{"paper_id":"2b9026e2-7299-468b-a73b-486b2c9f7373","body_text":"~ 27 ~ \nInternational Journal of Case Reports in Surgery 2024; 6(1): 27-29 \n \n \nE-ISSN: 2708-1508 \nP-ISSN: 2708-1494 \nIJCRS 2024; 6(1): 27-29 \nwww.casereportsofsurgery.com  \nReceived: 16-10-2023 \nAccepted: 20-12-2023 \n \nCyrine Chelly \n1. Department of Gynecology \nand Obstetrics, Farhat \nHached University Hospital, \nSousse, Tunisia \n2. Faculty of Medicine Ibn Al \nJazzar, Sousse, University of \nSousse, Tunisia \n \nOumayma Ben Rejeb \n1. MD, Department of \nGynecology and Obstetrics, \nFarhat Hached University \nHospital, Sousse, Tunisia \n2. Faculty of Medicine Ibn Al \nJazzar, Sousse, University of \nSousse, Tunisia \n \nSouhir Chelly \n1. Faculty of Medicine IBN Al \nJazzar, Sousse, University of \nSousse, Tunisia \n2. Department of Infection \nPrevention and Control, \nFarhat Hached University \nHospital, Sousse, Tunisia \n \nMouna Derouiche \n1. Department of Gynecology \nand Obstetrics, Farhat \nHached University Hospital, \nSousse, Tunisia \n2. Faculty of Medicine Ibn Al \nJazzar, Sousse, University of \nSousse, Tunisia \n \nSassi Boughizane \n1. Department of Gynecology \nand Obstetrics, Farhat \nHached University Hospital, \nSousse, Tunisia \n2. Faculty of Medicine Ibn Al \nJazzar, Sousse, University of \nSousse, Tunisia \n \n \n \n \n \n \n \nCorresponding Author: \nOumayma Ben Rejeb \n1. MD, Department of \nGynecology and Obstetrics, \nFarhat Hached University \nHospital, Sousse, Tunisia \n2. Faculty of Medicine Ibn Al \nJazzar, Sousse, University of \nSousse, Tunisia \n \nAppendectomy during surgery for ovarian \nendometrioma: A case report and review of literature \n \nCyrine Chelly, Oumayma Ben Rejeb, Souhir Chelly,  Mouna Derouiche \nand Sassi Boughizane \n \nDOI: https://doi.org/10.22271/27081494.2024.v6.i1a.96 \n \nAbstract \nEndometriosis is a widespread disease involving multiple pelvic and abdominal organs. Appendiceal \nendometriosis is considered a rare finding and its prevalence varies from 0.8% to 39%. It can be \nsymptomatic and can mimic appendicitis. That's why surgica l treatment of endometriosis requires \nincidental appendectomy. We present a case of appendicular endometriosis in a young woman with \npelvic and abdominal pain for several months. She had no significant pathologic history. Blood tests \nwere normal and pelvic  ultrasound showed findings suggestive of bilateral large endometriomas. \nDiagnostic laparoscopy was performed, which revealed severe stage 4 endometriosis. Therefore, we \ncouldn't perform surgery. The patient was discharged on the second day. She was given medical \ntreatment based on GnRH agonists to reduce the severity of the endometriosis so that she could \nundergo surgery again under better conditions. \n \nKeywords: Laparoscopy, endometriosis, Appendectomy, management \n \nIntroduction \nEndometriosis is a common disease affecting 10 to 15 percent of women of reproductive age. \nIt often leads to chronic pain, infertility and repeated surgeries. The pelvic organs and \nperitoneum are most commonly affected. \nIt can also occur in the gastrointestinal tract, in surgical s cars, and rarely in the lungs, skin, \nand kidneys [1]. The prevalence of intestinal endometriosis is estimated to be between 8% \nand 12% in patients with endometriosis. The rectum and sigmoid colon are the most \ncommonly affected sites, accounting for 90% of all bowel involvement. [2]. Appendiceal \nendometriosis is rare and its prevalence varies in the literature from 0.8% to 39% [3]. The \ndiagnosis of endometriosis is histologic and requires clinical and surgical decisions, but its \nmanagement is still controver sial. Furthermore, there is a large difference between \nlaparoscopic visual diagnosis of endometriosis and histologically proven endometriosis [4].  \nThe role of appendectomy in the surgical management of women with chronic pelvic pain or \nendometriosis has n ot been clearly defined by consensus guidelines [5]. Appendiceal \nendometriosis may be asymptomatic or present as acute or chronic appendicitis, lower \ngastrointestinal bleeding, bowel perforation, or bowel intussusception [6]. Therefore, several \nstudies have argued that incidental appendectomy is necessary for the surgical treatment of \nendometriosis. We present the case of a patient in whom appendiceal endometriosis was \ndiagnosed at the time of laparoscopy. \n \nCase presentation \nA 30 -year-old woman presented wi th a history of several months of moderate abdominal \npain