{"paper_id":"061895ee-489c-4815-ba7f-180a146444a8","body_text":"Citation: Hassan A. A Case Series of 10 Cases of Scar Endometriosis. Austin J Obstet Gynecol . 2018; 5(9): \n1130.\nAustin J Obstet Gynecol - Volume 5 Issue 9 - 2018\nSubmit your Manuscript | www.austinpublishinggroup.com \nHassan. © All rights are reserved\nAustin Journal of Obstetrics and Gynecology\nOpen Access\nAbstract\nIt is difficult to perform studies with larger series in rare condition. This is \na report of my experience in managing Cesarean Scar Endometriosis (CSE) \nand emphasize the diagnosis and treatment options. I have collected and \ndocumented a case series of 10 patients who underwent surgical widen bloc \nexcision for CSE. Patients’ demographic features, symptoms, and clinical and \noperative findings were collected. The mean age was 32.4 years. Cyclical pain \nwas documented in eight patients, while two patients presented with noncyclical \npain. Menstrually-related enlargement of the nodule was observed in six patients. \nThe mean operation time was 20min. The endometriotic lesions ranged from a \ndiameter of 2 to 7 cm in size. Patients recovered completely, and no recurrence \nwas observed. Four patients suffered from secondary infertility. Complete \nwide excision of CSE is both diagnostic and therapeutic. The most important \nissues to be considered during surgery is nonspreading endometriosis while \nmanipulation. During the 12 month, follow up the four patients who suffered from \ninfertility got pregnant.\nCase Report\nA Case Series of 10 Cases of Scar Endometriosis\nAhmed Hassan*\nFaculty of Medicine, Helwan University, Cairo, Egypt\n*Corresponding author:  Ahmed Hassan, Faculty of \nMedicine, Helwan University, Cairo, Egypt\nReceived: November 21, 2018; Accepted: December \n14, 2018; Published: December 21, 2018\nIntroduction\nEndometriosis is a common gynecological condition where the \nendometrial glands and stromal structures are found outside the \nuterus. It mainly affects women in reproductive ages [1]. Endometriosis \noccurs most often in pelvis, on the surface lining of the pelvic cavity, \nperitoneum, ovaries, posterior cul-de-sac, and uterosacral ligaments. \nRarely, implants of endometriosis can occur outside of the pelvis, \nand these forms are termed as extra pelvic endometriosis. It can also \narise from scar tissues especially after cesarean section. The most \naccepted cause is mechanical iatrogenic implantation. Endometrial \ncells are inoculated directly into the surgical area and can progress \nto endometriosis in optimal conditions. This causes various clinical \nsymptoms due to proliferation of these cells under the influence of \nfemale hormones. Usually there is delay in diagnosing CSE, the most \ncommon clinical symptoms and signs are swelling, tenderness on \nlocal site, and cyclic pain. Widen block excision with surrounding \nclear margins is both diagnostic and therapeutic intervention.\nMethods\nA case series of 10 patients who underwent surgical management \nfor CSE in our obstetrics and gynecology Department – Ain Shams \nUniversity. All patients were informed about surgical management \nand written informed consents were obtained. \nAll patients had a history of previous cesarean section, and \ntheir initial cesarean sections were performed in different hospitals. \nAfter the clinical assessment, the diagnosis was suspected by pelvic \nultrasonography.\nWe performed sharp dissection with a scalpel within the area \nof the incision from the previous cesarean section. The cystic mass, \nwhich was surrounded by fibrosis, was removed carefully with a safe \nmargin. The surgical intervention was followed by the reconstruction \nof the abdominal wall in anatomical layers.\nAll in cases, the definitive diagnosis was confirmed by the \npathological examination. \nAll patients were operated under spinal anesthesia. Age, parity, \nbody mass index, symptoms, size of tumor, time between cesarean \nsection and the onset of symptoms, operative findings, and surgical \noutcomes were evaluated. Demographic features and operative \nfindings of the cases are demonstrated in Table 1.