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Pagano F, Dedes I, Imboden S, Mueller MD. Connecting the dots: Exploring appendiceal endometriosis in women with diaphragmatic endometriosis. Eur J Obstet Gynecol Reprod Biol 2024; 302:134-140. [PMID: 39265199 DOI: 10.1016/j.ejogrb.2024.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 08/23/2024] [Accepted: 08/30/2024] [Indexed: 09/14/2024]
Abstract
OBJECTIVES This study aims to ascertain the prevalence of appendiceal endometriosis (AppE) in patients diagnosed with diaphragmatic endometriosis (DiaE), compare it with the prevalence in patients without DiaE, and delineate the anatomical distribution of endometriotic lesions within these cohorts. STUDY DESIGN Comparison of the characteristics of patients with AppE and DiaE with the characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study. SETTING Tertiary referral center; endometriosis center. PATIENTS A cohort of 1765 patients with histologically confirmed endometriosis INTERVENTIONS: Evaluation of correlations between demographic, clinical, and surgical variables of AppE patients with DiaE and without DiaE. We performed appendectomies selectively, in the presence of gross abnormalities of the appendix, such as endometriotic implants, edema, tortuosity, and discoloration of the organ. MEASUREMENTS Patients' characteristics were evaluated using basic descriptive statistics (chi-square test or Fisher's exact test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between patient characteristics and the presence of DiaE and AppE. MAIN RESULTS Within a cohort of 1765 patients with histologically confirmed endometriosis, 31 were identified with AppE (1.8 %), and 83 with DiaE (4.7 %). The prevalence of DiaE was significantly elevated at 30.1 % (25/83), among patients with AppE compared to those without AppE, who showed a DiaE prevalence of 7.2 % (6/83). The calculated odds ratio for DiaE given the presence of AppE was 5.5, 95 % CI 2.1-14.4, p = 0.0004, and risk ratio was 4.2, 95 % CI 1.8-9.6, p = 0.0008, indicating a profound association. Surgical interventions did not lead to significant perioperative or postoperative complications. In the group with DiaE, the left ovary was affected in 96 % of cases (24/25), p < 0.05, the right ureter in 80 % of cases (20/25), p < 0.01 (in 19/25 only the serosa was affected, due to external compression of an endometriotic nodule of the parametrium). Concurrent AppE and right diaphragm was found in 92 % of cases (23/25 patients), p < 0.001. The concurrent presence of DiaE and AppE was often associated with severe endometriosis, rASRM IV 72 % OR = 3, 95 % CI (1.216-7.872). CONCLUSION The investigation delineates a marked association between AppE and DiaE, with an odds ratio of 5.5 and risk ratio of 4.2, suggesting a markedly increased likelihood of DiaE in patients with AppE. These statistics significantly substantiate the notion that AppE can serve as a predictive marker for DiaE, underscoring the necessity for a meticulous intraoperative assessment of diaphragmatic regions in patients diagnosed with AppE. The absence of a significant correlation between the depth of DiaE infiltration and the presence of AppE implies that the detection of AppE should prompt a thorough search for DiaE, regardless of the perceived severity of the endometriosis or preoperative results of diaphragmatic MRI.
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Affiliation(s)
- Flavia Pagano
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland.
| | - Ioannis Dedes
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Sara Imboden
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Michael D Mueller
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland
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Galaviz VD, Nguyen AD, Sticco PL, Downing KT. Appendectomy in endometriosis: an update on surgical indications and management of uncommon diseases. Curr Opin Obstet Gynecol 2023; 35:377-382. [PMID: 37144569 DOI: 10.1097/gco.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE OF REVIEW Abnormal appendiceal disease is commonly encountered following an appendectomy when performed in patients with endometriosis. Appendiceal endometriosis is the most notable finding and can affect up to 39% of patients with endometriosis. Despite this knowledge, guidelines for performing an appendectomy have not been formally established. In this article, we review the surgical indications for an appendectomy at the time of endometriosis surgery and discuss the management of other diseases that may be encountered following the histopathologic evaluation of an excised appendix. RECENT FINDINGS Removal of the appendix in patients with endometriosis contributes to optimal surgical management. Relying on abnormal appendiceal appearance for removal may leave endometriosis-affected appendices. For this reason, utilizing risk factors to guide surgical management is essential. Common appendiceal diseases are sufficiently managed with appendectomy. Uncommon diseases may require further surveillance. SUMMARY Emerging data in our field support the performance of an appendectomy at the time of endometriosis surgery. Guidelines for performing a concurrent appendectomy should be formalized to encourage preoperative counselling and management for patients with risk factors for appendiceal endometriosis. Abnormal diseases is frequently encountered after appendectomy in the setting of endometriosis surgery and further management is based on the histopathology of the specimen.
