{"paper_id":"f274c1ba-6f26-4a0b-a03a-dda99adc1337","body_text":"Open Journal of Obstetrics and Gynecology, 2024, 14, 1867-1872 \nhttps://www.scirp.org/journal/ojog \nISSN Online: 2160-8806 \nISSN Print: 2160-8792 \n \nDOI: 10.4236/ojog.2024.1412155  Dec.  25, 2024 1867 Open Journal of Obstetrics and Gynecology \n \n \n \n \nSurgical Management of Appendicular \nEndometriosis: A Series of Cases \nHaley Calcagnotto1, Gabriela Françoes Rostirolla1*, Arthur Henry Michelon1,  \nÉlvio Heitor Michelon2, Eduardo Brambilla3 \n1Department of Gynecology, Caxias do Sul University, Rio Grande do Sul, Brazil \n2Endoelite Institute, Caxias do Sul, Brazil \n3Department of Coloproctology, Caxias do Sul University, Rio Grande do Sul, Brazil \n \n \n \nAbstract \nEndometriosis is a condition characterized by the presence of endometrial tis-\nsue outside the uterine cavity. This tissue, found in the inner lining of the \nuterus, develops in other pelvic organs, such as the ovaries, fallopian tubes, \nperitoneum, and bowel. In cases of deep endometrios is, the appendix may be \naffected, and consequently, appendectomy becomes a perioperative possibil-\nity. From February 2018 to February 2023, the surgical team performed 133 \nlaparoscopic procedures. The number of appendectomies by the time of the \nsurgical procedure was 19.5% (26 cases), with 50% of these (13 cases) confirm-\ning the histological presence of appendiceal endometriosis (AE), no increasing \nof postoperative complications w as noticed. This report is important to rein-\nforce multidisciplinary training, review postoperative complications, and pro-\nvide training in advanced pelvic surgery. Furthermore, it aims to emphasize \nthat appendectomy performed during the surgical act is a safe and viable pro-\ncedure that does not increase complication rates. \n \nKeywords \nEndometriosis, Appendix, Appendicular Endometriosis, Appendectomy, \nLaparoscopy \n \n1. Introduction \nEndometriosis is an estrogen-dependent disease characterized by its high replica-\ntive and expansive capacity within the abdominal cavity. The pathophysiology of \nendometriosis arises from the presence of endometrial -like tissue and/or stroma \noutside the uterine cavity, typically resulting in inflammation of the affected tissue. \nThis inflammatory response is accompanied by increased cytokine and growth \nHow to cite this paper: Calcagnotto, H . \nRostirolla, G.F., Michelon, A.H., Michelon, \nÉ.H. and Brambilla, E. (2024) Surgical Man-\nagement of Appendicular Endometriosis: A \nSeries of Cases . Open Journal of Obstetrics \nand Gynecology, 14, 1867-1872. \nhttps://doi.org/10.4236/ojog.2024.1412155 \n \nReceived:  November 21, 2024 \nAccepted: December 22, 2024 \nPublished: December 25, 2024 \n \nCopyright © 2024 by author(s) and  \nScientific Research Publishing Inc. \nThis work is licensed under the Creative \nCommons Attribution International  \nLicense (CC BY 4.0). \nhttp://creativecommons.org/licenses/by/4.0/   \n  \nOpen Access\n\nH. Calcagnotto et al. \n \n \nDOI: 10.4236/ojog.2024.1412155 1868 Open Journal of Obstetrics and Gynecology \n \nfactor secretion, stimulation of angiogenesis, nerve involvement, and anatomical \ndistortion [1]. Common sites of endometriosis include the ovaries, fallopian tubes, \npelvic peritoneum, and uterosacral ligaments, whereas atypical sites may involve \nthe gastrointestinal tract, urinary tract, soft tissues, and thoracic cavity [1] [2]. \nAbrão et al. [3] describe that women with deep endometriotic lesions may also \nexperience appendicular endometriosis (AE) with associated intestinal symptoms. \nClinical manifestations of AE in affected women may include acute or chronic \npelvic pain, fever, intussusception, or lower gastrointestinal bleeding, which often \nworsens during menstruation [2] [4] [5]. Although AE incidence remains low, its \npotential for mimicking acute appendicitis necessitates a prepared clinical ap-\nproach to differentiate it from acute appendicitis and may require surgical inter-\nvention in elective cases [6]. \nLaparoscopic examination of the affected appendix often reveals signs such \nas