\nResults\nThis study includes the medical records of 10 patients who \nunderwent surgical treatment for CSE. The first admissions of seven \npatients were to gynecologists, two to general surgeons, and one to \na dermatologist. All were referred to our hospital. Based on medical \nrecords, Pfannenstiel incision had been performed for cesarean \nsection in all patients.\nThe median age was 32.6 ± 6.1 years (range from 26 to 38 years), \nand the mean BMI was 30.95 ± 6.59 kg/m\n2 (range from 23.30 to \n37.50 kg/m2). The common complaint of the patients was a palpable \nmass under the incision scar. Eight patients suffered from cyclical \npain. Noncyclic pain was seen in two patients, and four patients had \nexperienced the enlargement of the nodule during the menstrual \nperiod. The mean time interval between initial cesarean section and \nthe onset of symptoms was 29.2 months (range of 18 to 42).\nThe preoperative diagnosis was correct in all patients. Two \npatients had failed medical treatment before admission to our clinic.\nAll of the patients were treated surgically. Almost all the nodules \nwere excised easily. In nine cases, extensions of the lesions through \nthe facial layer were seen during surgery. In these cases, facial defects \nwere repaired after excision\nThe mean operation time was 20.1 (11–30) min. The diameter of \nthe endometriotic lesions ranged from 2 to 7 cm in size. All patients \nwere completely recovered without relapse of symptoms. The follow-\nup period was 12 months.\n\nAustin J Obstet Gynecol 5(9): id1130 (2018)  - Page - 02\nAhmed Hassan Austin Publishing Group\nSubmit your Manuscript | www.austinpublishinggroup.com\nNo recurrence was observed during the follow-up period. \nFour patients suffered from 2ry infertility and they got pregnant \nspontaneously during the first year after the operation. \nDiscussion\nEndometriosis in cesarean scar is a rarely observed finding. \nThere are a limited number of publications discussing CSE, and most \nof them are case reports. It is difficult to conduct well-controlled \nclinical trials in rarely observed disease. The common symptom \nof CSE includes palpable mass, typically accompanied by cyclic, \nnoncyclic, or constant pain. Menstruation usually aggravates disease. \nThe history and complain of the patient helps in diagnosis of the \nillness. De Oliveira et al. reported a case–control study to identify \nthe risk factors of scar endometriosis. According to this study, early \nhysterotomy in pregnancy especially before 22\nnd week of gestation \nis the main risk factor [2]. Additionally, increased menstrual flow \nand alcohol consumption are also concluded as risk factors, while \nhigh parity may be a protecting factor [2]. The most common risk \nfactor for the presence of endometriosis in scar tissue is a previous \nhistory of obstetric surgical procedures [3]. The reason was defined by \nWang et al. first of all, obstetric surgery can expose a large amount of \nendometrial cells, and these cells can be entrapped in the wound [4]. \nThe separation of active cells may be facilitated by amniotic fluid and \nsignificantly, more blood loss in obstetric surgery would provide a \nrelatively rich nutritional environment for the growth of endometrial \ntissue in the wound [4]. In this study, more than half of our patients \nwere overweight. This can provide wide surgical surface for the \nentrapment of endometrial active cells and may be an impact on the \nillness. In this study, the time interval between cesarean section and \nthe onset of symptoms is ranged from 18 months to 42 months. The \nrelative late onset of symptoms after surgery is the probable cause of \nmisdiagnosis [1]. The mean duration of the symptoms was higher in \npatients whom first admission was not to the obstetrician. Overall, \ngeneral surgeons are infrequently involved in the management of \ncesarean section scar lesions [5].\nHistory and physical examination is essential for an accurate \ndiagnosis. Scar endometriosis is usually developed in superficial layers \nof the connective tissue, and nodules are usually found by palpation. \nThe clinical evaluation can be confirmed by pelvic ultrasonography. \nUltrasound is the most accessible, reliable, and cost-effective \nprocedure. Some additional diagnostic procedures such as fine-needle \naspiration, computed tomography, and magnetic resonance imaging \ncan be performed [5,6]. The imaging modalities are nonspecific and \nmore useful for differential diagnoses and detecting the relationship \nbetween the mass and the other tissues. These are also used in \nplanning of operative resection, to identify and to evaluate the extent \nof disease. Awareness of its typical clinical manifestations remains the \nmainstay for intervention and diagnosis.