Surgical Management of Appendicular Endometriosis: A Series of Cases

Endometriosis is a condition characterized by the presence of endometrial tis- sue outside the uterine cavity. This tissue, found in the inner lining of the uterus, develops in other pelvic organs, such as the ovaries, fallopian tubes, peritoneum, and bowel. In cases of deep endometrios is, the appendix may be affected, and consequently, appendectomy becomes a perioperative possibil- ity. From February 2018 to February 2023, the surgical team performed 133 laparoscopic procedures. The number of appendectomies by the time of the surgical procedure was 19.5% (26 cases), with 50% of these (13 cases) confirm- ing the histological presence of appendiceal endometriosis (AE), no increasing of postoperative complications w as noticed. This report is important to rein- force multidisciplinary training, review postoperative complications, and pro- vide training in advanced pelvic surgery. Furthermore, it aims to emphasize that appendectomy performed during the surgical act is a safe and viable pro- cedure that does not increase complication rates.

Endometriosis, Appendix, Appendicular Endometriosis, Appendectomy, Laparoscopy 1. Introduction Endometriosis is an estrogen-dependent disease characterized by its high replica- tive and expansive capacity within the abdominal cavity. The pathophysiology of endometriosis arises from the presence of endometrial -like tissue and/or stroma outside the uterine cavity, typically resulting in inflammation of the affected tissue. This inflammatory response is accompanied by increased cytokine and growth How to cite this paper: Calcagnotto, H . Rostirolla, G.F., Michelon, A.H., Michelon, É.H. and Brambilla, E. (2024) Surgical Man- agement of Appendicular Endometriosis: A Series of Cases . Open Journal of Obstetrics and Gynecology, 14, 1867-1872. https://doi.org/10.4236/ojog.2024.1412155 Received: November 21, 2024 Accepted: December 22, 2024 Published: December 25, 2024 Copyright © 2024 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access H. Calcagnotto et al. DOI: 10.4236/ojog.2024.1412155 1868 Open Journal of Obstetrics and Gynecology factor secretion, stimulation of angiogenesis, nerve involvement, and anatomical distortion [1]. Common sites of endometriosis include the ovaries, fallopian tubes, pelvic peritoneum, and uterosacral ligaments, whereas atypical sites may involve the gastrointestinal tract, urinary tract, soft tissues, and thoracic cavity [1] [2]. Abrão et al. [3] describe that women with deep endometriotic lesions may also experience appendicular endometriosis (AE) with associated intestinal symptoms. Clinical manifestations of AE in affected women may include acute or chronic pelvic pain, fever, intussusception, or lower gastrointestinal bleeding, which often worsens during menstruation [2] [4] [5]. Although AE incidence remains low, its potential for mimicking acute appendicitis necessitates a prepared clinical ap- proach to differentiate it from acute appendicitis and may require surgical inter- vention in elective cases [6]. Laparoscopic examination of the affected appendix often reveals signs such as edema, rigidity, hyperemia, and congestion; however, a definitive diagnosis of AE can only be confirmed through resection and histopathological analysis [2] [3] [7]. Appendectomy during endometriosis surgery can potentially alle- viate chronic pelvic pain, reduce future appendectomy risk, prevent appendi- citis in endometriosis patients, and thereby reduce associated healthcare costs [2] [8] [9]. This study aims to evaluate the prevalence of AE in surgical proce- dures performed between February 2018 and February 2023 in symptomatic women with endometriosis and to examine potential complications associated with this condition . 2. Patients and Methods This retrospective cross -sectional study included 133 patients who underwent surgery for endometriosis performed by the same surgical team, with an analysis of cases in which appendectomy was conducted for specific clinical indications. All patients had a history of chronic abdominal pain, either intermittent or con- tinuous, lasting six months or more, and had been using contraceptives and anal- gesics chronically to manage symptoms (Table 1 ). All procedures were perform ed via video laparoscopy by the same team, pri- marily for endometriosis treatment due to either pain or infertility. Appendec- tomy was performed by the co -author when indicated intraoperatively, based on abnormal appendiceal findings such as visible AE lesions, adhesions, rigidity, con- gestion, hyperemia, and color changes. The appendectomy technique involved ligation of the appendicular artery, mo- bilization of the appendix, closure of the stump with non-invaginated sutures, and cold scissor resection. The specimen was extracted through the laparoscopic tro- car and preserved in formalin for histopathological analysis. Hemostasis of oper- ative fields was verified following excision. Preoperative investigations included transvaginal ultrasound, computed to- mography, magnetic resonance imaging, and/or colonoscopy. All exams were re- alized with intestinal preparation. H. Calcagnotto et al. DOI: 10.4236/ojog.2024.1412155 1869 Open Journal of Obstetrics and Gynecology 3. Results