edema, rigidity, hyperemia, and congestion; however, a definitive diagnosis \nof AE can only be confirmed through resection and histopathological analysis \n[2] [3] [7]. Appendectomy during endometriosis surgery can potentially alle-\nviate chronic pelvic pain, reduce future appendectomy risk, prevent appendi-\ncitis in endometriosis patients, and thereby reduce associated healthcare costs \n[2] [8] [9]. This study aims to evaluate the prevalence of AE in surgical proce-\ndures performed between February 2018 and February 2023 in symptomatic \nwomen with endometriosis and to examine potential complications associated \nwith this condition . \n2. Patients and Methods \nThis retrospective cross -sectional study included 133 patients who underwent \nsurgery for endometriosis performed by the same surgical team, with an analysis \nof cases in which appendectomy was conducted for specific clinical indications. \nAll patients had a history of chronic abdominal pain, either intermittent or con-\ntinuous, lasting six months or more, and had been using contraceptives and anal-\ngesics chronically to manage symptoms (Table 1 ). \nAll procedures were perform ed via video  laparoscopy by the same team, pri-\nmarily for endometriosis treatment due to either pain or infertility. Appendec-\ntomy was performed by the co -author when indicated intraoperatively, based on \nabnormal appendiceal findings such as visible AE lesions, adhesions, rigidity, con-\ngestion, hyperemia, and color changes. \nThe appendectomy technique involved ligation of the appendicular artery, mo-\nbilization of the appendix, closure of the stump with non-invaginated sutures, and \ncold scissor resection. The specimen was extracted through the laparoscopic tro-\ncar and preserved in formalin for histopathological analysis. Hemostasis of oper-\native fields was verified following excision. \nPreoperative investigations included transvaginal ultrasound, computed to-\nmography, magnetic resonance imaging, and/or colonoscopy. All exams were re-\nalized with intestinal preparation. \n\nH. Calcagnotto et al. \n \n \nDOI: 10.4236/ojog.2024.1412155 1869 Open Journal of Obstetrics and Gynecology \n \n3. Results \nBetween February 2018 and February 2023, 133 patients were included in the \nstudy. The mean patient age was 39 years (range: 22  - 53 years). Surgical indica-\ntions included complaints of pelvic and abdominal pain, either chronic, intermit-\ntent, or continuous for six months or more, in association with endometriosis \n(Table 1 ). \n \nTable 1 . Preoperative signs and symptoms. \nSIGNS AND SYMPTOMS No AE With AE \nAbdominal pain All All \nInfertility 42 6 \nDyschezia 7 3 \nDysmenorrhea 6 1 \nLow back pain 3 - \nDysuria 2 1 \nIntestinal nodule 2 - \nConstipation 2 - \nDyspareunia 2 - \nHematochezia - 1 \nRight shoulder pain 1 - \n \nThe appendectomy procedure was performed in 26 patients (19.5%), over the 132 \npatients that showed bowel endometriosis. Other treatments included 55 shaving \nresections (38.8%), 43 segmental resections (30.3%) and 36 discoid resections of the \nrectal anterior wall (25.3%). Additional procedures are detailed in Figure 1.  \n \n \nFigure 1 . GIT procedures performed during surgery. \n\n\nH. Calcagnotto et al. \n \n \nDOI: 10.4236/ojog.2024.1412155 1870 Open Journal of Obstetrics and Gynecology \n \nHistopathological analysis confirmed endometriosis in 13 of the 26 appendec-\ntomy specimens (50%), representing 10% of the total sample. No postoperative \ncomplications related to appendectomy were observed. Documented intestinal \ncomplications included six cases (4.5%) of constipation, small bowel obstruction, \nrectal granulomas, fistula formation, late bleeding, and hematomas (Table 2 ). \n \nTable 2 . Postoperative complications. \nCOMPLICATIONS (n = 10) No Appendectomy With Appendectomy \nLate bleeding 3 cases 1 case \nFistula 2 cases - \nHematoma 2 cases - \nIntestinal obstruction - 1 case \nIntestinal colitis 1 case - \nTotal= 8 2 \n4. Discussion \nThe presence of appendicular endometriosis (AE) was initially described in 1860 \nby the Austrian pathologist Karl von Rokitansky [8] . In 