\nIn this study, all cesarean sections were performed outside of our \nhospital. Hence, we could not contribute to the literature about the \nincidence of CSE. It can be assumed as a methodological limitation \nof our study. Based on literature reviewed, the estimated incidence \nof scar endometrioma ranges from 0.02 to 3.4 % and more frequently \nobserved with an incidence of 0.03 to 0.47 % following cesarean \ndelivery [3,7].\nNominato et al. suggested that cesarean section is the commonest \ncause of developing scar endometriosis [8]. It should be suspected in \nany patient, with scar-related masses, who had a history of uterine \nsurgery, especially cesarean section.\nHowever, endometriosis on the abdominal wall can be observed \nin some sporadic cases that have not been previously exposed to any \ntype of surgery [9]. Furthermore, some presentations of abdominal \nwall endometriomas are referred to surgery performed by general \nsurgeons such as appendectomy [10]. In these cases, hematogenous \noutspread, lymphatic dissemination, coelomic metaplasia, and some \nelse theories could be addressed for probable pathogenesis. In our \nstudy, all cases had a history of at least one cesarean section. By the \nfact that the number of cesarean sections is constantly increasing, this \ncomplication becomes more frequent [11-13].\nIn this case, series, we did not find any evidence of pelvic \nendometriosis. Iatrogenic mechanical transplantations on incision \nscars during the operations are the most accepted pathogenesis. So \nit is important to take some precautions to avoid transplantation \nof endometrial cells. To minimize endometriosis contamination, \nsome authors recommend careful isolation of the wall incision and \nlavage with saline before the closure of the wall [14]. The others \nhypothesized that failure to close the parietal and visceral peritoneum \nwith sutures at the time of ces arean section may markedly increase \ncase age parity BMI Previous abdominal surgery Asymptomatic period in months 2ry infertility Operative time in min.\n1 32 1 25 CS 24 no 25\n2 28 2 30 CS (2) 18 no 15\n3 30 1 33 CS 40 yes 20\n4 36 1 29 CS 42 yes 11\n5 26 1 31 CS 18 no 25\n6 34 3 34 CS (3) 24 no 30\n7 31 2 37 CS (2) 24 no 15\n8 32 1 23 CS, appendictomy 30 yes 20\n9 38 2 35 CS (2) 48 no 15\n10 33 1 24 CS 24 yes 25\nTable 1:\nAsymptomatic period was defined as the time interval between the previous surgery and the onset of the symptoms. Number in the parentheses indicates the number \nof procedures.\n\nAustin J Obstet Gynecol 5(9): id1130 (2018)  - Page - 03\nAhmed Hassan Austin Publishing Group\nSubmit your Manuscript | www.austinpublishinggroup.com\nthe postoperative occurrence of an endometrioma in the skin incision \nscar [15]. \nReplacing instruments and needles with a new one is \nrecommended when suturing other abdominal layers [16]. Based \non literature reviewed, we did not find any correlation between the \nindications of cesarean section and development of CSE. On the other \nhand, some authors reported the correlations with timing of cesarean \nsection and CSE. \nWicherek et al. stated that cesarean section performed before \nspontaneous onset of labor may increase substantially the risk of \noccurrence of scar endometriomas [17]. Immune tolerance during \npregnancy was suggested to be an important factor predisposing to \nthe implantation [17]. Similarly in this study, 7 of 10 patients had \ncesarean section without the presence of regular uterine contractions. \nIn other words, seven cases were elective. Medical treatment gives \nonly partial relief of pain and with regard to the almost certain \nrecurrence of the condition after cessation of medication [5,18]. The \nuse of progestogens, oral contraceptive pills, and danazol are not \neffective [5]. \nDue to side effects of androgens, patients have poor compliance \nto these drugs [5]. Two of our patients had a history of medical \ntreatment failure before admission to the hospital. Treatment of \nchoice is wide excision. Surgical treatment is overly recommended \n[1,19,20].