cyclically associated with menstrual bleeding. There were no associated genitourinary \nor gastrointestinal symptoms. The pain was not relieved by common analgesics. Her \nmenstrual cycle was irregular and dysmenorrheic, and her last menstrual period was 10 days \nbefore admission. Her medical and surgical history was unremarkable. \nShe was in good general condition and her vital signs were normal. The abdomen was soft, \npalpable but painful to deep palpatio n with no obvious signs of peritoneal irritation, pelvic \nexamination was not performed as the patient was a virgin. \nWhite blood cell count and neutrophil percentage were 7900 mm 3 and 64%, respectively, \nserum C-reactive protein was 8 mg/L, and pregnancy tes t was negative. Pelvic ultrasound \nshowed a normal uterus and two laterouterine views at the expense of each ovary with  \n\nInternational Journal of Case Reports in Surgery http://www.casereportsofsurgery.com \n \n~ 28 ~ \nhypoechogenic content of 7 cm and 6 cm, suggesting \nbilateral endometriomas. \nThe patient underwent a diagnostic laparoscopy for chronic \npelvic pain with bilateral endometriomas, in which we \nfound severe stage 4 endometriosis with multiple pelvic \nadhesions preventing access to the pelvic organs, some \nnodules of peritoneal endometriosis on the anterior wall as \nwell as on the appendix, which was congested (Figure 1), so \nwe couldn't perform any surgical procedure. The patient was \ndischarged on the second day. And she was put on medical \ntreatment based on GnRH agonist to reduce the severity of \nendometriosis in order to re -operate her under bette r \nconditions. The patient was started on a GnRH agonist and \nreturned in 3 months for clinical and ultrasound follow -up. \nAfter 3 months, the medical treatment helped to relieve the \npain caused by the endometriosis and to reduce the size of \nthe endometriomas. Therefore, we decided to continue the \nmedical treatment for a total of 6 months and to schedule \nanother laparoscopy in the meantime. \n \n \n \nFig 1: Intraoperative appearance of endometriotic nodule above \nthe Appendix During Laparoscopy \n \nDiscussion  \nEndometriosis is the presence of endometrial tissue outside \nthe uterus, it can affect the pelvic organs, peritoneum, \ndigestive tract, omentum, surgical scar, appendix and even \nthe lungs, kidneys and skin. The most common symptoms \nare dysmenorrhea, chronic pelvic pa in, infertility, \ndyspareunia, dysuria, and digestive symptoms [7]. Due to the \nlack of pathognomonic clinical or radiologic signs, \npreoperative diagnosis of appendiceal endometriosis is \ndifficult. Therefore, in patients with one or more risk factors \nfor appendiceal injury, it is important to suspect appendiceal \nendometriosis. For this reason, the diagnosis of appendicular \nendometriosis should always be suspected in a young \nwoman who presents with chronic non -menstrual pelvic \npain and who has a history of inf ertility and pelvic \nendometriosis. [8]. Similarly, our patient was young and had \na history of chronic pain in the lower abdomen, which is \nhelpful in making the diagnosis. According to Mabrouk et \nal, appendiceal endometriosis was independently associated \nwith posterior pelvic endometriosis, ileocecal endometriosis, \nand bladder endometriosis [8]. A significant association \nbetween the presence of right -sided endometriomas and \nappendiceal endometriosis, especially in cases of large \novarian cysts, was also found in this study. The proximity of \nthe two organs and the clockwise circulation pattern of the \nperitoneal fluid may account for this association. Our case is \nin agreement with these findings, our patient presents 2 \nlarge endometriomas in addition to the appe ndicular \nlocalization. Several studies have shown a different \ndistribution of endometriosis lesions between the 2 sides of \nthe abdominopelvic cavity, which correlates with the \nanatomical differences between the 2 hemipelvises and the \ncirculation of peritoneal fluid. [9]. \nA study published by Ross et al. showed a strong correlation \nbetween appendiceal endometriosis and endometriosis \nstage, as well as a correlation between laparoscopic \nappendiceal appearance and the presence of appendiceal \nendometriosis, conc luding that these intraoperative clues \nmay indicate when to perform appendectomy [10]. \nThe same study showed that appendiceal endometriosis was \npresent in 7.0% of women with stage I -II endometriosis and \n35.2% of women with stage III -IV