1955, Collins D.C. [9]  \nidentified AE in 0.054% of cases within a study of 50,000 appendix specimens. \nSubsequently, Feldhaus et al. [4], reported AE in less than 1% of women on post-\nappendectomy pathological analysis. \nAE manifestations range from asymptomatic presentations to acute appendici-\ntis-like symptoms, lower gastrointestinal bleeding, perforation, or intestinal ob-\nstruction due to intussusception [2] [6] [7]. The clinical signs often mimic gastro-\nintestinal diseases, with symptoms such as abdominal pain, diarrhea, constipa-\ntion, bloating, flatulence, nausea, and vomiting [2]  [6] [10]-[14]. Melena [2]  [6] \n[9], proctalgia [15] , and gut microbiota alterations [13]  have also been docu-\nmented. Symptoms resembling appendicitis, particularly in young women with a \nhistory of infertility and pelvic endometriosis, may prompt suspicion of AE [2]  \n[4] [6] [7] [15]. \nIn two-thirds of AE cases, histopathological involvement extends to muscular \nand seromuscular layers, with one-third involving only the serosal surface [7]. AE \nmay exhibit mucosal or submucosal infiltration, leading to symptoms similar to \ninflammatory diseases like Crohn’s disease, enteritis, and ischemic colitis [7] [14]. \nDue to endometriosis’ diverse manifestations and nonspecific indications, ac-\ncurate preoperative AE diagnosis is challenging [14] . Transvaginal ultrasonogra-\nphy, MRI, and Doppler ultrasound are not definitively diagnostic for AE, though \nLuzier J. et al. [15] reported the “doughnut sign” on ultrasound as indicative of \nAE with intussusception. Serum CA125 levels may be elevated but tend to nor-\nmalize postoperatively [14]. \nLaparoscopy, confirmed through histopathology, remains the most effective di-\nagnostic tool. Appendectomy is recommended for pain resolution and visibly \n\nH. Calcagnotto et al. \n \n \nDOI: 10.4236/ojog.2024.1412155 1871 Open Journal of Obstetrics and Gynecology \n \nabnormal appendices [2]  [4] [7] [16]. Abrão MS et al. [16] adds that in laparos-\ncopy, it is impossible to state that a normal -appearing appendix is truly  free of \ndisease, however, they believe this to be clinically irrelevant as they also imply that \nit would be unethical to perform an appendectomy on an appendix laparoscopi-\ncally normal. Mabrouk M. et al. [12] emphasize that patients with endometriosis \nundergoing surgery should be counseled on the potential for appendectomy.  \nIn this study, histopathological abnormalities were confirmed in 13 of the 26 \nresected appendices. Abnormal findings during laparoscopy, such as intussuscep-\ntion, edema, adhesion, or nearby endometriosis, were reliable indicators for AE, \nthough only half were histologically confirmed. \n5. Conclusion \nAppendicular endometriosis is an important but relatively uncommon finding. \nSurgical assessment of the appendix during endometriosis procedures is critical. \nWhile clinical symptoms and imaging may suggest AE, definitive diagnosis relies \non histopathological evaluation. Appendectomy is warranted when laparoscopy \nidentifies abnormalities; however, there is no consensus on removal in cases with \na macroscopically normal appendix. Patients should receive appropriate counsel-\ning prior to surgery, and further prospective, randomized studies are necessary to \nestablish a standard recommendation for appendectomy in women with endome-\ntriosis. \nConflicts of Interest \nThe authors declare no conflicts of interest regarding the publication of this paper. \nReferences \n[1] Song, S.Y., Jung, Y.W., Shin, W., Park, M., Lee, G.W., Jeong, S., et al. (2023) Endo-\nmetriosis-Related Chronic Pelvic Pain. Biomedicines, 11, Article 2868.  \nhttps://doi.org/10.3390/biomedicines11102868 \n[2] Allahqoli, L., Mazidimoradi, A., Momenimovahed, Z., Günther, V., Ackermann, J., \nSalehiniya, H., et al. (2023) Appendiceal Endometriosis: A Comprehensive Review of \nthe Literature. Diagnostics, 13, Article 1827.  \nhttps://doi.org/10.3390/diagnostics13111827 \n[3] Abrao, M.S., Goncalves, M.O.D.C., Dias, J.A., Podgaec, S., Chamie, L.P. and Blasbalg, \nR. 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