The clinical features and long-term surgical outcomes of different types of abdominal wall endometriosis

Surgical and Percutaneous Image-guided Therapies of Abdominal Wall Endometriosis: a Systematic Review of Current Evidence

OBJECTIVE

Despite various surgical and non-surgical strategies for abdominal wall endometriosis, the lack of definitive guidance on optimal treatment choice leads to clinical uncertainty. This review scrutinizes the safety and efficacy of abdominal wall endometriosis treatments to aid in decision-making.

DATA SOURCES

We performed a systematic literature review of PubMed, Embase and Cochrane Library databases from 1947 until December 2023.

METHODS OF STUDY SELECTION

A comprehensive literature search identified studies that assessed both surgical and nonsurgical interventions, including high-intensity focused ultrasound (HIFU), cryoablation, radiofrequency ablation (RFA), and microwave ablation (MWA). This review is registered in NIHR-PROSPERO (CRD 42023494969). Local tumor control (LTC), local pain relief (LPR) and adverse events (AE) were recorded.

TABULATION, INTEGRATION, AND RESULTS

This review included 51 articles among 831 identified. All study designs were considered eligible for inclusion. A total of 2,674 patients are included: 2,219 patients (83%) undergoing surgery, and 455 (17%) undergoing percutaneous interventions (342 HIFU, 103 cryoablation, 1 RFA, 9 MWA). Follow-up length was 18 months in median, ranging from 1 to 235 months. Overall LTC rates ranged from 86% to 100%. Surgical interventions consistently demonstrated the highest rate of LTC with a median rate of 100%, and LPR with a median rate of 98.2% (95% confidence interval [CI]: 93.9-97.7). HIFU showed median LTC and LPR rates, respectively of 95.65% (95% CI, 87.7-99.9) and 76.1% (95% CI, 61.8-90.4); and cryoablation of 85.7% (95% CI, 66.0-99.9) and 79.2% (95% CI, 67.4-91.03). Minor AE were reported after surgery in 17.5% of patients (225/1284) including 15.9% (199/1284) of mesh implantation; 76.4% (239/313) after HIFU; and 8.7 % (9/103) after cryoablation. Severe AE were reported in 25 patients in the surgery group and 1 in the percutaneous group.

CONCLUSION

The safety profile and efficacy of nonsurgical interventions support their clinical utility for management of abdominal wall endometriosis.

Effectiveness and complication rates of high intensity focused ultrasound treatment for abdominal wall endometriosis: A systematic review

In this review, a systematic literature search on the effectiveness and complication rates of ultrasound-guided and magnetic resonance-guided high-intensity focused ultrasound (USg-/MRgHIFU) for abdominal wall endometriosis (AWE) was conducted in six databases in May/June 2023. Original articles of (non)randomized trials, cohort studies, case-control studies and case series published in peer-reviewed journals were included. Of the included studies the level of evidence (LoE) and methodological quality using the ROBINS-I and IHE-QAT was assessed. Primary outcomes were non-perfused volume ratio (NPV%), lesion size, pain scores, side effects and complication rates according to Society of Interventional Radiology (SIR) guidelines. Secondary outcomes were recurrence and re-intervention rates. Seven cohort studies (one of good methodological quality) (LoE 3) on USgHIFU were included (n = 212, AWE lesions = 240-245). Six months after USgHIFU treatment, pain scores were reduced with 3.3-5.2 points (baseline: 5.1-6.8, n = 135). Self-limiting side effects were pain (85.7 % (114/133)) and swelling (34.6 % (46/133)) in the treatment area. Complications occurred in 17.7 % (32/181), all of which were minor. Recurrence occurred in 12.8 % (11/86). Three of these seven cohort studies compared USgHIFU (n = 61) with surgical excision (n = 74). Pooled results showed no significant differences in pain scores, complications (resp. 26.3 % (10/38) vs. 32.6 % (15/46) (p = 0.53)) and recurrences (resp. 4.9 % (3/61) vs. 5.4 % (4/74) (p = 0.90)). This systematic review suggests that HIFU is an effective and safe treatment option for AWE. USgHIFU treatment led to reduced pain scores and lesion size, was free of major complications and had a pooled recurrence rate of 12.8 %. Compared to surgical excision pooled results showed no significant differences in pain scores, complications and recurrences after USgHIFU. However, many of the included studies had limitations in their methodological quality and therefore the results should be interpreted with caution. Well-structured high-quality randomized controlled trials comparing HIFU to standard care should be conducted to provide more conclusive evidence.