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Allahqoli L, Mazidimoradi A, Momenimovahed Z, Günther V, Ackermann J, Salehiniya H, Alkatout I. Appendiceal Endometriosis: A Comprehensive Review of the Literature. Diagnostics (Basel) 2023; 13:diagnostics13111827. [PMID: 37296678 DOI: 10.3390/diagnostics13111827] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Objective: the purpose of this review was to evaluate the prevalence of appendiceal endometriosis and the safety of concomitant appendectomy in women with endometriosis or pelvic pain. Materials and Methods: We searched the electronic databases Medline (PubMed), Scopus, Embase, and Web of Science (WOS). The search was not subject to any limitation in terms of time or method. The primary research question was: what is the prevalence of appendiceal endometriosis? The secondary research question was: is it safe to perform appendectomy during surgery for endometriosis? Publications that reported data about appendiceal endometriosis or appendectomy in women with endometriosis were reviewed regarding the inclusion criteria. Results: We found 1418 records. After review and screening, we included 75 studies published between 1975 and 2021. With regard to the first question of the review, we found 65 eligible studies and divided these into the following two categories: (a) endometriosis of the appendix presenting as acute appendicitis, and (b) endometriosis of the appendix as an incidental finding in gynecological surgery. Forty-four case reports described appendiceal endometriosis in women who were admitted for the treatment of pain in the right-sided lower abdomen. Endometriosis of the appendix was observed in 2.67% (range, 0.36-23%) of women who were admitted due to acute appendicitis. In addition, appendiceal endometriosis was an incidental finding during gynecological surgery in 7.23% of cases (range, 1-44.3%). With regard to the second question of the review, which was the safety of appendectomy in women with endometriosis or pelvic pain, we found 11 eligible studies. Reviewed cases had no significant intraoperative or follow-up complications during the 12 weeks. Conclusion: Based on the reviewed studies, coincidental appendectomy appears reasonably safe and was associated with no complications in the cases reviewed for the present report.
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Affiliation(s)
- Leila Allahqoli
- Ministry of Health and Medical Education, Tehran 1467664961, Iran
| | - Afrooz Mazidimoradi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Zohre Momenimovahed
- Department of Midwifery and Reproductive Health, Qom University of Medical Sciences, Qom 3716993456, Iran
| | - Veronika Günther
- University Hospitals Schleswig-Holstein, Kiel School of Gynaecological Endoscopy, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| | - Johannes Ackermann
- University Hospitals Schleswig-Holstein, Kiel School of Gynaecological Endoscopy, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| | - Hamid Salehiniya
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand 9717853577, Iran
| | - Ibrahim Alkatout
- University Hospitals Schleswig-Holstein, Kiel School of Gynaecological Endoscopy, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
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O'Brien MS, Gupta A, Quevedo A, Lenger SM, Shah V, Warehime J, Gaskins J, Biscette S. Postoperative Complications of Appendectomy in Gynecologic Laparoscopic Surgery for Benign Indications. Obstet Gynecol 2023; 141:354-360. [PMID: 36649317 DOI: 10.1097/aog.0000000000005033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/17/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To assess whether concomitant appendectomy in patients who undergo laparoscopic surgery for benign gynecologic indications is associated with increased rates of complications in the 30-day postoperative period. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent laparoscopic surgery by a gynecologist. Patients were excluded if they underwent open abdominal surgeries, bowel resections, urogynecologic surgeries, or if diagnoses of cancer or appendicitis were present. There were 246,987 patients included in the population cohort from 2010 to 2020. Demographic information and postoperative outcomes of patients who underwent concomitant appendectomy were compared with patients who did not undergo appendectomy. A matched cohort was created by computing propensity scores, and outcomes were again compared between groups. All patients undergoing appendectomy were 1:1 matched to a unique patient who did not undergo appendectomy using a greedy matching based on the propensity score calculated from demographic and surgical characteristics. RESULTS A total of 1,760 patients (0.7%) underwent concomitant appendectomy. There was an 8.0% complication rate in the appendectomy group, compared with 5.5% in the group of those without appendectomy ( P <.001), and this was similar to the results in the propensity-matched sample. Patients who underwent appendectomy had significantly higher rates of readmission (4.3% vs 2.3%), which remained significant in the propensity-matched sample. There were no differences in the rates of postoperative thromboembolic events, blood transfusion, or reoperation. CONCLUSION Patients who are undergoing concomitant appendectomy have an increased risk of any complication and hospital readmission. Additional studies may be conducted to identify patients with optimal risk benefit profiles when considering performing concomitant appendectomy at time of gynecologic surgery.