Between February 2018 and February 2023, 133 patients were included in the study. The mean patient age was 39 years (range: 22 - 53 years). Surgical indica- tions included complaints of pelvic and abdominal pain, either chronic, intermit- tent, or continuous for six months or more, in association with endometriosis (Table 1 ). Table 1 . Preoperative signs and symptoms. SIGNS AND SYMPTOMS No AE With AE Abdominal pain All All Infertility 42 6 Dyschezia 7 3 Dysmenorrhea 6 1 Low back pain 3 - Dysuria 2 1 Intestinal nodule 2 - Constipation 2 - Dyspareunia 2 - Hematochezia - 1 Right shoulder pain 1 - The appendectomy procedure was performed in 26 patients (19.5%), over the 132 patients that showed bowel endometriosis. Other treatments included 55 shaving resections (38.8%), 43 segmental resections (30.3%) and 36 discoid resections of the rectal anterior wall (25.3%). Additional procedures are detailed in Figure 1. Figure 1 . GIT procedures performed during surgery. H. Calcagnotto et al. DOI: 10.4236/ojog.2024.1412155 1870 Open Journal of Obstetrics and Gynecology Histopathological analysis confirmed endometriosis in 13 of the 26 appendec- tomy specimens (50%), representing 10% of the total sample. No postoperative complications related to appendectomy were observed. Documented intestinal complications included six cases (4.5%) of constipation, small bowel obstruction, rectal granulomas, fistula formation, late bleeding, and hematomas (Table 2 ). Table 2 . Postoperative complications. COMPLICATIONS (n = 10) No Appendectomy With Appendectomy Late bleeding 3 cases 1 case Fistula 2 cases - Hematoma 2 cases - Intestinal obstruction - 1 case Intestinal colitis 1 case - Total= 8 2 4. Discussion The presence of appendicular endometriosis (AE) was initially described in 1860 by the Austrian pathologist Karl von Rokitansky [8] . In 1955, Collins D.C. [9] identified AE in 0.054% of cases within a study of 50,000 appendix specimens. Subsequently, Feldhaus et al. [4], reported AE in less than 1% of women on post- appendectomy pathological analysis. AE manifestations range from asymptomatic presentations to acute appendici- tis-like symptoms, lower gastrointestinal bleeding, perforation, or intestinal ob- struction due to intussusception [2] [6] [7]. The clinical signs often mimic gastro- intestinal diseases, with symptoms such as abdominal pain, diarrhea, constipa- tion, bloating, flatulence, nausea, and vomiting [2] [6] [10]-[14]. Melena [2] [6] [9], proctalgia [15] , and gut microbiota alterations [13] have also been docu- mented. Symptoms resembling appendicitis, particularly in young women with a history of infertility and pelvic endometriosis, may prompt suspicion of AE [2] [4] [6] [7] [15]. In two-thirds of AE cases, histopathological involvement extends to muscular and seromuscular layers, with one-third involving only the serosal surface [7]. AE may exhibit mucosal or submucosal infiltration, leading to symptoms similar to inflammatory diseases like Crohn’s disease, enteritis, and ischemic colitis [7] [14]. Due to endometriosis’ diverse manifestations and nonspecific indications, ac- curate preoperative AE diagnosis is challenging [14] . Transvaginal ultrasonogra- phy, MRI, and Doppler ultrasound are not definitively diagnostic for AE, though Luzier J. et al. [15] reported the “doughnut sign” on ultrasound as indicative of AE with intussusception. Serum CA125 levels may be elevated but tend to nor- malize postoperatively [14]. Laparoscopy, confirmed through histopathology, remains the most effective di- agnostic tool. Appendectomy is recommended for pain resolution and visibly H. Calcagnotto et al. DOI: 10.4236/ojog.2024.1412155 1871 Open Journal of Obstetrics and Gynecology abnormal appendices [2] [4] [7] [16]. Abrão MS et al. [16] adds that in laparos- copy, it is impossible to state that a normal -appearing appendix is truly free of disease, however, they believe this to be clinically irrelevant as they also imply that it would be unethical to perform an appendectomy on an appendix laparoscopi- cally normal. Mabrouk M. et al. [12] emphasize that patients with endometriosis undergoing surgery should be counseled on the potential for appendectomy. In this study, histopathological abnormalities were confirmed in 13 of the 26 resected appendices. Abnormal findings during laparoscopy, such as intussuscep- tion, edema, adhesion, or nearby endometriosis, were reliable indicators for AE, though only half were histologically confirmed. 5. Conclusion Appendicular endometriosis is an important but relatively uncommon finding. Surgical assessment of the appendix during endometriosis procedures is critical. While clinical symptoms and imaging may suggest AE, definitive diagnosis relies on histopathological evaluation. Appendectomy is warranted when laparoscopy identifies abnormalities; however, there is no consensus on removal in cases with a macroscopically normal appendix. Patients should receive appropriate counsel- ing prior to surgery, and further prospective, randomized studies are necessary to establish a standard recommendation for appendectomy in women with endome- triosis. Conflicts of Interest The authors declare no conflicts of interest regarding the publication of this paper.

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