결찰수술과 silastic band에 의한 난관결찰수술후 난관이 폐쇄되어가는 병리조직학적 변화를 비교관찰함으로써 silastic band의 행방 및 안전성은 물론 silastic band에 의한 난관폐쇄과정 및 기전을 찾아보고자 본 연구를 시행하였다.

연구재료 및 방법

실험동물로는 체중 2,000gm 내외의 자성가토 35마리를 사용하였다.

난관결찰수술은 secobarbital(60mg)을 정맥주사 마취한후 가토의 복부를 iodine과 alcohol등으로 수술전 처치를 하고 개복하여 난관결찰방법으로 우측난관은 silastic band applicator를 사용하여 자궁각에서 2-3cm되는 부위의 난관을 silastic band로 결찰하였고 좌측 난관은 자궁각에서 역시 2-3cm되는 부위의 난관을 장사(chromic catgut oo)로 단순결찰하였다. 복벽봉합에는 견사를 사용하였다.

난관결찰수술후 각군 5마리씩 7군으로 나누어 12시간(Ⅰ), 24시간(Ⅱ), 72시간(Ⅲ), 1주(Ⅳ), 2주(Ⅴ), 4주(Ⅵ), 12주(Ⅶ)후에 각각 공기전색으로 도살, 재개복하여 육안검색하고 자궁 및 난관을 적출하여 난관의 폐쇄여부를 관찰하기 위하여 60% meglumine diatrizoate 2-3cc를 질을 통하여 주입한후 난관조영술을 실시하고 silastic band와 장사를 제거한후 결찰된 부위의 난관을 절제하여 10% formalin에 고정한후 통상의 방법에 의하여 H-E, van Gieson 및 Trichrome염색을 시행하여 광학현미경으로 관찰하였다.

연구성적 및 결론

이상과 같은 실험에 의하여 다음의 성적과 결론을 얻었다.

1. 난관조영술 결과 silastic band결찰군 및 장사결찰군에서 결찰직후부터 난관이 폐쇄되었음을 확인할 수 있었다.

2. 육안소견상 silastic band는 결찰부위에 그대로 남아있었으나 장사는 결찰 12주후 흡수되었다. 양군 대부분 결찰된 직후의 루프형을 이루고 초기에는 충혈 및 출혈소견을 보이나 소실되고 섬유화성 폐쇄현상 및 다소의 유착소견을 보였다.

3. 병리조직학적소견은 앙군 모두 1주에는 난관점막상피의 탈락, 울혈 및 부종, 염증반응, 점막괴사가 일어나나 흡수소실되고 2주부터는 난관강이 섬유화 조직으로 폐쇄되었다.

모세혈관은 결찰 24-72시간후 4주까지 중식되었고 교원섬유의 증식은 결찰 1주부터 계속 관찰되었고 난관점막상피의 재생은 관찰되지 않았다.

4. 난관조영술, 육안 및 병리조직학적 변화등을 종합하면 silastic band결찰군과 장시결찰군간에는 대체적으로 유사하나 이물반응에 있어서는 장사결찰 12주에는 이물반응이 있었으나 silastic band결찰 12주에는 이물반응을 관찰할 수 없었다.

이상의 실험성적으로 보아 silastic band 난관결찰법은 정확하며 이물반응 및 기타 부작용이 적어 수태조절에 있어 크게 기여할 수 있는 안전하고 효과적인 방법이라고 사료된다.

[영문]

In 1880 Lungren first carried out tubal ligation following cesarean section for the purpose of female sterilization (Knight and Summit, 1946), which Blundell had suggested in 1834 (Young, 1944). Thereafter numerous methods have been devised by many investigators to assure tubal sterilization but with varying failure pregnancy rates (Madlener, 1919; Irving, 1924; Pomeroy, 1930; Kroener, 1935; Uchida, 1961; et al.).

Among those the Pomeroy method of tubal ligation is the most widely used because of its effectiveness and ease with which it can be performed. Its failure rate has been reported between 0.19 and 0.5% (Garb, 1957; Overstreet, 1964; White, 1996).

In recent years laparoscopic tubal sterilization has become popularized in conformity with increased demand of world-wide family planning programs, because it can be performed as an outpatient procedure with either general or local anesthetics. In laparoscopic sterilization, the electrocagulation of the tube has

been the standard technique of tubal occlusion (Anderson, 1937; Power and Barnes, 1941; Palmer, 1962; Steptoe, 1967), however, it has the danger of causing serious burns during the procedure.

To avoid such a burn injury during electrocagulation, non-electrical methods such as the clip application technique by Evans (1953) and they are under further study.