endometriosis based on \nintraoperative visualization, similar to Moulder and \ncolleagues [3] who found appendiceal endometriosis in \n11.6% of women with superficial endometriosis and 39.0% \nwith deep infiltrating endometriosis. Since the stage of \nendometriosis present can predict  appendiceal \nendometriosis, it is reasonable to adopt a selective approach \nto appendectomy, prioritizing the performance of incidental \nappendectomy in women with stage III -IV endometriosis \nand/or endometriosis involving multiple sites [9]. Because \nwomen with endometriosis are at high risk for re -operation \n[11], it is incumbent upon gynecologic surgeons and \nresearchers to find ways to minimize this risk. Although \nlong-term results after appendectomy are lacking [12], it has \nbeen shown to be beneficial in red ucing pain in a subset of \nwomen with chronic right lower quadrant pain. \nMore complete and effective treatment of endometriosis \nusually requires surgical removal of the affected tissue or \norgan. According to recent recommendations, \nappendectomy should be pe rformed laparoscopically unless \ncontraindicated [12]. \nLaparoscopic surgery significantly reduced overall pain at 6 \nand 12 months compared with diagnostic laparoscopy \ncombined with GnRH agonists for endometriosis [13].  \nAccording to several authors, inciden tal appendectomy \ncould allow complete eradication of the disease, complete \nrelief of symptoms, and elimination of potential \ncomplications related to appendiceal endometriosis \n(intussusception or minor gastrointestinal bleeding) [3, 14]. \nAfter incidental ap pendectomy during laparoscopic \ntreatment of ovarian endometriosis, the negative histology \nrate for appendiceal endometriosis is higher than selective \napproach (86.8% vs. 69.0%). [8]. Another study of 106 \npatients who underwent routine appendectomy during \nlaparoscopic treatment of ovarian endometriosis showed \nmacroscopic abnormality in only 3.3%, while microscopic \nexamination showed endometriosis of the appendix in \n13.2% of patients [15]. \n \nConclusion \nAppendicular endometriosis is observed in 2.6% of cases \nduring surgery for endometriosis, which is often associated \nwith adenomyosis, large endometriomas, deep \nendometriosis, and ileocecal and bladder endometriosis. \nTherefore, it is imperative to inform endometriosis patients \nscheduled for surgery about the risk of appendectomy, \nespecially in stage III -IV endometriosis or widespread \nendometriosis. The causes of infertility in patients with \nendometriosis remain unclear. Laparoscopic surgical \ntreatment of endometriosis in combination with medical \ntreatment improves fertility. Appendectomy may be part of \nthe surgical treatment of endometriosis, but this is still \ncontroversial. Prospective randomized trials are needed to \nevaluate and compare the benefits and risks of selective, \ninvoluntary appendectomy for appendicular endometriosis. \n\nInternational Journal of Case Reports in Surgery http://www.casereportsofsurgery.com \n \n~ 29 ~ \nReferences \n1. Mowers EL, Lim CS, Skinner B, Mahnert N, Kamdar \nN, Morgan DM, As -Sanie S. Prevalence of \nEndometriosis During Abdominal or Laparoscopic \nHysterectomy for Chronic Pelvic Pain. Obstet . \nGynecol. 2016 Jun;127(6):1045-1053.  \n10.1097/AOG.0000000000001422 \n2. Abrão MS, Dias JA Jr, Rodini GP, Podgaec S, Bassi \nMA, Averbach M. Endometriosis at several sites, cyclic \nbowel symptoms, and the likelihood of the appendix \nbeing affected. Fertil. Steril. 2010 Aug;94(3):1099-101. \n10.1016/j.fertnstert.2009.10.031 \n3. Moulder JK, Siedhoff MT, Melvin KL, et al . Risk of \nappendiceal endometriosis among women with deep -\ninfiltrating endometriosis. 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Obstet. 2002 Oct;79(1):53-54.  \n10.1016/s0020-7292(02)00195-9 \n \nHow to Cite This Article \nChelly C, Rejeb  OB, Chelly  S, Derouiche M, Boughizane S. \nAppendectomy during surgery for ovarian endometrioma: A case \nreport and review of literature . International Journal of Case Reports \nin Surgery. 2024;6(1):27-29. \n \n \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the \nterms of the Creative C ommons Attribution -Non Commercial-Share \nAlike 4.0 International (CC BY -NC-SA 4.0) License, which allows \nothers to remix, tweak, and build upon the work non -commercially, \nas long as appropriate credit is given and the new creations are \nlicensed under the identical terms.","source_license":"CC0","license_restricted":false}