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Affiliation(s)
- M Shea O'Brien
- Department of Obstetrics, Gynecology, and Women's Health, the Department of Urogynecology, Female Pelvic Medicine and Reconstruction, the Department of Minimally Invasive Gynecologic Surgery, and the School of Public Health and Information Science, University of Louisville, Louisville, Kentucky
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Kathopoulis N, Rellias I, Zacharakis D, Chatzipapas I, Diakosavvas M, Kypriotis K, Grigoriadis T, Protopapas A. Benign appendiceal lesions, a case where a gynecologist should be able to perform laparoscopic appendectomy. J Minim Invasive Gynecol 2022; 29:1030-1032. [PMID: 35691548 DOI: 10.1016/j.jmig.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Nikolaos Kathopoulis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Greece.
| | - Ioannis Rellias
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Greece
| | - Dimitrios Zacharakis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Greece
| | - Ioannis Chatzipapas
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Greece
| | - Michail Diakosavvas
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Greece
| | - Konstantinos Kypriotis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Greece
| | - Themos Grigoriadis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Greece
| | - Athanasios Protopapas
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Greece
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Villaescusa M, Andres MP, Amaral AC, Barbosa RN, Abrão MS. Endometriosis and its relation with carcinoid tumor of the appendix: a systematic review. Minerva Obstet Gynecol 2021; 73:606-613. [PMID: 33904692 DOI: 10.23736/s2724-606x.21.04792-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The prevalence of appendiceal endometriosis ranges from 0.4% to 22%. The carcinoid tumor is the most common neoplasm of the appendix, with incidence ranging from 0.3% to 0.9%. Appendix lesions develop in up to 22% of women with deep infiltrative endometriosis. Even though these are most likely endometriosis, carcinoid tumors should always be considered. The aim of this review was to assess the prevalence of appendiceal carcinoid tumors and appendiceal endometriosis in patients undergoing gynecologic surgery, its association with endometriosis, and related symptoms. EVIDENCE ACQUISITION We included retrospective and prospective studies that assessed women who underwent appendicectomy in the past 20 years for appendiceal endometriosis and/or appendix carcinoid tumor confirmed by histological analysis. Results were reported as relative and absolute frequencies. Due to the heterogeneity of included studies, a statistical analysis (meta-analysis) was not performed. EVIDENCE SYNTHESIS The prevalence of appendiceal endometriosis was 15.2% in patients who underwent surgery for pelvic endometriosis and 11.4% in those who underwent benign gynecological surgery. Conversely, carcinoid tumors of the appendix were present in 2.4% of endometriosis patients and 1.3% of other benign gynecological surgeries. CONCLUSIONS The rates of carcinoid tumors in patients with endometriosis are the same as in the general population. Given the risk of a malignant appendiceal tumor, in all gynecological surgeries, especially those for endometriosis, the appendix should be inspected and removed if it has an abnormal appearance.