Despite the various methods of tubal sterilization, only a few investigators have studied the pathologic process of tubal occlusion by gross and microscopic examination. Anatomical findings by Marquez-Monter et al (1972) were presented of

fallopian tubes occluded from 4-28 months via culdoscopy and using tantalum clips for the purpose of fertility control in 47 women. They described that different patterns of lumen narrowing leading to permanent occlusion may be obtained in consequence of either different individual tubal response to the clipping procedure or to a different force of compression of the clip.

Yoon et al (1974) had within 1 year laparoscopic reexamination in 4 patients who had tubal ligation by the silastic band; 3 patients demonstrated separation and closure of the proximal and distal ends of the fallopian tubes at the site of the applied silastic bands. Therefore, these were similar in appearance to fallopian tubes following the Pomeroy procedure. In the lst one, the silastic bands were in position and contained fibrosed segments of tube. So far, there is no systematic explanation about the foreign-body reaction and the location of silastic band as well as the condition of the tube after long application of a silastic band, and also there is a lack of information concerning the pathologic process to the tubal occlusion.

This experiment was undertaken to study the fallopian tubes ligated by silasic band and by chromic catgut for the pathologic process of tubal occlusion. It was done to investigate the mechanism of tubal occlusion in rabbits using both silastic and chromic catgut as well as to study the foreign body reaction and ultimate location of the silastic band.

Material and Methods

35 female rabbits were used in the experiment, each weighing around 2,000gm.

procedure medication consists of intravenous secobarbital 60mg which was dissolved in 3cc of the distilled water. The entire abdomen was prepared with iodine and alcohol and draped.

The abdominal cabity being entered through a short low midline inclision, the grasping forceps was employed to pick up the right fallopian tube, 2-3cm from the cornu of the uterus. The tube was then drawn into the inner cylinder of the silastic band applicator device. A silastic band was then applied to the grasped segment of the right fallopian tube by moving the outer cylinder forward. After the application of the silastic band, the grasping forceps was moved forward out of the inner cylinder to release the occluded segment of tube.

Then the opposite tube was grasped with Babcock 2-3cm from the cornu of the uterus and simply ligated with chromic catgut 00. The abdominal wound was approximated with No. 4 silk suture.

Rabbits were divided into 7 groups after tubal ligation. Each group consisted of 5 rabbits.

They were sacrificed by air embolism: 12 hours (Ⅰ), 24 hours (Ⅱ), 72 hours (Ⅲ), 1 week (Ⅳ), 2 weeks (Ⅴ), 4 weeks (Ⅵ), 12 weeks (Ⅶ) respectively after tubal ligation.

Gross examination was made in order to observe the tubal condition and the location of the silastic band.

After regments of the uterus and both ligated fallopian tubes, a salpingogram was done using 2-3cc of 60% meglumine diatrizoate to confirm tubal lumen occlusion.

All segments occluded by either silastic band or by chromic catgut were fixed in 10% formalin.

The paraffin embedded sections were stained by hematoxylin and eosin, and by van Gieson and Trichrome for connective tissue.

RESULTS AND SUMMARY

Morphological findings of the rabbit fallopian tubes occluded by silastic band and by chromic catgut were studied. Salpingograms were done to confirm that the tubes were satisfactorily occluded.

The results of this study are summarized as follows:

1. Salpingograms in both groups (silastic band and chromic catgut) revealed obstruction of the fallopian tubes after 12 hours of tubal ligation.

2. All silastic bands remained in situ, but all chromic catgut was absorbed in 12 weeks fooowing tubal ligation. Tubal status in the above mentioned groups was similar in appearance to the fallopian tubes following the Madlener procedure. Early gross findings consisted of congestion and hemorrhage in the loop of the tube but was gone 1 week later. One week following tubal ligation, the silastic band was partially or completely hidden in the adhesive tubal structures and contained fibrosed segments of tube.

3. Histopathologic changes in the mucosa of the fallopian tube were remarkable and consisted characteristically of exfoliated tubal mucosal epithelium, congestion and edema of the lamina propria, mild infiltration of acute inflammatory cells and mucosal necrosis, which continued up to 1 week following tubal ligation when they essentially disappeared. Two weeks following tubal ligation, the lumen was completely occluded with fibrous tissue paralleling the marked proliferation of collagen fibers.

4. There was no difference between the above 2 groups concerning the pathologic process in the salpingogram, gross and microscopic examination. A foreign body reaction was not the salpingogram, gross and microcopic examination. A foreign body

reaction was not observed 12 weeks after the silastic band ligation but it was observed with chromic catgut ligation.

In summary, tubal occlusion by the silastic band was effective mechanically from the beginning and microscopically afterwards. The silastic band causcd little harm and its technique was safe and effective as a routine ligation method.

Therefore it is believed that the new silastic band ligation procedure contributes more and more to female tubal sterilization and thus helps to meet the increasing demand for family planning and fertility control.