Surgical management of abdominal wall sheath and rectus abdominis muscle endometriosis: a case report and literature review

Introduction

Endometriosis, defined as the presence of endometrial glands and stroma outside the uterine cavity, mainly affects the pelvic viscera and peritoneum. Endometriosis can also occur at sites of surgical incisions on the abdominal wall, mainly in women with a history of cesarean section (CS). The incidence of abdominal wall endometriosis after CS reaches 1%. Clinical suspicion, along with imaging, plays a crucial role in diagnosis. The preferred treatment involves extensive surgical excision with clear margins, ensuring a definitive diagnosis through histopathology examination.

Case presentation

This case report is of a 44-year-old woman with a history of two CS procedures who developed pain and pigmentation at the incisional site one year after the last CS. Thirteen years after the surgical excision of an abdominal wall endometriosis (AWE) mass, followed by hormone therapy, she presented in our hospital with worsening pain for further management. Pelvic MRI findings were consistent with AWE. During surgery, the abdominal wall endometriosis foci were removed, and the defect in the aponeurosis was repaired using a dual-sided mesh in a tension-free procedure.

Conclusion

Although AWE is a rare condition, we foresee an increase in cases because of the ever-increasing CS rates and the important association between AWE and CS. Healthcare practitioners should remain vigilant for this condition in women of reproductive age who exhibit cyclic pain, a palpable mass in the abdomen, and a background of previous uterine surgeries.

Percutaneous Imaging-guided Cryoablation of Endometriosis Scars of the Anterior Abdominal Wall

STUDY OBJECTIVE

To evaluate the safety and clinical efficacy of percutaneous imaging-guided cryoablation for the management of anterior abdominal wall endometriosis.

DESIGN

Patients with abdominal wall endometriosis underwent percutaneous imaging-guided cryoablation and had a 6-month follow-up.

SETTING

Data dealing with patients' and anterior abdominal wall endometriosis (AAWE) characteristics, cryoablation, and clinical and radiologic outcomes were retrospectively collected and analyzed.

PATIENTS

Twenty-nine consecutive patients underwent cryoablation from June 2020 to September 2022.

INTERVENTIONS

Interventions were performed under US/computed tomography (CT) guidance or magnetic resonance imaging (MRI) guidance. Cryoprobes were directly inserted into the AAWE, and cryoablation was performed with a single 5 to 10 minute freezing cycle, which was stopped when the iceball expanded 3 to 5 mm beyond AAWE borders as assessed on intra-procedural cross-sectional imaging.

MEASUREMENTS AND MAIN RESULTS

Fifteen patients (15/29; 51.7%) had prior endometriosis, 28 (28/29; 95.5%) had previous cesarian section, and 22 (22/29; 75.9%) referred association between symptoms and menses. Cryoablation was performed under local (16/29; 55.2%) or general anesthesia (13/29; 44.8%) and mainly in an out-patient basis (18/20; 62%). There was only one (1/29; 3.5%) minor procedure-related complication. Complete symptom relief was recorded in 62.1% (18/29) and 72.4% (21/29) patients at 1 and 6 months, respectively. In the whole population, pain significantly dropped at 6 months compared to the baseline (1.1 ± 2.3; range 0-8 vs 7.1 ± 1.9; range 3-10; p <.05). Eight (8/29; 27.6%) patients presented residual symptoms at 6 months, and 4 (4/29; 13.8%) had an MRI-confirmed residual/recurring disease. Contrast-enhanced MRI obtained for the first 14 (14/29; 48.3%) patients of the series, all without signs of residual/recurring disease, demonstrated a significantly smaller ablation area compared to the baseline volume of the AAWE (1.0 cm3 ± 1.4; range 0-4.7; vs 11.1 ± 9.9 cm3; range 0.6-36.4; p <.05).

CONCLUSION

Percutaneous imaging-guided cryoablation of AAWE is safe and clinically effective in achieving pain relief.