\nThe mean operation time was 20min. None of them have required \nfurther surgical intervention in the follow-up. So in order to prevent \nthe recurrences, surgical excision remains the preferable method. \nLocal recurrence is likely to be after an inadequate surgical excision \n[1,20].\nFour patients in this study achieved spontaneous pregnancy \nwithin the first year after the excision of the CSE, which suggest \nthat scar endometriosis may have biochemical effect that affects \nthe process of ovulation and implantation, further studies needed \nto confirm this finding as no data in the literature to support this \nobservational finding.\nReferences\n1. Gupta P, Gupta S. Scar Endometriosis: a Case Report with Literature Review. \nActa Med Iran. 2015; 53: 793-795. \n2. Vellido-Cotelo R, Muñoz-González JL, Oliver-Pérez MR, de la Hera-Lázaro \nC, Almansa-González C, Pérez-Sagaseta C, et al. Endometriosis node in \ngynaecologic scars: a study of 17 patients and the diagnostic considerations \nin clinical experience in tertiary care center. BMC Womens Health. 2015; 15: \n13-15. \n3. Vural B, Vural F, Müezzinoglu B. An Abdominal Wall Desmoid Tumour \nMimicking Cesarean Scar Endometriomas: A Case Report and Review of the \nLiterature. J Clin Diagn Res. 2015; 9: 14-15. \n4. Uçar MG, Şanlıkan F, Göçmen A. Surgical Treatment of Scar Endometriosis \nFollowing Cesarean Section, a Series of 12 Cases. Indian J Surg. 2015; 77: \n682-686. \n5. Padmanabhan LD, Mhaskar R, Mhaskar A. Scar endometriosis. J Obstet \nGynaecol India. 2003; 53: 59-60. \n6. Bhowmick RN, Paul P, Dutta S. Endometriosis of laparotomy scar. J Obstet \nGynaecol India. 1986; 36: 130-131. \n7. Chatterjee SK. Scar endometriosis: A Clinicopathological study of 17 cases. \nObstet Gynecol. 1980; 56: 81-84. \n8. Nirula R, Greaney GC. Incisional endometriosis: An under appreciated \ndiagnosis in general surgery. Am Coll Surg. 2000; 190: 404-407. \n9. Ideyi SC, Schein M, Niazi M. Spontaneous endometriosis of the abdominal \nwall. Dig Surg. 2003; 20: 246-248. \n10. Tomas E, Martin A, Garfia C, Gomez FS, Morillas JD, Tortajada GC. \nAbdominal wall endometriosis in absence of previoussurgery. J Ultrasound \nMed. 1999; 18: 373-375. \n11. Demiral G, Aksoy F, Ozclik A, Saban B, Kusak M, Ekinci O, Erengul C. \nCesarean scar endometriosis: presentation of eleven clinical cases and \nreview of the literature. J Turk Soc Obstet Gynecol. 2011; 8: 209- 213. \n12. Elabsi M, Lahlou MK, Rouas L, Essadel H, Benamer S, Mohammadi A, et \nal. Cicatrix endometriosis of the abdominal wall. Ann Chir. 2002; 127: 65-67. \n13. Phupong V, Triratanachat S. Ceserean section scar endometriosis: a case \nreport and review of the literature. J Med Assoc Thai. 2002; 85: 733-734. \n14. Zhang J, Liu X. Clinicopathological features of endometriosis in abdominal \nwall-clinical analysis of 151 cases. Clin Exp Obstet Gynecol. 2016; 43: 379-\n383. \n15. Akdemir A, Akman L, Yavuzsen HT, Zekioglu O. Clinical features of patients \nwith endometriosis on the cesarean scar. Kaohsiung J Med Sci. 2014; 30: \n541-543. \n16. Blanco RG, Parithivel VS, Shah AK, Gumbs MA, Schein M, Gerst PH. \nAbdominal wall endometriomas. Am J Surg. 2003; 185: 596-597. \n17. Ozler A, Yaldız S, Değirmencioglu AI. Karın duvarı endometriozisi: Olgu \nsunumu. Dicle Tip Derg. 2010; 37: 410. \n18. Andolf E, Thorsell M, Kallen K. Caesarean section and risk for endometriosis: \na prospective cohort study of Swedish registries. BJOG. 2013; 120: 1061-\n1065. \n19. Medeiros F, Cavalcante DI, Medeiros MA, Eleutério J. Fine-needle aspiration \ncytology of scarendometriosis: study of seven cases and literature review. \nDiagn Cytopathol. 2011; 39: 18-21. \n20. Veda P, Srinivasaiah M. Incisional endometriosis: diagnosed by fine needle \naspiration cytology. J Lab Phys. 2010: 2; 117-120.\nCitation: Hassan A. A Case Series of 10 Cases of Scar Endometriosis. Austin J Obstet Gynecol . 2018; 5(9): \n1130.\nAustin J Obstet Gynecol - Volume 5 Issue 9 - 2018\nSubmit your Manuscript | www.austinpublishinggroup.com \nHassan. © All rights are reserved","source_license":"CC0","license_restricted":false}