Abdominal wall endometriosis: an update in diagnosis, perioperative considerations and management

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.

Laparoscopic treatment of abdominal wall endometriosis: A case series

Objective

This report summarizes the characteristics of a series of 8 recent (2020-2022) patients with abdominal wall endometriosis (AWE) who underwent laparoscopic surgery. The feasibility and advantages of laparoscopy in the treatment of AWE are set out.

Methods

The clinical data of the 8 AWE patients were retrospectively analysed. Basic clinical characteristics, operation details and postoperative details were collected and analysed.

Results

Laparoscopic treatment was successful in all 8 cases. The mean operation time was 212.13 ± 48.16 min, the mean estimated blood loss was 25.00 ± 11.18 ml, and the mean postoperative hospital stay was 5.25 ± 1.39 days. 7 of the patients were found to have concomitant pelvic endometriosis, and 1 patient was found to have concealed inguinal hernias during surgery. Concomitant laparoscopic surgery for pelvic lesions was performed, including electrocautery or lesion resection of the pelvic endometriosis lesions in 7 patients, uterine fibroidectomy in 2 patients, high ligation of the hernia sac in 1 patient and endometrial biopsy under hysteroscopy in 1 patient. Endometrial-like tissue was confirmed by postoperative pathological examination of resected AWE lesions in all patients. There were no intraoperative or postoperative complications. The mean follow-up time was 18.75 ± 3.96 months, and no recurrence of AWE was found.

Conclusion

Laparoscopic surgery is a safe, effective and feasible treatment option for AWE patients and has the advantages of simultaneous diagnosis and treatment of other pelvic lesions.

Abdominal Wall Endometriosis: Early Diagnosis of a Rare Iatrogenic Complication Following Cesarean Section

Abdominal wall endometriosis is a rare form of extrapelvic endometriosis, frequently diagnosed with delay in most cases. It is typically iatrogenic and primarily associated with procedures such as cesarean sections or other gynecological surgeries. In our patient, endometriosis at the laparotomy scar was diagnosed relatively early, approximately two months after the onset of symptoms, which manifested 10 months after the last cesarean section. The patient, who had an obstetric history of three cesarean sections, presented at the Gynecology outpatient clinic of the General Hospital of Trikala, complaining of pain associated with menstruation located in the lower abdomen, near the surgical scar. Based on clinical and imaging findings, abdominal wall endometriosis was suspected, leading to a decision for wide excision of the endometriotic lesion. Histological examination of the surgical specimen confirmed the diagnosis. The postoperative course was uneventful, and three months after the surgery, the patient reported complete resolution of symptoms. This case report emphasizes the importance of integrating advanced diagnostic methods alongside classic clinical findings for the accurate diagnosis of abdominal wall endometriosis. It also highlights the contribution of surgical treatment through wide excision of the endometriotic lesion, in facilitating early diagnosis, achieving cure, and minimizing the risk of disease recurrence in the future.

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.

Exploring the Diagnostic Performance of Magnetic Resonance Imaging in Ultrasound-Guided High-Intensity Focused Ultrasound Ablation for Abdominal Wall Endometriosis

OBJECTIVE

This study aimed to explore the clinical value of magnetic resonance imaging (MRI) combined with ultrasound-guided high-intensity focused ultrasound (USg-HIFU) for the diagnosis and treatment of abdominal wall endometriosis (AWE).

METHODS

Magnetic resonance imaging was performed before and after USg-HIFU. Information on clinical characteristics of patients, MRI characteristics of lesions, and treatment outcomes were collected. Thirty AWE lesions in 29 patients were examined before HIFU treatment, while 27 patients were examined after treatment. The results of MRI and color doppler ultrasound before surgery, as well as the volume and the apparent diffusion coefficient (ADC) values of the lesions before and after USg-HIFU treatment were compared. We also observed the clinical symptoms remission, recurrence, and ablation rates of the lesions in follow-up after HIFU treatment.

RESULTS

The locations of the 30 AWE lesions were identified by MRI before USg-HIFU treatment. Their sizes appeared larger on MRI than ultrasound (P < 0.05). A total of 27 lesions were evaluated by MRI after USg-HIFU treatment, of which 92.6% (25/27) lesions were of high or slightly high signal intensity on T1-weighted images, and 77.8% (21/27) lesions were of mixed signal intensity on T2-weighted images. The mean ADC values of AWE lesions were 1.47 (1.20-1.59) × 10-3mm2/s and 1.86 (1.61-2.12) × 10-3mm2/s for pre-and post-HIFU treatment (P < 0.05). Patients with higher ablation rates (>50%) had a higher complete/partial remission rate than those with lower ablation rates (<50%), and had a lower recurrence rate (P < 0.05).

CONCLUSION

MRI is a useful tool for identifying the location, size, and concurrent changes of AWE before and after USg-HIFU treatment, which is beneficial for follow-up monitoring and defining treatment efficacy.