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Affiliation(s)
- Marina Villaescusa
- Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Marina P Andres
- Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil.,Endometriosis Section, Gynecologic Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alexandre C Amaral
- Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo N Barbosa
- Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil.,Endometriosis Section, Gynecologic Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mauricio S Abrão
- Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil - .,Endometriosis Section, Gynecologic Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Ross WT, Chu A, Li L, Kunselman AR, Harkins GJ, Deimling TA, Benton AS. Appendectomy in the surgical management of women with endometriosis and pelvic pain. Int J Gynaecol Obstet 2021; 154:526-531. [PMID: 33483967 DOI: 10.1002/ijgo.13614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/16/2020] [Accepted: 01/21/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To evaluate the role of appendectomy in surgical excision of endometriosis and to assess complications associated with appendectomy. METHODS Retrospective study of women undergoing appendectomy for pelvic pain and/or endometriosis during a primary gynecologic procedure. RESULTS Record review was performed for 609 women who underwent appendectomy between 2013 and 2019 for pelvic pain (6.9%, 42/609), stage I-II endometriosis (63.7%, 388/609), or stage III-IV endometriosis (29.4%, 179/609). Appendiceal endometriosis (AppE) was present in 14.9% (91/609); 2.4% without endometriosis (1/42, reference group), 7.0% with stage I-II endometriosis (27/388, odds ratio [OR] 3.06, 95% confidence interval [CI] 0.41-23.11, P = 0.278), and 35.2% with stage III-IV endometriosis (63/179, OR 22.24, 95% CI 2.99-165.40, P = 0.002). AppE was significantly associated with endometriosis present in other locations (OR 5.27, 95% CI 2.66-10.43, P < 0.001). The predicted probability of identifying AppE ranged from 6% with 0 positive endometriosis sites to 56% when 4 or more sites were identified. There were no complications related to the performance of an appendectomy. CONCLUSION Women with chronic pelvic pain and/or endometriosis have an increased risk of AppE. Modern appendectomy at the time of gynecologic surgery is safe, with no associated complications in this study. Our findings support the consideration of appendectomy as part of the comprehensive surgical management of endometriosis.
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Affiliation(s)
- Whitney Trotter Ross
- Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Amanda Chu
- Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Linda Li
- Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Penn State Health Hershey Medical Center, Hershey, PA, USA
| | - Allen R Kunselman
- Public Health Sciences, Penn State Hershey College of Medicine, Hershey, PA, USA
| | - Gerald J Harkins
- Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Penn State Health Hershey Medical Center, Hershey, PA, USA
| | - Timothy A Deimling
- Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Penn State Health Hershey Medical Center, Hershey, PA, USA
| | - Andrea S Benton
- Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Penn State Health Hershey Medical Center, Hershey, PA, USA
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Akbulut S, Koç C, Sarıcı B, Özcan M, Şamdancı E, Yılmaz S. Histopathological features of incidental appendectomy specimens obtained from living liver donors. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2020; 31:257-263. [PMID: 32343238 PMCID: PMC7197931 DOI: 10.5152/tjg.2020.19010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND/AIMS To determine the histopathological features of incidental appendectomy specimens obtained from living liver donors (LLDs) Materials and Methods: Between September 2005 and November 2018, 1910 LLDs underwent living donor hepatectomy at our institute. Incidental appendectomy together with living donor hepatectomy (LDH) was performed in 170 LLDs. The decision for incidental appendectomy was made by experienced gastrointestinal surgeons. Histopathological features of the appendectomy specimens were analyzed by two pathologists, and the following parameters were retrospectively evaluated: age, sex, appendix length (mm), appendix width (mm), presence of appendicitis, and unusual histopathological findings. RESULTS Histopathological findings from 97 male and 73 female LLDs aged between 18 and 64 (median: 30) years were retrospectively examined. The length of the appendix vermiformis ranged from 25 to 120 (median: 70) mm, whereas its width ranged from 4 to 13 (median: 6) mm. The following histopathological findings were observed: normal appendix vermiformis (n=137), fibrous obliteration (n=13), acute appendicitis (n=5), enterobius vermicularis (n=4), lymphoid hyperplasia (n=4), low-grade appendiceal mucinous neoplasm (n=2), mucinous cystadenoma (n=1), grade 1 neuroendocrine tumor (n=1), hyperplastic polyp (n=1), enterobius vermicularis with fibrous obliteration (n=1), and acute appendicitis with eosinophilic infiltration (n=1). CONCLUSION This study showed that a careful inspection of the abdominal cavity was useful, and appendectomy should be performed when required. In addition, even if the macroscopic appearance of the appendectomy specimens is normal, histopathological evaluations facilitate an early diagnosis of numerous unusual appendiceal diseases.
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Affiliation(s)
- Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University School of Medicine, Malatya, Turkey
| | - Cemalettin Koç
- Department of Surgery and Liver Transplant Institute, Inonu University School of Medicine, Malatya, Turkey
| | - Barış Sarıcı
- Department of Surgery and Liver Transplant Institute, Inonu University School of Medicine, Malatya, Turkey
| | - Mehmet Özcan
- Department of Pathology, Inonu University School of Medicine, Malatya, Turkey
| | - Emine Şamdancı
- Department of Pathology, Inonu University School of Medicine, Malatya, Turkey
| | - Sezai Yılmaz
- Department of Surgery and Liver Transplant Institute, Inonu University School of Medicine, Malatya, Turkey
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